Since the development of antibiotics in the 1940s, patients with an infection could be expected to respond quickly to antibiotic treatment prescribed by their doctor. While the antibiotic prescribing model has helped countless lives, this paradigm has broken down over time due to the emergence of antimicrobial resistance (AMR). The net impact is a global health crisis, compounded by the continued overprescription and misuse of antibiotics.
The more drugs a patient receives, the smarter the bacteria become to outsmart the antibiotic, rendering the drug ineffective. This RAM process has now become one of the leading causes of death in the world. AMR afflicts Americans alone at a rate of 2,800,000 million infections per year, and we now face a disaster of our own making.
While the medical community has long been aware of AMR and its growing potential impact, COVID-19 has exacerbated the alarming rates of AMR development around the world. A recent 2022 CDC Special Report describes the ramifications of the pandemic, emphasizing that antimicrobial resistance will now be the next global health crisis. At the height of the pandemic, antibiotics were aggressively prescribed to treat potential secondary infections in these critically ill COVID patients in an effort to reduce overall disease severity and mortality. We now know that these symptoms were directly indicative of COVID-19 and therefore antibiotics added little to the management of this aggressive viral illness. So too many COVID-19 patients have been given unnecessary antibiotics, opening the door for bacteria to become drug resistant.
To curb rising rates of antimicrobial resistance, we need to critically review the clinical settings where antibiotic overprescription and misuse are commonplace. Unfortunately, the hospital setting is one where patients are often exposed to too high or even unnecessary doses of antibiotics. A space in the hospital environment plays a major role in this dynamic: the operating room.
The operating room: where does the infection begin?
More than one million hospital-acquired infections (HAIs) occur each year in the United States healthcare system, that is, when a patient acquires an infection while receiving treatment for a medical condition or surgical. Digging deeper, studies show that one out of every 25 hospitalized patients develop an IASS, 44 percent which results from a surgical site infection (SSI). These infections can cause significant morbidity and mortality, claiming the lives of 40% of patients with an infection.
Due to 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 SSIs, as surgery is responsible with an average of 70 percent hospital revenue. The impact is compounded when considering the impact on reported quality measures and hospital readmission rates which are at a level all-time high. As science advances, we realize that the current practice of SSI antibiotic prophylaxis has significant limitations and risks, not the least of which is putting patients at risk of developing antimicrobial resistance. .
Systemic administration of antibiotics remains common in operating rooms and can lead to catastrophic outcomes, not only failing to prevent infections, but actively contributing to causing antimicrobial resistance. With systemic administration, patients receive high doses of antibiotics 30 to 60 minutes before surgery. However, drugs must first travel through the bloodstream before reaching the incision site, and studies show that an inconsistent and often small percentage of the drug reaches the surgical site. Additionally, surgical wound trauma further reduces systemic drug delivery to the wound site. As a result, the amount of antibiotics in the surgical wound decreases rapidly during and after surgery. However, as antibiotic levels decrease to nominal levels, bacterial contamination actually increases. The inability to eradicate the bacterial contamination present at the time of wound closure explains the presentation of SSI 4 to 10 days after the intervention.
This unmet need for antimicrobial prophylaxis has prompted renewed interest and research into wound decontamination alternatives, particularly local antibiotic delivery options. The goal of these novel drug delivery technologies allows the surgeon to directly apply the greatest amounts of antimicrobials to wound surfaces for continued management of wound contamination, but without significant systemic drug levels. . These prophylactic antimicrobials can provide continuous, consistent drug delivery for up to 30 days to significantly 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 complement or potentially replace age-old practices that contribute to loss of antibiotic efficacy due to antimicrobial resistance. As local drug delivery becomes commonplace in operating rooms across the country, we can alter the risk of drug resistance and expect reduced SSI rates and hospital readmissions that result in the United States. What’s most exciting is that these technologies make it possible to use existing antibiotics rather than waiting for new antibiotics to be developed – a cumbersome and expensive undertaking that can take a decade or more to bring to market. market.
To protect patients from unnecessary infections and systemic exposure to antimicrobials, clinicians now have the tools they need to keep patients safe. As RAM rates continue to rise, time is running out. As operating rooms across the country adopt these solutions, surgeons and healthcare teams can take an active role in the fight against antimicrobial resistance, protecting the lives of patients now and in the future.
Anthony J. Senagore is a colorectal surgeon.
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