Personalized Prophylaxis for Patients With ESBL Carriage Reduces Surgical Site Infection Risk

Screening for extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) carriage before and personalizing prophylaxis for carriers after elective colorectal surgery reduces the risk for surgical site infections, according to results of a study published in Clinical Infectious Diseases.

One of the most common healthcare-associated infections (HAI) in acute care hospitals are surgical site infections, which account for 21.8% of HAIs in the United States and are associated with increased mortality, length of hospital stays, and healthcare costs. Colorectal surgeries are extensive procedures that involve opening the fecal flora–containing lumen, and as such, surgical site infections are a common complication, with rates ranging from 17% to 26%. ESBL-PE are often multidrug resistant, and carbapenems have been recommended as the most reliable empiric and definitive regimen.

In 2016, the World Health Organization issued global guidelines to prevent surgical site infections. Listed among these guidelines to help prevent surgical site infections was pre-surgical screening for ESBL-PE carriage and prophylaxis modification for people who are carriers undergoing abdominal surgery, but, due to a lack of evidence, recommendations were not officially endorsed. Currently, the recommended routine prophylaxis for colorectal surgery is a cephalosporin directed at the aerobic flora combined with metronidazole to provide anaerobic coverage.

However, because the prevalence of ESBL-PE carriage in the gastrointestinal tract is increasing, prophylaxis with cephalosporins may be less effective for colorectal surgery. Therefore, this prospective, nonrandomized, non-blinded, interventional study tested whether ESBL-PE screening and personalized prophylaxis with ertapenem reduces surgical site infection risk among carriers undergoing elective colorectal surgery.

This study included 3 hospitals in Israel, Serbia, and Switzerland, and consisted of 2 phases: a baseline phase and an intervention phase. Researchers included patients who were undergoing an elective colorectal surgery; all patients were screened for ESBL-PE carriage. During the baseline phase, prophylaxis with a cephalosporin plus metronidazole were used to follow departmental guidelines. During the interventional phase, guidelines were changed for individuals who carried ESBL-PE to receive ertapenem.

In total, 209 patients who demonstrated ESBL-PE carriage were included in the baseline phase and 269 ESBL-PE carriers were included in the interventional phase. The primary outcome was any type of surgical site infection within 30 days. Following logistic regression, adjusted risk differences were calculated.

Results demonstrated that screening for ESBL-PE carriage before colorectal surgery and personalizing prophylaxis reduced surgical site infection rates among carriers. In the baseline and interventional phases, the surgical site infection rates were 21.5% and 17.5%, respectively (adjusted risk difference [ARD], -4.7%). The rate of surgical site infections caused by an ESBL-producing pathogen decreased by 79% from the baseline phase to the interventional phase (7.2% and 1.5%, respectively). Of note, during the interventional stage, 21% of the EBSL-PE carriers did not receive ertapenem due to lack of adherence to the prophylaxis guidelines, which caused crossover that biased the effectiveness results.

Therefore, to assess efficacy, an as-treated analysis was performed comparing 247 patients who received cephalosporin-based prophylaxis with 221 patients who received ertapenem-based prophylaxis. This analysis resulted in surgical site infection rates of 22.7% and 15.8%, respectively (ARD, -7.7%); an over reduction of 33%. The rates of surgical site infection caused by ESBL-PE were 6.5% and 0.9%, respectively (ARD, ‑5.6%); an 86% overall reduction. The rate of deep surgical site infection did not significantly differ between the 2 groups.

Overall, the study authors concluded that, “Routine use of ertapenem prophylaxis for all patients should be discouraged because of the risk of resistance.”

Reference

Nutman A, Temkin E, Harbarth S, et al. Personalized ertapenem prophylaxis for carriers of extended-spectrum β-lactamase-producing Enterobacteriaceae undergoing colorectal surgery. Clin Infect Dis. 2020;70(9):1891–1897