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preoperative biliary decompression, antibiotic resistance, biliary infection, antibiotic therapy

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Dronov , O., Кovalska І., Nastashenko , I., Levchenko , L., Shchigel , I., Onishchenko , M., & Malish , A. (2021). EVALUATION OF THE CHARACTER OF MICROBIAL FLORA AT THE STAGES OF TREATMENT IN PATIENTS WITH MALIGNANT OBSTRUCTIVE JAUNDICE. Medical Science of Ukraine (MSU), 17(4). https://doi.org/10.32345/2664-4738.4.2021.07


Relevance. The feasibility of preoperative billiary decompression (PBD) remains controversial in patients with malignant billiary obstruction (MOJ), due to the increased risk of multidrug-resistant (MDR), in most cases, catheter-associated microflora and postoperative infection complications. Analysis of biliary infection (BI) and its antibiotic sensitivity is an important aspect of clinical management of patients with resectable tumors of the pancreatobiliary region, which will improve treatment outcomes and reduce postoperative complications.

Objective: to assess the nature of the microbial flora at the stages of treatment in patients with MOJ.

Мaterials and methods. Prospective single-center cohort study of 136 patients with OJ. Patients were divided into two groups depending on the conduct of biliary decompression in the preoperative stage: group A (n = 84) – patients who underwent biliary decompression; group B (n = 52) – patients who did not perform biliary decompression. Collection of material (bile, drainage) for bacteriological examination was carried out in group A in three stages: 1) during PBD (stage I); 2) during the main surgery – ductus choledochus or endobiliary stent culture (stage II – intraoperative) and in the postoperative period for 3-5 days – culture of exudate from the drainage lumen (stage III – postoperative). In group B, material collection was performed – intraoperatively and postoperatively. The object of the study – microbial isolates, which were isolated in the above terms from the bile, which were identified by conventional methods of bacteriological laboratory. Aerobic and facultative anaerobic flora were studied. The taxonomic structure of microorganism (MO) was assessed by the level of acquired antimicrobial resistance, which is stratified by the European Center for Disease Control. During the bacteriological study, the sensitivity of MO to the following antibiotics was tested: ampicillin-sulbactam, ceftazidime, cefoperazone-sulbactam, ciprofloxacin, levofloxacin, piperacillin-tazobactam, meropenem, vancomycin.

Results. BI identified in I stage of the study was represented by monomicrobial in 54.8% of patients and in 45.2% of cases by polymicrobial flora. At the II and III stages of treatment, mixed flora prevailed - 89.3% and 85.7% of cases, respectively. In group A, E. coli was most often sown at the PDB stage (44.5%). E.coli (34.1% and 26.8%) and Kl.pneumoniae were sown most often at the intra- and postoperative stages (20.8% and 28.0%). In group B, monomicrobial flora was presented in 96.2% of cases at the intraoperative stage, while in the postoperative period only in 42.3% of cases. The flora that prevailed in stages II-III of group B was represented by E. coli (31.5% and 29.4%), E. faecalis (18.5% and 15.3%), C.frendii (16.7% and 11.8%).                                   

Conclusions. Bacterial infection that causes cholangitis in patients with MOJ, detected primarily during interventional methods of biliary decompression is not a complication. PBD is a risk factor for MDR flora. Each additional day with biliary drainage increases the probability of developing antibiotic resistance by HR 0.17 (95% ВІ 0.07- 0.4), p<0,001 at endobilliary stent placement, and at percutaneous transhepatic biliary drenage by HR 0.59 (95% CI 0.95-0.98), p <0.042. Routine performance of  bile culture, knowledge of nosocomial microbial background and indicators of its resistance, the primary method of Gram staining allows the use of early targeted antibiotic therapy, which prevents the development of MDR flora and improves the quality of the postoperative period.  Strict adherence to escalation antibiotic therapy scheme at each stage of treatment can prevent the development of MDR flora. The development of new techniques to prevent the development of stent-associated colonization of MO is an important step in preventing bacteriobilia.

