Empiric Antimicrobial Treatment of Anastomotic Leakage after Esophageal Resection: The Most Commonly Used Antimicrobial Regimens in the Netherlands and an Antimicrobial Treatment Recommendation Based on a Single-Center Population.

Introduction: The development of anastomotic leakage (AL) after esophagectomy is a severe complication, often leading to mediastinitis and systemic infections. Effective empiric antimicrobial therapy is crucial, but there is no consensus on the optimal regimen. This study aimed to document antimicrobial regimens used in the Netherlands and to evaluate culture results from AL after esophagectomy at our center.

Methods: An online questionnaire about the preferred antimicrobial treatment of AL after esophagectomy was sent to all upper gastrointestinal surgeons in the Netherlands. In addition, drain culture results from patients with AL after esophagectomy in our center were retrospectively analyzed.

Results: From 76 responses, 28 were included, representing 13 of the 15 esophagectomy-performing centers in the Netherlands. For treating AL after esophagectomy, respondents typically choose broad-spectrum regimens covering Gram-negative, Gram-positive, and anaerobic bacteria. The cultures of 57 patients were analyzed. Overall, 61% had positive cultures for yeast, 61% of patients for Enterobacterales, and 16% for Pseudomonas and other non-fermenters.

Conclusion: Based on the studied cultures, empiric antibiotics should cover Gram-positive, Gram-negative, anaerobe bacteria and Pseudomonas. We recommend the use of empiric amoxicillin/clavulanic acid with tobramycin for patients with AL after esophagectomy, which is now protocol in our center. The addition of antifungals remains debatable. Given the high incidence of yeast-positive cultures in the studied cohort, we recommend the addition of an echinocandin in clinically unstable patients.