Be a champion to stop infections in surgery

Antimicrobial resistance (AMR) has emerged as one of the principal public health problems of the 21st century. This has resulted in a public health crisis of international concern, which threatens the practice of modern medicine, animal health and food security. The increase in AMR has been dramatic, and combating this growth is a top priority for global policy and public health. Antibacterial and antifungal use in animal and agricultural industries aggravates selective pressure on microbes. A One Health approach is urgently required.
New AMR mechanisms emerge and spread globally threatening our ability to treat common infections [1].
The burden of AMR is difficult to quantify in some regions of the world because enhanced surveillance requires personnel, equipment and financial resources that are not always available.
The global nature of AMR calls for a global response, both in the geographic sense and across the whole range of sectors involved.
No single country can protect itself from multidrug resistant organisms (MDROs) imported through travel and trade.
The impact of AMR worldwide is significant, both in economic terms, and clinical morbidity and mortality because it may:

  • lead to some infections becoming untreatable or requiring antibiotics of last resort when the treatment is mandatory;
  • increase length of hospital stay, morbidity, mortality and cost.

The World Health Organization (WHO) is now leading a global effort to address antimicrobial resistance. At the 68th World Health Assembly in May 2015, the World Health Assembly endorsed a global action plan to tackle antimicrobial resistance [2]. It sets out five strategic objectives:

  • to improve awareness and understanding of antimicrobial resistance;
  • to strengthen knowledge through surveillance and research;
  • to reduce the incidence of infection;
  • to optimize the use of antimicrobial agents; and
  • to develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions.

In 2017 a global declaration for appropriate use of antimicrobials across the surgical pathway was shared by over 230 experts from 83 different countries [1]. Within this declaration, the authors highlighted the effects of antibiotic exposure, misuse, and overuse on antibiotic resistance and outlined the fundamental principles of appropriate antibiotic prophylaxis and therapy in surgery.

Not specifically highlighted in their declaration but of significant importance in limiting antibiotic exposure are efforts to prevent hospital-acquired infections. Prevention of hospital-acquired infections can limit significantly the need for antibiotic therapy [3]. HAIs including surgical site infections (SSIs), hospital and ventilator-associated pneumonia, central line-associated bloodstream infections, and catheter-associated urinary tract infections are the most common nosocomial infections. Healthcare-associated infections continue to be of significant importance in surgical patients.

SSIs is a major clinical problem in terms of morbidity, mortality, length of hospital stay and overall direct and indirect costs globally [4-5]. However, knowledge, attitude, and awareness of infection prevention and control measures vary significantly among surgeons. Most significantly, a gap seems to exist between best evidence and clinical practice with regards to SSIs prevention.
In November  2016 World Health Organization (WHO) launched its evidence-based global guidelines [6] on the prevention of SSIs with the dual aim of providing guidance on a wide range of issues that influence infection risk and to overcome some inconsistencies in the interpretation of evidence and recommendations in existing national  guidelines. Importantly, these guidelines have been developed to be valid for any country and amenable to local adaptation. They take account of the strength of available scientific evidence, cost and resource implications, as well as patient values and preferences.
In 2017, updated evidence-based recommendations from the United States Centers for Diseases Control and Prevention (CDC) were also issued and deal with similar topics [7].
Despite clear evidence and guidelines to direct SSIs prevention strategies, compliance is unacceptably poor.
Recently WHO has published a new document on implementation approaches for preventing the surgical site infections from a global perspective [8].
The purpose of this document is to present a range of tested approaches to achieve successful SSIs prevention implementation at the facility level, including in the context of a broader surgical safety climate.

Preoperative antibiotic prophylaxis (AP) is a cornerstone of SSIs prevention. The use of AP contributes considerably to the total amount of antibiotics used in hospitals worldwide. AP has been shown to be an effective measure for the prevention of SSIs, but its use should be limited to specific, well-accepted indications to avoid cost, toxicity, and antimicrobial resistance, and should never substitute for good medical practice of infection prevention and control. Guidelines stress the importance of cessation of antibiotic prophylaxis immediately after surgery, and refrain from extension of prophylaxis outside the operating theater [6]. High rates of inappropriate use of prophylactic antibiotics in surgery continue to be reported in the literature.

Antibiotic therapy is an additional key component of daily surgical practice. Antibiotics are life-saving when treating bacterial infections but are often used inappropriately, specifically when not indicated. Antibiotic therapy plays an integral role in the management of surgical infections, especially in critically-ill patients who require immediate empiric antibiotic therapy. Poor antibiotic coverage and inappropriate regimen are the variables most strongly associated with unfavorable outcomes [1]. The timing, regimen, dose, route of administration and duration of antibiotic therapy should be always optimized. In most patients with surgical infections antibiotic therapy aims to treat any residual infection after adequate source control. In these patients prolonging antibiotic treatment, which can lead to antibiotic resistance, does not prevent the persistence or recurrence of the infection. When source control is obtained, the duration of antibiotic therapy should be shortened as much as possible, unless there are special circumstances that require prolonging antimicrobial therapy, such as signs of an ongoing infection. Patients who have systemic signs of sepsis beyond 5 to 7 days of treatment warrant diagnostic investigation to determine an ongoing uncontrolled source of infection needing intervention [1].

Raising awareness of AMR by education and dissemination of information to stakeholders is an important factor in changing behaviors. Although efforts must be aimed at the general public, healthcare professionals, food producing farmers, civil society organizations and policy makers, healthcare workers play a central role in preventing the emergence and spread of resistance.

An effective and cost-effective strategy to reduce AMR should involve a multi-faceted approach aimed at optimizing antibiotic use, strengthening surveillance and infection prevention and control, and improving clinician education regarding appropriate prevention and management of infections in surgery.

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References

  1. A Global Declaration on Appropriate Use of Antimicrobial Agents across the Surgical Pathway. Surg Infect (Larchmt). 2017 Nov/Dec;18(8):846-853.
  2. World Health Organization (WHO). Global action plan on antimicrobial resistance. http://apps.who.int/iris/bitstream/10665/193736/1/9789241509763_eng.pdf?ua=1.
  3. Itani KMF, May AK. Surgical Infection Society: We Endorse Antimicrobial Stewardship We Stand by Our International Colleagues and Societies in the Fight for Proper Antimicrobial Therapy. Surg Infect (Larchmt). 2017 Nov/Dec;18(8):843-845.
  4. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, Keohane C, Denham CR, Bates DW. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013 Dec 9-23;173(22):2039-46.
  5. GlobalSurg Collaborative. Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study. Lancet Infect Dis. 2018 May;18(5):516-525.
  6. Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, de Vries F, Gomes SM, Gans S, Wallert ED, Wu X, Abbas M, Boermeester MA, Dellinger EP, Egger M, Gastmeier P, Guirao X, Ren J, Pittet D, Solomkin JS; WHO Guidelines Development Group. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016 Dec;16(12):e288-e303.
  7. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Segreti J, Parvizi J, Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP; Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017 Aug 1;152(8):784-791.
  8. Preventing surgical site infections: implementation approaches for evidence-based recommendations. http://apps.who.int/iris/handle/10665/273154