American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Antibiotic stewardship: Careful use today will save patients tomorrow

OCTOBER 23, 2017
Clinical Congress Daily Highlights, Monday First Edition

When it comes to antibiotic resistance, doing what’s right for the patient means thinking about future patients, too. Although an extended course of antibiotics may offer peace of mind to doctor and patient in one case, over time it can lead to the loss of antibiotic effectiveness, which profoundly impacts the practice of surgery.

Antibiotic resistance limits the efficacy of antibiotic prophylaxis, thereby leading to worse outcomes in surgical patients. A 30 percent reduction in the efficacy of antibiotic prophylaxis would result in 120,000 additional infections per year in the United States.

That’s why it is crucial to give the right antibiotic at the right time, in the right dose and for the right duration, said John Mazuski, MD, PhD, FACS, Washington University in St. Louis, MO. Dr. Mazuski spoke during a Monday panel on antibiotic stewardship.

Antibiotics are meant to maximize the outcome for the patient and minimize unintended consequences such as toxicity, pathogenic organisms such as Clostridium difficile, and resistant organisms such as MRSA, according to panel moderator Kamal M.F. Itani, MD, FACS, Boston University, MA. In addition, he said that antibiotic stewardship reduces health care costs. It is also is an important patient safety issue.

Good antibiotic stewardship requires measuring the quantity of drugs used, the number of days of therapy, and cost of therapy, said David C. Borgstrom, MD, FACS, West Virginia University, Morgantown, WV. He said his institution has a multidisciplinary team that reviews days of therapy, resistance and use, keeps a list of restricted drugs and gives post-prescription review and feedback.

Resistance is a significant problem that promises to grow, said Robert G. Sawyer, MD, FACS, University of Virginia, Charlottesville. By 2050, deaths due to resistance may total 317,000 in North America, 390,000 in Europe, and up to 4.15 million in Africa and 4.73 million in Asia, due to such practices as using antibiotics in livestock feed, he said. The overall cost of resistance could potentially hit $100 trillion.

Costs can be reduced by aggressive and early source control, using the narrowest-spectrum agent against the identified pathogen, using older class or generic agents when indicated, avoiding the use of redundant antibiotics, and curtailing the duration of therapy after antibiotics have adequately decreased the pathogen burden.

But there are also consequences to inadequate antibiotic use, including increased risk of mortality and treatment failure in individual patients, especially those who are critically ill with conditions, such as septic shock, Dr. Mazuski said. Inadequate use can also increase development of bacterial resistance in the institution, he said.

Surgeons should carefully select broad-spectrum empiric therapy based on local epidemiology; refrain from using combination therapy in most patients who don’t have risk factors for MDR pathogens; and use de-escalation and short duration whenever possible, Dr. Mazuski said.

Too often, surgeon decisions about how to treat infection get short shrift, said Philip S. Barie, MD, Master CCM, FIDSA, FACS, Cornell University, Ithaca, NY. He cited a recent call to action that urges all who prescribe antibiotics to participate in the process, with surgeons playing a major role and practicing judicious antibiotic administration. If surgeons do not exhibit better stewardship, he said, there may soon come a time when they no longer have the autonomy to prescribe antibiotics.

The future of antibiotics stewardship will feature rapid diagnostic tests to identify the pathogen quickly at the patient’s bedside, enabling better decision making about which antibiotic to use, when to use it, when to escalate its use and when to de-escalate it, said Pamela A. Lipsett, MD, MHPE, FACS, MCCM, Johns Hopkins University, Baltimore, MD. Whole genome sequencing may help identify patients with resistant genes, measure the antibiotic’s level of toxicity and determine pathogen virulence. Advances in the study of the microbiome will also bring advances in preventing infection, she said.

Additional Information:
The Panel Session, Antibiotic Stewardship: The Key to Avoiding the Loss of Effective Antibiotics in Surgery: Part I, was held October 23, at the 2017 Clinical Congress of the American College of Surgeons in San Diego, CA. Program, webcast and audio information is available online at FACS.org/clincon2017.

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