Since the development of antibiotics in the 1940s, patients presenting with an infection could be expected to respond quickly to a prescribed course of antibiotics by their physician. While the antibiotic prescription model has helped countless lives, this paradigm has degraded over time due to the emergence of antimicrobial resistance (AMR). The net impact is a global health crisis, worsened by continuing the over-prescription and misuse of antibiotics.
The more drugs a patient is administered, the smarter bacteria become at outsmarting the antibiotic, rendering the drug ineffective. This process of AMR has now become a leading cause of death globally. AMR plagues Americans alone at a rate of 2,800,000 million cases of infection annually, and we are now facing a disaster of our own making.
While the medical community has long been aware of AMR and its potential growing impact, COVID-19 exacerbated the alarming rates of AMR developing worldwide. A recent CDC 2022 Special Report outlines the ramifications of the pandemic, highlighting that AMR will now be the next global health crisis. At the height of the pandemic, antibiotics were prescribed aggressively to address potential secondary infections in these critically ill COVID patients in an attempt to reduce overall illness severity and death. We now know that these symptoms were indicative of COVID-19 directly, and as a result, antibiotics added little to the management of this aggressive viral illness. Thus, too many COVID-19 patients were administered unnecessary antibiotics, opening the door for bacteria to become resistant to medication.
To curb the growing rates of AMR, we need to critically review clinical settings where over-prescription and antibiotic misuse are commonplace. Unfortunately, the hospital care setting is one in which patients are often exposed to antibiotic dosages that are too high and even unnecessary. One area within the hospital setting plays a large role in this dynamic: the operating room (OR).
The OR: Where infection begins?
More than one million hospital-acquired infections (HAI) occur across the United States health care system every year, this is when a patient gets an infection while receiving treatment for a medical or surgical condition. Digging deeper, studies show that one out of every 25 hospitalized patients develops an HAI, 44 percent of which results from surgical site infection (SSI). These infections can lead to significant morbidity and mortality, taking the lives of 40 percent of patients battling infection.
Because of the successful reduction in rates of catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI), hospitals must turn aggressively to reduce SSI because surgery is responsible for an average of 70 percent of a hospital’s revenue. The impact is worsened when one considers the impact on reported quality measures and hospital readmission rates which are at an all-time high. As science advances, we realize that the current practice of antibiotic SSI prophylaxis has important limitations and risks, not the least of which is exposing patients to the risk of developing antimicrobial resistance.
Systemic antibiotic administration remains commonplace in ORs and can lead to catastrophic outcomes, not only failing to prevent infections but actively contributing to causing antimicrobial resistance. With systemic administration, patients are administered high doses of antibiotics 30-60 minutes before surgery. However, the drugs must first circulate in the bloodstream before reaching the incision site, and studies show that an inconsistent and often small percentage of the drug reaches the surgical site. Moreover, surgical wound trauma further reduces the delivery of systemic drugs to the wound site. As a result, the amount of antibiotics in the surgical wound rapidly decreases during and after the surgical procedure. However, during the time the antibiotic levels decrease to nominal levels, the bacterial contamination is actually increasing. The inability to eradicate the bacterial contamination present at the time of wound closure accounts for the presentation of SSI 4 to 10 days after the procedure.
This unmet need in antimicrobial prophylaxis has led to renewed interest and investigation into alternatives for wound decontamination, especially local antibiotic delivery options. The goal of these new drug delivery technologies allows the surgeon to directly apply the higher amounts of antimicrobial to the wound surfaces for continued management of the wound contamination but without significant systemic drug levels. These prophylactic antimicrobials can provide continued constant drug delivery for up to 30 days to dramatically increase the duration of bacterial reduction beyond the current 24 hours, which should significantly reduce SSI rates.
New local drug delivery technologies will begin to supplement or potentially replace age-old practices that contribute to the loss of efficacy of antibiotics due to AMR. As local drug administration delivery becomes commonplace in ORs across the country, we can change the risk of drug resistance and expect to see a reduction in the rates of SSIs and the resulting hospital readmissions in the United States. What is most exciting is that such technologies allow for the use of existing antibiotics rather than waiting for new antibiotics to be developed – a hefty and expensive endeavor that can take a decade if not more to bring to market.
To protect patients from unnecessary infection and systemic antimicrobial exposure, clinicians now have the tools to keep patients safe. As AMR rates continue to rise, time is of the essence. As ORs across the country embrace these solutions, surgeons and care teams can take an active role in curbing AMR, protecting the lives of patients now and in the future.
Anthony J. Senagore is a colorectal surgeon.
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