Clinical Impact of Early Positive Drain Culture on Outcomes and Management After Pancreaticoduodenectomy

Background Early drain fluid contamination after pancreaticoduodenectomy (PD) may predict postoperative complications. We investigated the significance of positive drain cultures on postoperative day 1 (POD1). Methods We retrospectively reviewed 637 consecutive patients undergoing PD between 2020 and 2024. Patients were divided into POD1 drain culture–positive (PDC) and negative (NDC) groups to assess risk factors and outcomes. Results PDC was identified in 87 patients (14%). In 73% of PDC cases, organisms isolated from POD1 drain cultures matched those from intraoperative bile cultures. Multivariate analysis identified high BMI, biliary tract cancer, soft pancreas, and preoperative biliary drainage as independent risk factors for PDC. Compared with the NDC group, the PDC group had higher rates of Clavien‐Dindo grade ≥ IIIa complications (40% vs. 15%), clinically relevant postoperative pancreatic fistula (51% vs. 20%), and postpancreatectomy hemorrhage (9% vs. 3%), as well as longer hospital stay (26 vs. 20 days) (all p < 0.01). Even among patients with a hard pancreas, PDC was associated with increased major complications (41% vs. 12%, p = 0.004). Among PDC patients, early administration of susceptible antibiotics by POD3 was associated with fewer major complications (25% vs. 62%, p = 0.001). Conclusions Positive POD1 drain cultures predict major complications after PD. Early culture‐guided antibiotic therapy may reduce postoperative morbidity.