Antibiotic Prophylaxis in Surgical Procedures and the Threats of Fecal Carriage of the ESBL Producer Organisms
Authors: Garcell Humberto Guanche 
Published: July 2019

Healthcare associated infections (HAI) are unnecessary adverse events as they are preventable with proper implementation of the best evidence about the topic. The surgical site infections (SSI) account the 17% of HAI in the U.S. In South Asian countries the pooled estimate of SSI incidence according to a recently published meta-analysis was 8.6%, meanwhile a report of Rosenthal and colleagues describes higher incidence in low-income countries compared with U.S. data. In addition to the patient safety issues, the economic impact of these infections should be considered. In U.S. the total annual costs for the 5 major infections were $9.8 billion, with SSI contributing the most to overall costs (33.7% of the total), followed by the devices associated infections and Clostridium difficile infections.

In European university hospital, the mean additional postoperative length of hospital stay was 16.8 days; and the mean additional in-hospital duration of antibiotic therapy was 7.4 days. The perioperative antibiotic prophylaxis constitutes a key prevention practice, with a high quality of evidence for its implementation. Antibiotic prophylaxis is aimed to reduce the incidence of SSI by preventing the development of infection caused by organisms that colonize or contaminate the surgical site. The adequate use of perioperative antibiotic prophylaxis can reduce the rate of SSI in up to 50%. Multidrug-resistant organisms Antimicrobial resistance is a worldwide problem with a significant impact in morbidity and mortality at the community level, and also in health care facilities. Nearly 20% of pathogens reported from all healthcare associated infections to NHSN (CDC) were multidrug-resistant organisms (MDRO).

The CDC estimates that the annual impact of antibiotic-resistant infections on the U.S. economy is $20–35 billion in excess direct health care costs, with additional costs to society for lost productivity as high as $35 billion per year and 8 million additional days in hospitals. Extended-spectrum β-lactamase producing Enterobacteriaceae is frequent in healthcare associated infections and in the community.

Worldwide dissemination of plasmid-borne extended-spectrum b-lactamases (ESBL) is a public health concern since community-acquired infections caused by ESBL-producing Escherichia coli (among other Enterobacteriaceae) are becoming increasingly frequent. The problem of ESBL production is no longer limited to community-onset or hospital-acquired infections. Faecal carriage of ESBL-producing Enterobacteriaceae, by asymptomatic individuals, has been noted in many parts of the world. There is observed a variable frequency of ESBL carriage in diverse studied population from Korea (9.3%), UK (11.3%), Sweden (6.8%) and Paris (6%). Studies conducted in Eastern Mediterranean countries has shown fecal carriage of 12.7% in Saudi Arabia, 13.4% in Lybia and 21% in Egypt. No reports about studies conducted in Qatar have been published. MDRO prevention approaches can be broadly categorized and should include measures to prevent infection among patients who are uninfected carriers of an MDRO. The problem Appendicitis is the most common reason for acute abdominal pain in with a lifetime risk of 8.6% for males and 6.7% for females. Appendectomy constitutes the principal emergency surgical procedure in The Cuban Hospital (Dukhan, Qatar). During the period January, 2013-October, 2015 have been performed 561 appendectomies, been reported 22 (4.1%) cases with surgical site infections. As a consequence, an excess of the length of stay of 3.8 days and antimicrobial consumption of 77.84 daily defined doses was identified in patients with SSI compared with those without SSI. In culture samples collected during surgical procedure, due to the evidence of fluid in the surgical site, was identified Escherichia coli ESBL producer in 23.3% of the positive cultures, meanwhile in positive cultures of surgical site infections the 65% of the microbial agents identified were extended spectrum beta-lactamase producers (E.coli, 12 patients; Klebsiella pneumonia, 1 patient). The standard perioperative prophylaxis performed in our patients is a combination of cefuroxime (beta-lactam antimicrobial) and metronidazole. Compliance with antibiotic prophylaxis in patients with surgical site infection was 86.4%, 100% and 91% for timely administration, proper doses and selection of the antimicrobials and discontinuation before 24 hr after the surgical procedure, respectively. – Research questionso Is the fecal carrier of ESBL producer organisms at increased risk of surgical site infections after appendectomy or others surgical procedures that involve intestinal incision? o Could be prevented these surgical site infections with a targeted antimicrobial prophylaxis? – Hypothesiso Fecal carriage of ESBL producer organisms increases the risk of surgical site infections in patients with appendicitis or colon surgeries, which could be prevented by a targeted antimicrobial prophylaxis. – Research o A cohort study of patients who underwent to appendectomies and colon surgery. – Expected resultso Identify the prevalence of fecal carriages of ESBL producer organismso Describe the risk of acquired surgical site infection in fecal carriage of ESBL producer organisms. o Analyze the potential use of targeted antimicrobial prophylaxis in surgical procedures that involve the colon. – Conclusiono The prevention of surgical site infections constitutes a challenge in the daily medical practice. o The changing environment of the MDROs in the community imposes of a challenge for healthcare professionals, which should review its practices according to the new trends of antimicrobial resistance and the frequency of microbial colonization in the population. Healthcare associated infections (HAI) are unnecessary adverse events as they are preventable with proper implementation of the best evidence about the topic.

