Gupta Neha, Sohanlal T, Soman Rajeev, Shetty Anjali, Rodrigues Camilla
PD Hinduja National Hospital & Medical Research Center, Veer Savarkar Marg, Mahim, Mumbai 400016, India.
J Assoc Physicians India. 2011 May;59:293-5.
In India, there is a high prevalence of ESBL producing organisms among intraabdominal isolates and in stool flora of 'normal' individuals. Hence, it may be presumed that unless antimicrobial therapy effective for ESBL flora is used perioperatively for abdominal surgery, the outcome will be adverse. We selected patients surgically treated for appendicitis as a model to explore the relevance of ESBL producing isolates in this retrospective observational study.
To assess the impact of ESBL producing isolates in patients surgically treated for acute appendicitis and to determine whether the perioperative antibiotic use needs to be changed in view of the high ESBL prevalence.
Chart review of 221 consecutive patients who had undergone appendicectomy between January 2004 and December 2009.
55 of 221 patients had cultures of relevant specimens done based on the discretion of the treating surgeon. 40 yielded 1 or more organisms. 19 showed ESBL producing Enterobacteriaceae (ESBL+) and 21 showed non ESBL producing Enterobacteriaceae (ESBL-). 118 of 221 patients had presented without any complications and had a good outcome after surgery. The other 33 of 221 patients had complications like perforation or an abscess at presentation. Out of these, 16 patients received inappropriate therapy and 17 received appropriate therapy. The patients with appropriate therapy had good outcome. Among the 16 patients with inappropriate therapy 15 were ESBL+and 1 was ESBL-. Out of the 15 ESBL+isolates, 9 developed an initial postoperative complication like postoperative fever or wound infection. The cultures of the relevant specimen were done in all these 9 patients, all of which were positive. Therapy was changed in 7 of these 9 patients to pathogen directed therapy like amikacin, chloramphenicol and levofloxacin. Meropenem was used in only one case. All these 7 patients as well as the 2 patients whose treatment was not changed made a complete recovery.
For patients surgically treated for acute appendicitis, a change of perioperative antibiotics to those effective for ESBL+organisms is not needed at present only on the basis of ESBL prevalence rates. Routine cultures may not be necessary. Cultures are needed if there is a complication such as an abscess or perforation at presentation or an initial post operative complication. A change to pathogen directed therapy, including even to older or non beta-lactam antimicrobials may be needed in these cases. Our results support continuing the use of older antimicrobials rather than changing to carbapenems and beta-lactamase-beta-lactamase inhibitor combination in low risk surgically treated patients. This may prevent generation of further resistance without compromising outcomes.
在印度，产超广谱β-内酰胺酶（ESBL）的微生物在腹腔内分离菌株以及“正常”个体的粪便菌群中普遍存在。因此，可以推测，除非在腹部手术围手术期使用对产ESBL菌群有效的抗菌治疗，否则结果将是不利的。在这项回顾性观察研究中，我们选择接受阑尾炎手术治疗的患者作为模型，以探讨产ESBL分离株的相关性。
评估产ESBL分离株对接受急性阑尾炎手术治疗患者的影响，并确定鉴于ESBL的高流行率围手术期抗生素的使用是否需要改变。
对2004年1月至2009年12月期间连续接受阑尾切除术的221例患者进行病历审查。
221例患者中有55例根据主治外科医生的判断进行了相关标本培养。40例培养出1种或更多种微生物。19例显示产ESBL的肠杆菌科细菌（ESBL+），21例显示非产ESBL的肠杆菌科细菌（ESBL-）。221例患者中有118例就诊时无任何并发症，术后恢复良好。221例患者中的其他33例就诊时出现穿孔或脓肿等并发症。其中，16例患者接受了不适当的治疗，17例接受了适当的治疗。接受适当治疗的患者预后良好。在16例接受不适当治疗的患者中，15例为ESBL+，1例为ESBL-。在15株ESBL+分离株中，9例出现术后早期并发症，如术后发热或伤口感染。所有这9例患者均进行了相关标本培养，结果均为阳性。这9例患者中有7例改为针对病原体的治疗，如阿米卡星、氯霉素和左氧氟沙星。仅1例使用了美罗培南。这7例患者以及治疗未改变的2例患者均完全康复。
对于接受急性阑尾炎手术治疗的患者，目前仅根据ESBL流行率不需要将围手术期抗生素改为对ESBL+微生物有效的抗生素。可能不需要常规培养。如果就诊时出现脓肿或穿孔等并发症或术后早期并发症，则需要进行培养。在这些情况下，可能需要改为针对病原体的治疗，甚至包括使用较老的或非β-内酰胺类抗菌药物。我们的结果支持在低风险手术治疗患者中继续使用较老的抗菌药物，而不是改为碳青霉烯类和β-内酰胺酶-β-内酰胺酶抑制剂联合用药。这可能在不影响治疗效果的情况下防止产生进一步的耐药性。
