Association Between Surgeons' Consideration of Suspected Biliary Contamination and Reported Antibiotic Duration After Pancreatoduodenectomy: An Exploratory Secondary Analysis of an International Survey.

Background/Objectives: Biliary contamination has been linked to infectious complications and clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD). It remains unclear whether surgeons consider suspected biliary contamination when assessing POPF risk and whether this is reflected in the antibiotic management they report. Methods: This exploratory secondary analysis examined responses from an international survey endorsed by the E-AHPBA. Associations between consideration of suspected biliary contamination and reported antibiotic class selection, routine duration category, and adaptation of duration in cases of suspected or proven biliary contamination were analyzed using Fisher's exact tests and ordinal logistic regression. Results: Among 283 respondents, 28 (9.9%) reported considering suspected biliary contamination when assessing POPF risk. Of 268 surgeons reporting perioperative antibiotic use, 185 (69.0%) reported adapting antibiotic duration in this setting. Surgeons who considered suspected biliary contamination reported longer antibiotic duration (OR 2.29, 95% CI 1.14-4.59; p = 0.020) and more often reported adapting duration (OR 4.15, 95% CI 1.21-22.11; p = 0.016). No statistically significant difference in reported antibiotic class selection was detected (global p = 0.192), including for ureidopenicillin use (OR 1.48, 95% CI 0.63-3.55; p = 0.422). Conclusions: In this international survey, few surgeons reported considering suspected biliary contamination when assessing POPF risk. Those who did reported longer routine antibiotic duration and more frequently reported adapting duration in cases of suspected or proven biliary contamination. Differences in reported antibiotic class selection remained uncertain. These findings are relevant from an antimicrobial stewardship perspective, as current evidence provides stronger support for covering the expected biliary pathogens than for prolonging prophylaxis, particularly in patients with preoperative biliary drainage.