1
|
Hoffman T, Lellouche J, Nutman A, Temkin E, Frenk S, Harbarth S, Carevic B, Cohen-Percia S, Kariv Y, Fallach N, Klausner J, Carmeli Y. The effect of prophylaxis with ertapenem versus cefuroxime/metronidazole on intestinal carriage of carbapenem-resistant or third-generation-cephalosporin-resistant Enterobacterales after colorectal surgery. Clin Microbiol Infect 2021; 27:1481-1487. [PMID: 33588061 DOI: 10.1016/j.cmi.2021.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/11/2021] [Accepted: 02/02/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Compared to cephalosporin-based prophylaxis, ertapenem prophylaxis lowers the risk of surgical site infection among carriers of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PEs) undergoing colorectal surgery. We aimed to determine whether ertapenem prophylaxis leads to increased postoperative colonization with carbapenem-resistant Enterobacterales (CREs) and third-generation-cephalosporin-resistant Enterobacterales (3GCR-Es). METHODS This study was nested within a quality improvement study of prophylaxis for ESBL-PE carriers undergoing colorectal surgery. Patients were screened 4-6 days after surgery for carriage of ESBL-PEs or other 3GCR-Es and CREs. When CREs were detected, pre- and postsurgical clones were compared using Fourier-transform infrared (FT-IR) spectroscopy. RESULTS The sample consisted of 56 patients who carried ESBL-PEs before surgery and received cefuroxime/metronidazole prophylaxis (Group 1), 66 who carried ESBL-PEs before surgery and received ertapenem (Group 2), and 103 ESBL-PE non-carriers who received cefuroxime/metronidazole prophylaxis (Group 3). CRE carriage was detected postoperatively in one patient (1.5%) in Group 2 versus eight patients (14.3%) in Group 1 (RD -12.8%; 95%CI -22.4% to -3.1%). For seven out of nine patients, preoperative ESBL-PE and postoperative CRE isolates were compared; in five of them, the pre- and postoperative clones were identical. Postoperative 3GCR-E carriage was detected in 37 patients (56.1%) in Group 2 versus 46 patients in Group 1 (82.1%) (aRD -20.7%, 95%CI -37.3% to -4.1%). CONCLUSIONS Among ESBL-PE carriers undergoing colorectal surgery, detection of short-term postsurgical colonization by CREs and 3GCR-Es was significantly lower among patients who received ertapenem prophylaxis than those who received cephalosporin-metronidazole prophylaxis. Resistance development in a colonizing bacterial clone, rather than carbapenemase acquisition, was the major mechanism of carbapenem resistance.
Collapse
Affiliation(s)
- Tomer Hoffman
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel; Infectious Disease Unit, Meir Medical Center, Kfar Saba, Israel
| | - Jonathan Lellouche
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Amir Nutman
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elizabeth Temkin
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Sammy Frenk
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, WHO Collaborating Center, Geneva, Switzerland
| | - Biljana Carevic
- Department of Hospital Epidemiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Shimrit Cohen-Percia
- National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Yehuda Kariv
- Department of Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Noga Fallach
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - Joseph Klausner
- Department of Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Yehuda Carmeli
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; National Institute for Antibiotic Resistance and Infection Control, Israel Ministry of Health, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | | |
Collapse
|
2
|
Nutman A, Temkin E, Harbarth S, Carevic B, Ris F, Fankhauser-Rodriguez C, Radovanovic I, Dubinsky-Pertzov B, Cohen-Percia S, Kariv Y, Buchs N, Schiffer E, Fallach N, Klausner J, Carmeli Y. Personalized Ertapenem Prophylaxis for Carriers of Extended-spectrum β-Lactamase–producing Enterobacteriaceae Undergoing Colorectal Surgery. Clin Infect Dis 2019; 70:1891-1897. [DOI: 10.1093/cid/ciz524] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 06/18/2019] [Indexed: 12/20/2022] Open
Abstract
Abstract
Background
Carriers of extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-PE) who receive cephalosporin-based prophylaxis have twice the risk of surgical site infection (SSI) following colorectal surgery as noncarriers. We tested whether ESBL-PE screening and personalized prophylaxis with ertapenem reduces SSI risk among carriers.
Methods
We conducted a prospective nonrandomized, nonblinded, interventional study in 3 hospitals in Israel, Switzerland, and Serbia. Patients were screened for ESBL-PE carriage before elective colorectal surgery. During the baseline phase, departmental guidelines advised prophylaxis with a cephalosporin plus metronidazole. In the intervention phase, guidelines were changed for ESBL-PE carriers to receive ertapenem. The primary outcome was any type of SSI within 30 days. We calculated adjusted risk differences (ARDs) following logistic regression.
Results
The intention-to-treat analysis compared 209 ESBL-PE carriers in the baseline phase to 269 in the intervention phase. SSI rates were 21.5% and 17.5%, respectively (ARD, –4.7% [95% confidence interval {CI}, –11.8% to 2.4%]). Unplanned crossover was high (15%), so to assess efficacy we performed an as-treated analysis comparing 247 patients who received cephalosporin-based prophylaxis with 221 who received ertapenem. SSI rates were 22.7% and 15.8%, respectively (ARD, –7.7% [95% CI, –14.6% to –.8%]), and rates of SSI caused by ESBL-PE were 6.5% and 0.9%, respectively (ARD, –5.6% [95% CI, –8.9% to –2.3%]). There was no significant difference in the rate of deep SSI. The number needed to treat to prevent 1 SSI in ESBL-PE carriers was 13.
Conclusions
Screening for ESBL-PE carriage before colorectal surgery and personalizing prophylaxis for carriers is efficacious in reducing SSI.
Collapse
Affiliation(s)
- Amir Nutman
- National Center for Infection Control and Antibiotic Resistance, Tel-Aviv Sourasky Medical Center
- Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Elizabeth Temkin
- National Center for Infection Control and Antibiotic Resistance, Tel-Aviv Sourasky Medical Center
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, World Health Organization Collaborating Center, Switzerland
| | - Biljana Carevic
- Department of Hospital Epidemiology, Clinical Center of Serbia, Belgrade
| | - Frederic Ris
- Department of Surgery, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Carolina Fankhauser-Rodriguez
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, World Health Organization Collaborating Center, Switzerland
| | - Ivana Radovanovic
- Department of Hospital Epidemiology, Clinical Center of Serbia, Belgrade
| | - Biana Dubinsky-Pertzov
- National Center for Infection Control and Antibiotic Resistance, Tel-Aviv Sourasky Medical Center
| | - Shimrit Cohen-Percia
- National Center for Infection Control and Antibiotic Resistance, Tel-Aviv Sourasky Medical Center
| | - Yehuda Kariv
- Department of Surgery, Tel-Aviv Sourasky Medical Center, Israel
| | - Nicolas Buchs
- Department of Surgery, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Eduardo Schiffer
- Department of Anesthesiology, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Noga Fallach
- National Center for Infection Control and Antibiotic Resistance, Tel-Aviv Sourasky Medical Center
| | - Joseph Klausner
- Department of Surgery, Tel-Aviv Sourasky Medical Center, Israel
| | - Yehuda Carmeli
- National Center for Infection Control and Antibiotic Resistance, Tel-Aviv Sourasky Medical Center
- Sackler Faculty of Medicine, Tel-Aviv University, Israel
| |
Collapse
|