Antibiotic stewardship program in pancreatic surgery: a multicenter, before-after analysis.

Author(s):
Salvatore Paiella; Matteo De Pastena; Erica Secchettin; Damiano Caputo; Roberto Coppola; Vincenzo La Vaccara; Roberto Cammarata; Luca Moraldi; Luca Tirloni; Ilenia Bartolini; Matteo Risaliti; Irene Urciuoli; Tommaso Giani; Elena Carrara; Anna Maria Azzini; Danila Azzolina; Laura Addari; Giuseppe Malleo; Evelina Tacconelli; Dario Gregori; Claudio Bassi; Roberto Salvia

Background:

Antibiotic stewardship programs (ASPs) can help optimize the use of antimicrobials and antibiotic prophylaxis, reducing the rate of surgical site infections (SSI). We created a novel ASP in pancreatic surgery, including a bundle of interventions and tailored antibiotic prophylaxis, and verified its clinical efficacy in reducing the incidence of SSI within 30 days of surgery.

Hypothesis:

The introduction of a novel ASP in pancreatic surgery, where the antibiotic prophylaxis is pivoted on the results of a preoperative rectal swab for multi-drug resistant bacteria, reduces the rate of SSI within 30 days of surgery.

Methods:

A multicenter, before-after, propensity score weighting prospective study was conducted. The prospective momentum (intervention cohort, IC) went from January 2020 to December 2023; the historical cohort (HC) went from January 2015 to December 2019. The ASP was shared among three national high-volume centers of pancreatic surgery. The antibiotic prophylaxis was tailored based on the results of a rectal swab aimed at detecting multi-drug resistant microbes.

Results:

The study population encompassed 3,262 patients, categorized into 1,094 in the IC and 2,198 in the HC. After implementing the ASP and tailored antibiotic prophylaxis, the SSI rate significantly decreased from 30% to 22% (p<0.001). Notably, a statistically significant reduction was observed in superficial (5.8% vs. 2.7%, p<0.001), organ/space SSIs (26% vs. 21%, p<0.001). After propensity score weighting, the estimated average treatment effect on the treated (ATT) was 0.92 (CI 0.89-0.96, p<0.001) for overall SSI (figure 1), and 0.87 for superficial SSI (CI 0.80-0.94, p<0.001). Additionally, a substantial reduction in any and major complications, pancreatic and biliary fistula, post-pancreatectomy hemorrhage, and length of stay was recorded in the IC (all p<0.05).

Conclusions:

A novel ASP in pancreatic surgery significantly reduced SSI and other clinically relevant complications. The infectious risk stratification based on the preoperative rectal swab proved effective. Its use should be implemented to promote the judicious use of antibiotics and optimize their efficacy.