The surgical site infections (SSI) account the 17% of HAI in the U.S. (Yokoe DS, 2014). In South Asian countries the pooled estimate of SSI incidence according to a recently published meta-analysis was 8.6% (95% CI, 5.8%–11.4%), meanwhile a report of Rosenthal and colleagues describes higher incidence in low-income countries compared with U.S. data (Rosenthal, 2013; Lin Ling M, 2015).

In addition to the patient safety issues, the economic impact of these infections should be considered. In U.S. the total annual costs for the 5 major infections were $9.8 billion (95% CI, $8.3–$11.5 billion), with surgical site infections contributing the most to overall costs (33.7% of the total), followed by the devices associated infections and Clostridium difficile infections (Zimlichman E, 2013).

In European university hospital, the mean additional postoperative length of hospital stay was 16.8 days (95% CI, 13–20.6 days); and the mean additional in-hospital duration of antibiotic therapy was 7.4 days (95% CI, 5.1–9.6 days) (Weber 2008). As is widely shown in the literature from high-income countries, including the United States, the incidence of HAI can be reduced by as much as 30%, and by 55% in the case of SSI, through the implementation of an effective surveillance approach (Umscheid CA, 2011).

The perioperative antibiotic prophylaxis constitutes a key prevention practice, which according to the 2014 SHEA recommendation achieve a high quality of evidence for its implementation (Anderson, 2008) (Yokoe, 2014). Antibiotic prophylaxis is aimed to reduce the incidence of SSI by preventing the development of infection caused by organisms that colonize or contaminate the surgical site.

The antimicrobial agents for prophylaxis should be: 1) active against the pathogens most likely to contaminate the surgical site, 2) given in an appropriate dosage and at a time that ensures adequate serum and tissue concentrations during the period of potential contamination, 3) Safe, and 4) administered for the shortest effective period to minimize adverse effects, the development of resistance, and costs. The predominant organisms causing SSIs after clean procedures are skin flora. In clean-contaminated procedures, including abdominal procedures and heart, kidney, and liver transplantations, the predominant organisms include gram-negative rods and enterococci in addition to skin flora. (Bratzler DW, 2013). The main target of antibiotic prophylaxis is the wound and should be considered, in addition of choose the proper antimicrobial (according to the surgical site or procedure), the timing of administration and it duration after the surgical procedure. The adequate use of perioperative antibiotic prophylaxis can reduce the rate of SSI in up to 50%. Multidrug-resistant organisms Antimicrobial resistance is a worldwide problem with a significant impact in morbidity and mortality at the community level, and also in health care facilities. Nearly 20% of pathogens reported from all healthcare associated infections to NHSN (CDC) were multidrug-resistant organisms (Sievert DM, 2013).