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Muessle B, Hempel S, Kahlert C, Distler M, Weitz J, Welsch T. Prognostic impact of bacterobilia on morbidity and postoperative management after pancreatoduodenectomy: a systematic review and meta-analysis. World journal of surgery. 2018; 42(9): 2951-2962. DOI: 10.1007/s00268-018-4546-5

View at:

Publisher Site: https://link.springer.com/article/10.1007%2Fs00268-018-4546-5

PubMed: https://pubmed.ncbi.nlm.nih.gov/29464345/

Zhou H F, Huang M, Ji J S, Zhu H D, Lu J, Guo J H, Chen Li, Zhong B-Y, Zhu G-Y, Teng G-J. Risk prediction for early biliary infection after percutaneous transhepatic biliary stent placement in malignant biliary obstruction. Journal of Vascular and Interventional Radiology. 2019; 30(8): 1233-1241. DOI: 10.1016/j.jvir.2019.03.001

View at:

Publisher Site: https://www.sciencedirect.com/science/article/pii/S1051044319302921?via%3Dihub

PubMed: https://pubmed.ncbi.nlm.nih.gov/31208946/

Lee JG. Diagnosis and management of acute cholangitis. Nat RevGastroenterol Hepatol. 2009; 6(9):533-41. DOI: 10.1038/nrgastro.2009.126

View at:

Publisher Site: https://www.nature.com/articles/nrgastro.2009.126

PubMed: https://pubmed.ncbi.nlm.nih.gov/19652653/

Moole H, Bechtold M, Puli S R. Efficacy of preoperative biliary drainage in malignant obstructive jaundice: a meta-analysis and systematic review. World journal of surgical oncology. 2016; 14(1):1-11. DOI: 10.1186/s12957-016-0933-2

View at:

Publisher Site: https://wjso.biomedcentral.com/articles/10.1186/s12957-016-0933-2

PubMed: https://pubmed.ncbi.nlm.nih.gov/27400651/

PubMed Central: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4940848/

Pavlidis E T, Pavlidis T E. Pathophysiological consequences of obstructive jaundice and perioperative management. Hepatobiliary & Pancreatic Diseases International. 2018; 17(1): 17-21. DOI: 10.1016/j.hbpd.2018.01.008

View at:

Publisher Site: https://www.sciencedirect.com/science/article/abs/pii/S1499387218300158?via%3Dihub

PubMed: https://pubmed.ncbi.nlm.nih.gov/29428098/

Fong Z V, McMillan M T, Marchegiani G, Sahora K, Malleo G, De Pastena M, Loehrer A P, Lee G C, Ferrone C R, Chang D C, Hutter M M, Drebin J A, Bassi C, Lillemoe K D, Vollmer C M, Castillo C F-D. Discordance between perioperative antibiotic prophylaxis and wound infection cultures in patients undergoing pancreaticoduodenectomy. JAMA surgery. 2016; 151(5): 432-439. DOI: 10.1001/jamasurg.2015.4510

View at:

Publisher Site: https://jamanetwork.com/journals/jamasurgery/fullarticle/2478330

PubMed: https://pubmed.ncbi.nlm.nih.gov/26720272/

Sugawara G, Yokoyama Y, Ebata T, Igami T, Yamaguchi J, Mizuno T, Yagi T, Nagino M. Preoperative biliary colonization/infection caused by multidrug-resistant (MDR) pathogens in patients undergoing major hepatectomy with extrahepatic bile duct resection. Surgery. 2018; 163(5): 1106-1113. DOI: 10.1016/j.surg.2017.12.031

View at:

Publisher Site: https://www.sciencedirect.com/science/article/abs/pii/S0039606018300011?via%3Dihub

PubMed: https://pubmed.ncbi.nlm.nih.gov/29398033/

Lee P J, Podugu A, Wu D, Lee A C, Stevens T, Windsor J A. Preoperative biliary drainage in resectable pancreatic cancer: a systematic review and network meta-analysis. HPB (Oxford). 2018; 20(6); 477-486. DOI: 10.1016/j.hpb.2017.12.007

View at:

