Intra-Abdominal Infections by Carbapenemase-Producing Enterobacteriaceae in a Surgical Unit: Counting Mortality, Stay, and Costs

Prolonged antibiotic prophylaxis after pancreatoduodenectomy: systematic review and meta-analysis

BACKGROUND

Previous studies have reported conflicting results of prolonged antibiotic prophylaxis on infectious complications after pancreatoduodenectomy. This study evaluated the effect of prolonged antibiotics on surgical-site infections (SSIs) after pancreatoduodenectomy.

METHODS

A systematic review and meta-analysis was undertaken of SSIs in patients with perioperative (within 24 h) versus prolonged antibiotic (over 24 h) prophylaxis after pancreatoduodenectomy. SSIs were classified as organ/space infections or superficial SSI within 30 days after surgery. ORs were calculated using a Mantel-Haenszel fixed-effect model.

RESULTS

Ten studies were included in the qualitative analysis, of which 8 reporting on 1170 patients were included in the quantitative analysis. The duration of prolonged antibiotic prophylaxis varied between 2 and 10 days after surgery. Four studies reporting on 782 patients showed comparable organ/space infection rates in patients receiving perioperative and prolonged antibiotics (OR 1.35, 95 per cent c.i. 0.94 to 1.93). However, among patients with preoperative biliary drainage (5 studies reporting on 577 patients), organ/space infection rates were lower with prolonged compared with perioperative antibiotics (OR 2.09, 1.43 to 3.07). Three studies (633 patients) demonstrated comparable superficial SSI rates between patients receiving perioperative versus prolonged prophylaxis (OR 1.54, 0.97 to 2.44), as well as in patients with preoperative biliary drainage in 4 studies reporting on 431 patients (OR 1.60, 0.89 to 2.88).

CONCLUSION

Prolonged antibiotic prophylaxis is associated with fewer organ/space infection in patients who undergo preoperative biliary drainage. However, the optimal duration of antibiotic prophylaxis after pancreatoduodenectomy remains to be determined and warrants confirmation in an RCT.

Carbapenem-resistant gram-negative bacteria in Germany: incidence and distribution among specific infections and mortality: an epidemiological analysis using real-world data

PURPOSE

Infections with carbapenem-resistant gram-negative bacteria (in Germany classified as 4MRGN) are a growing threat in clinical care. This study was undertaken to understand the overall burden of 4MRGN infections in Germany in the context of a Health Technology Appraisal (HTA) for Ceftazidime/Avibactam (CAZ/AVI). Besides, the incidences mortality was an endpoint of interest.

METHODS

To assess infections with carbapenem-resistant gram-negative bacteria and related mortality, three different data sources have been used. From the German statistics office (DESTATIS) data have been retrieved to obtain the overall frequency these pathogens. Via two other databases, the German analysis database (DADB) and a Benchmarking of > 200 hospitals in a representative sample (BM-DB), the distribution of the infections and the mortality have been analyzed.

RESULTS

DESTATIS data showed a total of 11,863 carbapenem-resistant gram-negative bacteria codings, of which 10,348 represent infections and 1515 carriers. The most frequent infections were complicated urinary tract infections (cUTI) (n = 2,337), followed by pneumonia (n = 1006) and intra-abdominal infections (n = 730). A considerable amount of patients had multiple infections in one hospital episode (n = 1258). In-hospital mortality was 18.6% in DADB and 14.3% in the BM-DB population, respectively. In cases with additional bloodstream infections, DADB mortality was correspondingly higher at 33.0%. DADB data showed an incremental mortality increase of 5.7% after 30 days and 10.0% after 90 days resulting in a cumulative 90 day mortality of 34.3%.

CONCLUSIONS

Infections with carbapenem-resistant gram-negative bacteria are still rare (6.8-12.4 per 100,000) but show a significant increase in mortality compared to infections with more sensitive pathogens. Using different data sources allowed obtaining a realistic picture.

Mortality-Related Risk Factors and Novel Antimicrobial Regimens for Carbapenem-Resistant Enterobacteriaceae Infections: A Systematic Review

OBJECTIVE

Carbapenem-resistant Enterobacteriaceae (CRE) has become a significant public health problem in the last decade. We aimed to explore the risk factors of mortality in patients with CRE infections and to focus on the current evidence on antimicrobial regimens for CRE infections, particularly from the perspective of mortality.