The Centers for Disease Control and Prevention (CDC) estimates that the annual impact of antibiotic-resistant infections on the U.S. economy is $20–35 billion in excess direct health care costs, with additional costs to society for lost productivity as high as $35 billion per year and 8 million additional days in hospitals. (Report of the US President, 2014). Extended-spectrum β-lactamase producing Enterobacteriaceae (ESBL) is frequent in healthcare associated infections and in the community.

Worldwide dissemination of plasmid-borne extended-spectrum b-lactamases (ESBLs) is a public health concern since community-acquired infections caused by ESBL-producing Escherichia coli (among other Enterobacteriaceae) are becoming increasingly frequent (Pitout JDD, 2005).

The problem of ESBL production is no longer limited to community-onset or hospital-acquired infections. Faecal carriage of ESBL-producing Enterobacteriaceae, particularly the CTX-M producers, by asymptomatic individuals has been noted in many parts of the world. There is observed a variable frequency of ESBL carriage in diverse studied population from Korea (9.3%), UK (11.3%), Sweden (6.8%) and Paris (6%) (Beom King J, 2014; Wickramasinghe NH, 2012, Stromdahl H, 2011, Nicolas-Chanoine MH, 2013). Studies conducted in Eastern Mediterranean countries has shown fecal carriage of 12.7% in Saudi Arabia (Kader AA, 2009), 13.4% in Lybia (Ahmed SF, 2014) and 21% in Egypt (Bassyouni RH, 2015). No reports about studies conducted in Qatar have been published. In the face of rising resistance rates and limited treatment options, prevention of MDRO infections is paramount. MDRO prevention approaches can be broadly categorized and should include measures to prevent infection among patients who are uninfected carriers of an MDRO. The Goals of the National action plan to combat antibiotic resistant bacteria (White House, Washington, 2015) define the need of the use of a rapid test for early diagnosis of multidrug-resistant organisms. The problem Appendicitis is the most common reason for acute abdominal pain in with a lifetime risk of 8.6% for males and 6.7% for females (Flum DR, 2015). Appendectomy, mainly using the laparoscopic technique, constitutes the principal emergency surgical procedure in The Cuban Hospital (Dukhan, Qatar). During the period January, 2013-October, 2015 have been performed 561 appendectomies, been reported 22 (4.1%) cases with surgical site infections. As a consequence, an excess of the length of stay of 3.8 days and antimicrobial consumption of 77.84 daily defined doses was identified in patients with SSI compared with those without SSI. In culture samples collected during surgical procedure, due to the evidence of fluid in the surgical site, was identified Escherichia coli ESBL producer in 23.3% of the positive cultures, meanwhile in positive cultures of surgical site infections the 65% of the microbial agents identified were extended spectrum beta-lactamase producers (E.coli, 12 patients; Klebsiella pneumonia, 1 patient). The standard perioperative prophylaxis performed in our patients is a combination of cefuroxime (beta-lactam antimicrobial) and metronidazole. Compliance with antibiotic prophylaxis in patients with surgical site infection was 86.4%, 100% and 91% for timely administration, proper doses and selection of the antimicrobials and discontinuation before 24 hr after the surgical procedure, respectively. – Research questions o Is the fecal carrier of ESBL producer organisms at increased risk of surgical site infections after appendectomy or others surgical procedures that involve intestinal incision? o Could be prevented these surgical site infections with a targeted antimicrobial prophylaxis? – Hypothesis o Fecal carriage of ESBL producer organisms increases the risk of surgical site infections in patients with appendicitis or colon surgeries, which could be prevented by a targeted antimicrobial prophylaxis. – Research o A cohort study of patients who underwent to appendectomies and colon surgery. – Expected results o Identify the prevalence of fecal carriages of ESBL producer organisms o Describe the risk of acquired surgical site infection in fecal carriage of ESBL producer organisms. o Analyze the potential use of targeted antimicrobial prophylaxis in surgical procedures that involve the colon. – Conclusion o The prevention of surgical site infections constitutes a challenge in the daily medical practice. o The changing environment of the multidrug-resistant organism in the community imposes of a challenge for healthcare professionals, which should review its practices according to the new trends of antimicrobial resistance and the frequency of microbial colonization in the population.