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

Abstract

Objectives: Compared to cephalosporin-based prophylaxis, ertapenem prophylaxis lowers the risk of surgical site infection among carriers of extended-spectrum b-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 thirdgeneration-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 4e6 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 e12.8%; 95%CI e22.4% to e3.1%). 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 e20.7%, 95%CI e37.3% to e4.1%). 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 cephalosporinemetronidazole prophylaxis. Resistance

Effect of Pharmacoprophylaxis on Postoperative Outcomes in Adult Elective Colorectal Surgery: A Multi-Center Retrospective Cohort Study within an Enhanced Recovery after Surgery Framework

“…Further, evidence suggests that ertapenem may be more effective than cefotetan [53]. Other more recent reports have shown similar results for ertapenem as ours, and this may be especially important in patients who are carriers of community-or hospital-acquired extended-spectrum β-lactamase-producing Enterobacteriaceae [54,55]. Now that ertapenem is available generically, guidelines and protocols for SSI prevention may require a re-examination.…”

Emerging Paradigms in the Prevention of Surgical Site Infection: The Patient Microbiome and Antimicrobial Resistance

“…The impact on efficacy of current standard surgical prophylaxis regimens has been modeled for U.S. surgical populations, estimating that (1) approximately 40 to 50% of surgical site infections are currently resistant to standard prophylactic agent(s) for the procedure, and (2) continuation of these trends in the United States could result in tens or hundreds of thousands of additional infections per year. 38 The presence of diverse antimicrobial-resistant strains within the microbiomes of patients presenting for care now poses a complex set of challenges for prophylaxis against endogenous infection in procedures such as surgery and cancer treatment, potentially necessitating individualized approaches tailored to the patient “resistome” 40 (fig. 2F).…”

Contribution of the patient microbiome to surgical site infection and antibiotic prophylaxis failure in spine surgery

“…Such a strategy might guide a more sustainable framework that preserves the efficacy of surgical prophylaxis while limiting the trend of escalation to more broadly acting agents in the face of increasing population-level resistance ( 7 ). A conceptually similar, culture-based strategy has been explored in a limited fashion in patients undergoing colorectal surgery and been shown to be effective ( 54 ) without selecting for resistance ( 55 ) but has not been widely embraced or studied in other procedure types (for example, extra-abdominal procedures involving skin incisions such as orthopedic, neurological, cardiac, obstetric, or plastic surgery). Similarly, the detection of qac family genes in some SSI strains, conferring resistance to the common surgical antiseptic chlorhexidine ( 56 ), suggests that alternative agents such as povidone-iodine could be leveraged in a targeted or complementary fashion.…”