Personalized Ertapenem Prophylaxis for Carriers of Extended-spectrum β-Lactamase–producing Enterobacteriaceae Undergoing Colorectal Surgery

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.

Outcomes of extended-spectrum beta-lactamases producing Enterobacteriaceae colonization among patients abdominal surgery patients

“…A recent study suggested that personalized ertapenem prophylaxis for enteric ESBL-producing Enterobacteriaceae carrier can reduce SSI among patients who underwent colorectal surgery. 12 In this study, given that majority of patients had superficial SSIs, we found no association between carbapenem use as surgical prophylaxis and reduction in SSIs. Our study has a few notable limitations.…”

The effect of prophylaxis with ertapenem versus cefuroxime/metronidazole on intestinal carriage of carbapenem-resistant or third-generation-cephalosporin-resistant Enterobacterales after colorectal surgery

“…We recently reported high rates of ESBL-PE carriage among colorectal surgery candidates, and showed that ESBL-PE carriers receiving cephalosporin-based prophylaxis were twice as likely to develop SSI as non-carriers [7]. We also demonstrated that ESBL-PE carriers undergoing colorectal surgery had significantly lower SSI rates when given ertapenem prophylaxis (15.8%) compared to cephalosporin-based prophylaxis (22.7%) [8].…”

“…This single-centre nested study was part of the Resistance in Gram-Negative Organisms: Studying Intervention Strategies (R-GNOSIS) project conducted in 2012e2017, in which patients undergoing colorectal surgery were screened for ESBL-PE carriage [7,8].…”

Risk factors for extended-spectrum beta-lactamase–producing Enterobacteriaceae enteric carriage among abdominal surgery patients

“…1,2 Screening for ESBL-pE and personalized ertapenem use was associated with reduction in the incidence of SSIs caused by ESBL-pE. 3 Despite the potential benefit, screening all patients for ESBL-pE carriage may be considered an excess cost in resourcelimited settings. Selective screening for high-risk groups with ESBL-pE carriage may be an alternative approach to surveillance screening and antimicrobial stewardship.…”

“…Clostridioides difficile-associated diarrhea (CDAD) is the most frequently reported healthcare-associated illness in the United States, with an annual economic burden >$1 billion and up to 9% mortality, and critically ill trauma patients may be uniquely at risk. [1][2][3][4] Military trauma patients have multiple CDAD risk factors, including frequent broad-spectrum antimicrobial exposure, transient immunosuppression, and challenges related to infection control in the deployed environment and along the evacuation chain. We describe the epidemiology of wounded military personnel diagnosed with CDAD.…”