Data from hospitals in seven low- and middle-income countries (LMICs) show high levels of multidrug resistance (MDR) in surgical-site infections (SSIs), limited microbiologic testing capacity, and frequently ineffective prophylactic (preventive) antibiotics, researchers reported late last week in The Lancet Global Health.
The findings are from a secondary analysis of data from the FALCON trial, which evaluated the effectiveness of two interventions (2% alcohol chlorhexidine and triclosan-coated sutures) recommended by the World Health Organization for reducing SSIs following abdominal surgery. SSIs are one of the most common healthcare-associated infections globally, but patients in low-resource counties are disproportionately affected compared with those in higher-income nations.
For the study, an international team led by researchers from the University of Birmingham collected and analyzed wound swabs from abdominal-surgery patients recruited for the trial from seven LMICs—Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa. Their aim was to assess the antimicrobial susceptibility of documented SSIs in trial participants and the microbiologic capacity and antimicrobial practices of the facilities where surgery was performed.
"Although the development of AMR [antimicrobial resistance] is a natural phenomenon, the inappropriate use of antimicrobial drugs and poor infection prevention and control practices contribute to the emergence of and further spread of AMR alongside an accelerated progression into multidrug resistance," the study authors wrote.
Limited microbiologic testing capacity
Of the 5,788 patients recruited for the trial, 1,163 patients (22%) at 50 hospitals developed an SSI, but only 228 (19.6%) of 1,163 had a wound swab collected for microbiologic analysis. Of the 935 patients who did not have a wound swab collected, 195 were from hospitals that lacked the capacity to carry out microbiologic analysis and 740 were from hospitals that had the capacity but did not swab the SSI wound. In 75% of the cases in which wound swabs were collected, turnaround time for results was 48 hours or longer.
Among the 235 bacterial species cultured from 200 wound swabs that grew microorganisms, Escherichia coli was the most common species identified (37.9%), followed by Klebsiella pneumoniae (14%). MDR organisms were found in 102 (69.4%) of 147 SSI patients with available data.
Of the 235 microorganisms detected, only 33% were susceptible to the antibiotic used prior to surgery. The infecting pathogen was covered by the prophylactic antibiotic in 44.6% of the patients with SSIs caused by non-MDR organisms, but only 26.7% of those with SSIs caused by MDR organisms.
"Despite widespread use of prophylactic antibiotics, they were frequently ineffective, which is associated with a substantial increase in MDR organisms," the study authors wrote.
The researchers also found that only half of the hospitals that performed microbiologic testing had regular reviews by infection control teams, and more than a third had no reviews.
In an adjusted analysis, appropriate prophylactic antibiotic coverage (adjusted odds ratio [aOR], 0.43; 95% confidence interval [CI], 0.19 to 0.96) and regular availability of infection control teams [aOR, 0.32; 95% CI, 0.11 to 0.93] were associated with reduced MDR.
The authors say the systemic weaknesses they found in testing capacity, prophylactic antibiotic use, and infection control are associated with subsequent non-targeted antibiotic treatment for SSIs, which further contributes to the development of MDR infections. And these conditions, they add, are likely to be seen in most hospitals where surgery is performed in LMICs.
"There is a lack of targeted antibiotic use and proper testing for SSIs," study co-author Elizabeth Li, MBChB, PhD, of the University of Birmingham, said in a university press release. "Improving testing capacity, creating local guidelines, and having infection control teams could help to prevent SSIs and reduce MDR."
