Profile and impact of antimicrobial resistance related to surgical site infections after abdominal surgery in a resource-limited country: a prospective observational cohort study

Background Surgical site infections (SSIs) are a major threat of safe surgical care. A one-year prospective observational cohort study on SSIs after abdominal surgery is being conducted in our department of surgery; with the goal to figure out the incidence, root causes, outcomes, and surveillance. Considering the amount of antimicrobial resistance (AMR) in SSIs, we thought to study its profile and impact on outcomes; in order to guide SSIs management and antibiotic stewardship. Methods After 8 months of this prospective observational cohort study (February 1, 2024-September 31, 2024), all patients above 15 years-old who had undergone surgical intervention in abdominal (digestive and parietal) surgery were included. The variable of interest, for this study, was the occurrence of SSI as well as its clinical and bacteriological characteristics, the antibiotic resistance phenotype, and outcomes. The WHO Protocol for surgical site infection surveillance with focus on settings with limited resources is used to compile parameters. Results The study involved 328 patients; the incidence of SSIs was 17.9% (n = 59). The mean age of patients with SSIs was 51 years and the sex ratio was 1.1. The SSIs was Superficial incisional (SI) in 81.3% (n=48); Deep incisional (DI) in 8.4% (n=5) and Organ/space (OS) in 10.1 % (n=6). Bacteria were identified for 37 patients (62.7%), with 44 germs found. The most common bacteria were Enterobacteria in 81.8% (n=36) of cases with Escherichia coli in the lead (50% of 44), followed by Klebsiella pneumoniae (13.6% of 44) and Enterobacter Cloacae (9% of 44). Non-fermentative Gram-negative bacilli were noted in 7 patients (16%); with Pseudomonas aeruginosa in 5 patients. 95.4 % (42/44) of bacteria were found to have AR phenotype. The resistance phenotype within Enterobacteria was Extended-spectrum beta-lactamase (ESBL) in 50% of cases, followed by Hypersecretion of cephalosporinase (HCASE) in 11.3% and then Penicillinase (PASE) in 11.3%. Among the non-fermentative gram-negative bacilli, in particular for Pseudomonas aeruginosa, the Ceftacidim-Resistant phenotype was noted for all (100%). SSIs were treated by wound care for the most (86.4%, n=51). Antibiotics were indicated for 5 patients (8.4%),1 DI and 4 OS. Surgery was indicated for 3 patients (5%), 1 DI and 2 OS. Negative pressure therapy was indicated for 5 (8.4%), 2 DI and 3 OS. The overall mortality was 10.1% (n=6). The main cause of death was septic shock related blood stream contamination with Multidrug resistance (MDR) bacteria. Conclusion Enterobacteria were the most founded germs; with a predominantly ESBL resistance phenotype. SSIs and AMR are twin's threats. Antibiotics were not mandatory for SSIs treatment. In fact, SSIs contribute to occurrence of AMR phenotype and MDR bacteria. The main cause of death related to bloodstream nosocomial MDR infections, shows that SSIs increase the length of stay and the risk of nosocomial infection with MDR bacteria. In our context, improving surgical wound management, antibiotic stewardship, multidisciplinary collaboration, and multimodal prevention strategies will reduce SSIs and avoid AMR for a sustainable and safe surgical practice.