EVALUATION OF THE CHARACTER OF MICROBIAL FLORA AT THE STAGES OF TREATMENT IN PATIENTS WITH MALIGNANT OBSTRUCTIVE JAUNDICE
Authors: Dronov O.I. , Кovalska І.О. , Nastashenko I.L. , Levchenko L.V. , Shchigel I.A. , Onishchenko M.O. , Malish A.O. 
Published: January 2022

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.