Publisher Site: https://www.sciencedirect.com/science/article/pii/S1365182X17311942?via%3Dihub

PubMed: https://pubmed.ncbi.nlm.nih.gov/29526466/

Kulezneva Yu V, Melekhina OV, Efanov MG, Alikhanov RB, Musatov AB, Ogneva A Yu, Tsvirkun VV. Disputable issues of biliary drainage procedures in malignant obstructive jaundice. Annals of HPB surgery. 2019; 24 (4): 111-122. DOI: 10.16931/1995-5464.20194111-122. [in Russian]

View at:

Publisher Site: https://hepato.elpub.ru/jour/article/view/463?locale=ru_RU

Shen Z, Zhang J, Zhao S, Zhou Y, Wang W, Shen B. Preoperative biliary drainage of severely obstructive jaundiced patients decreases overall postoperative complications after pancreaticoduodenectomy: a retrospective and propensity score-matched analysis. Pancreatology. 2020; 20(3): 529-536. DOI: 10.1016/j.pan.2020.02.002

View at:

Publisher Site: https://www.sciencedirect.com/science/article/abs/pii/S1424390320300387?via%3Dihub

PubMed: https://pubmed.ncbi.nlm.nih.gov/32107192/

Adler D G, McEntire D. Current Management of Ascending Cholangitis. Practical Gastroenterology. 2018 November; 7:28-45.

View at:

URL: https://practicalgastro.com/wp-content/uploads/2019/07/Current-Management-of-Ascending-Cholangitis.pdf

Tokyo Guidelines for Acute Cholangitis. 2018.

View at:

URL: https://www.mdcalc.com/tokyo-guidelines-acute-cholangitis-2018

Magiorakos A P, Srinivasan A, Carey R B, Carmeli Y, Falagas M E, Giske C G, Harbarth S, Hindler J F, Kahlmeter G, Olsson-Liljequist B, Paterson D L, Rice L B, Stelling J, Struelens M J, Vatopoulos A, Weber J T, Monnet D L. Multidrug‐resistant, extensively drug‐resistant and pandrug‐resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clinical microbiology and infection. 2012; 18(3); 268-281. DOI: 10.1111/j.1469-0691.2011.03570.x

View at:

Publisher Site: https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)61632-3/fulltext

PubMed: https://pubmed.ncbi.nlm.nih.gov/21793988/

[Determination of susceptibility to antibacterial drugs based on IPC limit values according to EUCAST in 11.0] [in Ukrainian]

View at:

Publisher Site: https://www.eucast.org/ast_of_bacteria/quality_control/

Ahmed M. Acute cholangitis – an update. World Journal of Gastrointestinal Pathophysiology. 2018; 9(1): 1-7. DOI: 10.4291/wjgp.v9.i1.1.

View at:

Publisher Site: https://www.wjgnet.com/2150-5330/full/v9/i1/1.htm

PubMed: https://pubmed.ncbi.nlm.nih.gov/29487761/

PubMed Central: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5823698/

Matsubara T, Nishida T, Hayashi S, Shimakoshi H, Tomimaru Y, Takahashi K, Nakamatsu D, Matsumoto K, Yamamoto M, Inada M. Comparison of double-layer large-diameter and conventional small-diameter plastic stents for preoperative biliary drainage in resectable distal malignant biliary obstruction. Scientific Reports. 2020; 10: article number: 13222. DOI: 10.1038/s41598-020-70183-y

View at:

Publisher Site: https://www.nature.com/articles/s41598-020-70183-y


PubMed Central:

Klimczak T, Kaczka K, Klimczak J, Tyczkowska-Sieroń E, Tyczkowska A. Primary bacterial culture of bile and pancreatic juice in tumor related jaundice (TROJ)-is ascending cholangitis always our fault? Scandinavian journal of gastroenterology. 2018; 53(12): 1569-1574. DOI: 10.1080/00365521.2018.1542454

View at:

Publisher Site: https://www.tandfonline.com/doi/abs/10.1080/00365521.2018.1542454?journalCode=igas20

