Third generation cephalosporin resistance in Rwandan surgical patients

Author(s):
Christophe Mpirimbanyi; Tori Sutherland; Claude Muvunyi; Jennifer Rickard; Elisabeth Riviello

Background:Antimicrobial resistance (AMR) is a significant barrier to effective treatment of infections across the globe. The World Health Organization has listed carbapenem and third generation cephalosporin resistance (3GCR) as areas of “critical priority”. The goal of this study was to determine the prevalence and types of AMR in surgical patients at a tertiary referral hospital in Rwanda.

Hypothesis:We hypothesized that 3GCR was common in Rwandan surgical patients and associated with increased mortality and prolonged length of stay.

Methods:Over a 6-month period (February – August 2017), samples were collected from all adult patients with an infection. We defined infection as any patient with temperature greater than 38 degrees Celsius or any patient undergoing operation for a suspected infectious process. Blood, tracheal aspirate, urine, and wound swabs were collected based on suspected etiology. All specimens were processed in the hospital microbiology lab. Data were collected on demographics, clinical presentation, operation, hospital course, microbiology, AMR, and in-hospital mortality.

Results:Over a 6-month period, we collected 54 surgical specimens. The mean patient age was 36 years, and 73% were female. Seven (13%) patients were positive for human immunodeficiency virus (HIV) infection. Most patients were transferred from another facility (n=37, 82%), underwent operation within the preceding 30 days (n=42, 78%), and received antibiotics within the preceding 30 days (n= 37, 82%). The most common diagnoses were obstetric complications (n=35, 65%) and necrotizing soft tissue infections (n=8, 15%). The most common operation was laparotomy (n=30, 56%). Most (n=37, 69%) patients were initially treated with ceftriaxone and metronidazole. In-hospital mortality was 7% (n=3) and median length of hospital stay was 17 days (Interquartile range: 9-34).

Of the surgical specimens, 24 (53%) were culture positive. The organisms most commonly isolated included Escherichia coli (n=12) and Klebsiella sp (n=5). Thirteen (54%) isolates had 3GCR. One (5%) isolate was resistant to carbapenems. Of patients with 3GCR, 11 (85%) had empirically received ceftriaxone and 5 (38%) had antibiotics changed based on culture results. In patients with 3GCR versus sensitive isolates, there was no difference in mortality; however, median length of hospital stay for survivors was significantly longer (25 versus 9 days, p=0.0264).

Conclusions:We found a high rate of 3GCR in surgical patients at a referral hospital in Rwanda with antibiotics infrequently changed based on culture results. Patients with 3GCR had prolonged hospital stay.