Surgical antibiotic prophylaxis for elective pancreatoduodenectomy: a propensity score-weighted comparative analysis.

BACKGROUND

Pancreatoduodenectomy (PD) is a morbid procedure often associated with high rates of postoperative infectious complications, contributing to worse prognosis. We sought to investigate the optimal surgical prophylaxis antibiotic for PD patients using the ACS-NSQIP.

STUDY

DESIGN

The ACS-NSQIP (2016-2023) was queried for elective PDs and their prophylactic antibiotics. Patients were categorized by antibiotic type: first-generation cephalosporin (FC), second/third-generation cephalosporin (STC), and broad-spectrum (BS - e.g., piperacillin-tazobactam, cefoxitin, and fourth-generation cephalosporins). The primary outcomes were surgical site infection (SSI) and Clostridium difficile colitis. Inverse probability weighting using multinomial propensity scores was applied to balance groups and estimate adjusted probabilities and pairwise risk differences.

RESULTS

Among 23,258 PD patients, adjusted SSI probabilities were 22.7% (21.7-23.8%), 22.3% (21.3-23.3%), and 20.0% (19.2-20.8%) for FC, STC, and BS, respectively (p < 0.001). BS antibiotics consistently reduced SSI risk without significant differences in other outcomes, including pancreatic fistula, readmission, reoperation, mortality, or major complications. Infection rates differed by biliary drainage status (p < 0.001). C. difficile rates were low and comparable across groups (1.1% vs. 1.9% vs. 1.7%).

CONCLUSION

Broader prophylactic coverage in elective PD reduces postoperative infections without increasing C. difficile risk, especially benefiting patients with preoperative biliary instrumentation.