PubMed: https://pubmed.ncbi.nlm.nih.gov/30621478/

Cortes A, Sauvanet A, Bert F, Janny S, Sockeel P, Kianmanesh R, Ponsot P, Ruszniewski P, Belghiti J. Effect of bile contamination on immediate outcomes after pancreaticoduodenectomy for tumor. Journal of the American College of Surgeons. 2006; 202(1): 93-9. DOI: 10.1016/j.jamcollsurg.2005.09.006

View at:

Publisher Site: https://www.journalacs.org/article/S1072-7515(05)01435-3/fulltext

PubMed: https://pubmed.ncbi.nlm.nih.gov/16377502/

Limongelli P, Pai M, Bansi D, Thiallinagram A, Tait P, Jackson J, Habib N A, Williamson RCN, Jiao LR. Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery. Surgery. 2007; 142(3): 313-318. DOI: 10.1016/j.surg.2007.04.022

View at:

Publisher Site: https://www.surgjournal.com/article/S0039-6060(07)00279-6/fulltext

PubMed: https://pubmed.ncbi.nlm.nih.gov/17723881/

Narkhede R, Desai G, Pande P. Bacteriobilia in Hepato-Pancreato-Biliary Surgery: an Enemy or a Friend in Disguise? Indian Journal of Surgery. 2019; 81(5): 479-484. DOI: 10.1007/s12262-019-01933-0

View at:

Publisher Site: https://www.springermedizin.de/bacteriobilia-in-hepato-pancreato-biliary-surgery-an-enemy-or-a-/17036908

Krüger CM, Adam U, Adam T, Kramer A, Heidecke CD, Makowiec F, Riediger H. Bacterobilia in pancreatic surgery-conclusions for perioperative antibiotic prophylaxis. World journal of gastroenterology. 2019; 25(41): 6238-47. DOI: 10.3748/wjg.v25.i41.6238

View at:

Publisher Site: https://www.wjgnet.com/1007-9327/full/v25/i41/6238.htm

PubMed: https://pubmed.ncbi.nlm.nih.gov/31749594/

PubMed Central: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6848011/

Herzog T, Belyaev O, Hessam S, Suelberg D, Janot M, Schrader H, Schmidt WE, Anders A, Uhl W, Mueller CA. Bacteribilia with resistant microorganisms after preoperative biliary drainage – the influence of bacteria on postoperative outcome. Scandinavian journal of gastroenterology. 2016; 47(7): 827-835. DOI: 10.3109/00365521.2012.679684

View at:

Publisher Site: https://www.tandfonline.com/doi/abs/10.3109/00365521.2012.679684?journalCode=igas20

PubMed: https://pubmed.ncbi.nlm.nih.gov/22507076/

Fong ZV, McMillan MT, Marchegiani G, Sahora K, Malleo G, De Pastena M, Loehrer AP, Lee GC, Ferrone CR, Chang DC, Hutter MM, Drebin JA, BassiC, Lillemoe KD, Vollmer CM, Fernández‐del Castillo C. Discordance between perioperative antibiotic prophylaxis and wound infection cultures in patients undergoing pancreaticoduodenectomy. JAMA surgery. 2016; 151(5): 432-439. DOI: 10.1001/jamasurg.2015.4510

View at:

Publisher Site: https://jamanetwork.com/journals/jamasurgery/fullarticle/2478330

PubMed: https://pubmed.ncbi.nlm.nih.gov/26720272/

Darnell EP, Wang TJ, Lumish MA, Hernandez-Barco YG, Weniger M, Casey BW, Qadan M, Lillemoe KD, Ferrone CR, Fernández‐del Castillo C, Krishnan K. Preoperative cholangitis is an independent risk factor for mortality in patients after pancreatoduodenectomy for pancreatic cancer. The American Journal of Surgery. 2021; 221(1):134-140. DOI: 10.1016/j.amjsurg.2020.07.025

View at:

Publisher Site: https://www.americanjournalofsurgery.com/article/S0002-9610(20)30479-7/fulltext

