Antimicrobial Stewardship

Treatment of chronic and complex wounds complicated by biofilm formed by pathogens remains a tremendous challenge for the health care industry. Recent increases in infections mediated by drug-resistant bacterial and fungal pathogens highlight the need for new antimicrobial therapies. The application of topical agents with antimicrobial and antiseptic properties is gaining traction as an alternative to antibiotic prescriptions.

Wound healing is often accompanied by bacterial infection. Many clinicians use antibiotics to treat wound infections. However, the overreliance on antibiotics is becoming an increasing concern for many global health organizations because it contributes to widespread antibiotic resistance. Excessive use of synthetic antibiotics leads to drug resistance, which poses a substantial threat to human health.

Antibiotics have been a source of increasing concern and subsequent regulation among providers, especially those within wound care. Antimicrobial stewardship has been emphasized within the medical system in recent years as antibiotic-resistant organisms have increased globally and among at-risk patient populations.

Antibiotic resistance is considered a significant public health concern by multiple international organizations. The US Centers for Disease Control and Prevention estimate that approximately 35,000 deaths occur in the United States each year related to antibiotic resistance. Moreover, the agency predicts that millions more deaths will occur in the coming decades. By 2050, it is estimated that the number of deaths resulting from drug-resistant infections will surpass 10 million, which equates to one person dying every three seconds. The total global cost to economic output related to these deaths is estimated at US $100 trillion.

The discovery of antibiotics has been associated with extending the human lifespan by 23 years. This phenomenon began in the 1900s and peaked in the 1950s, known as the "golden era" of antibiotics due to the rapid release of new antibiotic classes coupled with limited resistance. However, the gradual increase in antimicrobial resistance and associated infectious disease morbidity and mortality threatens to return the world to a post-antibiotic state where routine surgeries and minor infections become life-threatening.

Centuries ago, science took a back seat to superstition. Infectious diseases were seen as a sign of supernatural powers or the wrath of God. We now know that it was smallpox that led to the downfall of the Aztecs. We also know that bubonic plague was not a divine punishment, but it was caused by bacteria transmitted by fleas on rodents traveling on trading ships.

Antibiotic resistance is a growing health threat, not just in the United States, but throughout the world. Health care professionals are facing problems with antibiotic resistance, as well as with resistance to other antimicrobial agents. The Centers for Disease Control and Prevention (CDC) noted in 2019 that “more than 2.8 million antibiotic-resistant infections occur in the United States (US) each year, and more than 35,000 people die as a result.” The CDC lists 18 current threats, with three on the watch list as emerging causes of antibiotic resistance. Many of the bacteria on this threat list are found in chronically stalled wounds. Therefore, wound clinicians must be good stewards of antimicrobial treatments to prevent contributing to an already worsening problem.

Antimicrobial resistance is one of the greatest health threats of the 21st century. The current number of deaths attributed to drug-resistant infections is 700,000, yet this figure is expected to grow more than 10-fold by 2050. Although the rapid administration of antibiotics to treat infections often reduces morbidity and saves the lives of many patients each year, it has also been shown that up to 40% of all antibiotics prescribed are either unnecessary or inappropriate, which contributes to the growing problem of antibiotic resistance.

On the surface, topical antibiotics may appear to be a safe choice for some wounds, even some infected wounds, when compared to oral or intravenous options. A seemingly less dangerous adverse effect profile, less invasive nature, and potential for cost-effectiveness are logical, appealing features of topical antibiotics. However, a closer look reveals that the choice is not that simple, and, in fact, clinicians must take several points into consideration.

by the WoundSource Editors Advancements in molecular microbiology, microscopy technology, and techniques for study of bacteria have increased the ability to identify the existence of biofilms, but there still remains the unknown, such as differentiating between planktonic bacteria and biofilm.1 Chronic non-healing wounds harbor bacteria across the wound etiology classification.2–4 Malone et al. determined that the prevalence of biofilms in chronic wounds was 78.2% (confidence interval, 61.6–89, P < 0.002).2 The development of biofilms moves through a common pattern: attachment, microcolony formation, maturation, and dispersion. The initial attachment is reversible, but the attachment becomes stronger as cells multiply and change their gene expressions. This cell communication process is referred to as quorum sensing, allowing cells to survive.