METHODS

A systematic literature review was performed by searching the databases of EMBASE, PubMed, and the Cochrane Library to identify studies that evaluated mortality-related risk factors and antimicrobial regimens for CRE infections published from 2012 to 2022.

RESULTS

In total, 33 and 28 studies were included to analyze risk factors and antibiotic treatment, respectively. The risk factors most frequently reported as significantly associated with CRE mortality were antibiotic use (92.9%; 26/28 studies), comorbidities (88.7%; 23/26 studies), and hospital-related factors (82.8%; 24/29 studies). In 10 studies that did not contain ceftazidime/avibactam (CAZ-AVI) therapy, seven demonstrated significantly lower mortality in combination therapy than in monotherapy. However, 5 of 6 studies identified no substantial difference between CAZ-AVI monotherapy and CAZ-AVI combination therapy. Six studies reported substantially lower mortality in CAZ-AVI regimens than in other regimens.

CONCLUSION

Several risk factors, particularly antibiotic use and patients' comorbidities, are strong risk factors for CRE mortality. The optimal regimen for CRE infections remains controversial. Combination therapy should be considered when carbapenems, colistin, tigecycline, or aminoglycosides are administered. CAZ-AVI appears to be a promising antibiotic for CRE infections. Most importantly, treatment should be individualized according to the source and severity of the disease or other highly related risk factors.

[Infections by OXA-48 carbapenemase-producing Enterobacteriaceae in surgical patients: antibiotic consumption and susceptibility patterns]

Objetivos

Analizar la administración de antibióticos, la evolución temporal de sensibilidades y el tratamiento dirigido de las infecciones asociadas a enterobacterias productoras de carbapenemasas (EPC) OXA-48 en un servicio de Cirugía General y Digestivo.

Material y métodos

Estudio observacional retrospectivo, incluyendo pacientes con cultivo positivo de OXA-48 y datos clínicos de infección activa, hospitalizados en un servicio de Cirugía General y Digestivo entre enero 2013 y diciembre 2018.

Resultados

Se incluyeron 65 pacientes, con 66 aislamientos de OXA-48: Klebsiella pneumoniae, 57 (86,5%); Enterobacter cloacae, 5 (7,6%); Escherichia coli, 3 (4,5%); Morganella morganii, 1 (1,5%). La infección intraabdominal fue la más común (n=39, 60%), y el consumo previo de antibióticos fue: piperacilina-tazobactam (48%), meropenem (45%), ciprofloxacino (25,5%), ertapenem (16,5%), imipenem (12%), amikacina (12%), tigeciclina (12%). La evolución temporal (2013/14, 2015/16 y 2017/18) de las sensibilidades (porcentajes) según antibiograma fue: ceftazidima-avibactam X-X-100; amikacina 100-96-84 (p=0,518); tigeciclina 100-92-80 (p=0,437); colistina 100-67-66 (p<0,001); meropenem 37-64-72 (p=0,214); imipenem 51-41-77 (p=0,109); gentamicina 13-19-18 (p=0,879); ertapenem 35-0-0 (p<0,001). El tratamiento dirigido tuvo una mediana de duración de 14 [RIQ 9-20] días, destacando en frecuencia: tigeciclina (57%); meropenem (40,5%); amikacina (37,5%); ceftazidima-avibactam (9%); imipenem (7,5%); colistina (7,5%). La mortalidad global a 30 días fue del 12% (8 individuos). El tratamiento dirigido fue adecuado según antibiograma en el 87,7%, utilizando un régimen de terapia combinada en el 76,9%, régimen que incluyó algún carbapenémico en el 49,2%.

Conclusiones

En Cirugía General y Digestivo destaca la infección intraabdominal asociada a OXA-48, con elevado consumo previo de antibióticos de amplio espectro. El tratamiento dirigido con mayor sensibilidad de cepas productoras de OXA-48 incluye ceftazidima-avibactam, amikacina, tigeciclina, meropenem e imipenem.