PubMed: https://pubmed.ncbi.nlm.nih.gov/32847686/

Sahora K, Morales‐Oyarvide V, Ferrone C, Fong ZV, Warshaw AL, Lillemoe KD, Fernández‐del Castillo C. Preoperative biliary drainage does not increase major complications in pancreaticoduodenectomy: a large single center experience from the Massachusetts General Hospital. Journal of Hepato‐Biliary‐Pancreatic Sciences. 2016; 23(3): 181-187. DOI: 10.1002/jhbp.322

View at:

Publisher Site: https://onlinelibrary.wiley.com/doi/10.1002/jhbp.322

PubMed: https://pubmed.ncbi.nlm.nih.gov/26768943/

Tanaka K, Nakamura T, Imai S, Kushiya H, Miyasaka D, Nakanishi Y, Asano T, Noji T, Tsuchikawa T, Okamura K, Shichinohe T, Hirano S. The use of broad-spectrum antibiotics reduces the incidence of surgical site infection after pancreatoduodenectomy. Surgery today. 2018; 48(9): 825-834. DOI: 10.1007/s00595-018-1658-3

View at:

Publisher Site: https://link.springer.com/article/10.1007%2Fs00595-018-1658-3

PubMed: https://pubmed.ncbi.nlm.nih.gov/29687153/

Maatman TK, Weber DJ, Qureshi B, Ceppa EP, Nakeeb A, Schmidt CM, Zyromski NJ, House MG. Does the microbiology of bactibilia drive postoperative complications after pancreatoduodenectomy? Journal of Gastrointestinal Surgery. 2020 Nov; 24(11):2544-2550. DOI: 10.1007/s11605-019-04432-5

View at:

Publisher Site: https://link.springer.com/article/10.1007%2Fs11605-019-04432-5

PubMed: https://pubmed.ncbi.nlm.nih.gov/31745903/

Kagedan DJ, Mosko JD, Dixon ME, Karanicolas PJ, Wei AC, Goyert N, Li Q, Mittmann N, Coburn NG. Changes in preoperative endoscopic and percutaneous bile drainage in patients with periampullary cancer undergoing pancreaticoduodenectomy in Ontario: effect on clinical practice of a randomized trial. Current Oncology. 2018; 25(5): e430-e435. DOI: 10.3747/co.25.4007

View at:

Publisher Site: https://www.mdpi.com/1718-7729/25/5/4007

PubMed: https://pubmed.ncbi.nlm.nih.gov/30464694/

PubMed Central: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6209556/

Itoyama R, Okabe H, Nakao Y, Yusa T, Nakagawa S, Imai K, Hayashi H, Yamashita Y-I, Baba H. The pivotal predictor of severe postoperative complications of pancreatoduodenectomy: complex links of bacterial contamination from preoperative biliary drainage. Surgery Today. 2020; 50(12):1594-1600. DOI: 10.1007/s00595-020-02061-z

View at:

Publisher Site: https://link.springer.com/article/10.1007%2Fs00595-020-02061-z

PubMed: https://pubmed.ncbi.nlm.nih.gov/32651685/

Kaneko T, Imaizumi H, Kida M, Miyata E, Yamauchi H, Okuwaki K, Iwai T, Koizumi W. Influence of cholangitis after preoperative endoscopic biliary drainage on postoperative pancreatic fistula in patients with middle and lower malignant biliary strictures. Digestive Endoscopy. 2018; 30(1): 90-97. DOI: 10.1111/den.12894

View at:

Publisher Site: https://onlinelibrary.wiley.com/doi/10.1111/den.12894

PubMed: https://pubmed.ncbi.nlm.nih.gov/28475221/

Scheufele F, Aichinger L, Jäger C, Demir IE, Schorn S, Sargut M, Erkan M, Kleeff J, Friess H, Ceyhan GO. Effect of preoperative biliary drainage on bacterial flora in bile of patients with periampullary cancer. Journal of British Surgery. 2017; 104(2): e182-e188. DOI: 10.1002/bjs.10450

View at:

Publisher Site: https://academic.oup.com/bjs/article/104/2/e182/6123066

PubMed: https://pubmed.ncbi.nlm.nih.gov/28121036/

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