Microbiology-guided antimicrobial prophylaxis, surgical site infection and delivery of adjuvant chemotherapy after resection of perihilar cholangiocarcinoma.

INTRODUCTION

Surgical site infection (SSI) is the dominant morbidity after resection of perihilar cholangiocarcinoma (pCCA). Preoperative biliary instrumentation results in biliary colonisation with antimicrobial-resistant microorganisms, limiting the effectiveness of standard perioperative prophylaxis. Whether microbiology-guided prophylaxis improves outcomes, and whether sepsis compromises adjuvant chemotherapy delivery, is unknown.

METHODS

Retrospective cohort study of consecutive patients undergoing resection of pCCA at a UK tertiary centre (2009-2026). Routine intraoperative bile culture informed changes in institutional antimicrobial prophylaxis in 2019 from cefuroxime and metronidazole to teicoplanin and piperacillin-tazobactam. The primary outcome was SSI. In patients resected from April 2017, when adjuvant capecitabine became routine, chemotherapy receipt and timing were compared by SSI status.

RESULTS

Seventy-four patients were managed prior to the revised protocol and 58 thereafter. Biliary colonisation was near-universal (92 vs. 88%). Resistance to cefuroxime/metronidazole was detected in 70% of culture-positive baseline patients, and 14% for the revised regimen. SSI fell from 42/74 (57%) to 17/58 (29%; p = 0.003), driven by organ/space infections (46 vs. 24%; p = 0.033), and remained associated with the revised protocol after adjustment (OR 0.31, 95% CI 0.13-0.72). Among 67 post-BILCAP-era patients, chemotherapy began within 12 weeks in 16% with SSI compared to 50% without; among recipients, median time to first cycle was 104 vs. 78 days (p = 0.010).

CONCLUSIONS

Microbiology-guided prophylaxis was associated with clinically meaningful reductions in SSI. Reducing septic complications does not just limit perioperative morbidity, but avoids delay in adjuvant chemotherapy.