The following blog is adapted with permission from content originally appearing on the Wound Care Learning Network. For more information on the author and the original piece, click here.

Introduction

The discovery of antibiotics has been associated with extending the human lifespan by 23 years.¹ 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. The O'Neill report, commissioned by the UK prime minister in 2014 and released in 2016, predicted that without urgent action, antibiotic-resistant infection mortality would reach 10 million people per year by 2050.² The 2019 Centers for Disease Control and Prevention Antibiotic Resistance Threat Report found that over 2.8 million antibiotic-resistant infections occur in the United States each year, and more than 35,000 people die from these infections.³ This is especially concerning given the dearth of new antibiotics being released and indicates a clear need for systematic, targeted measures to promote the optimal use of antimicrobial agents. In wound care, as in other outpatient settings, antimicrobial stewardship aims to maximize clinical outcomes while minimizing the adverse outcomes of their use, including side effects, antimicrobial resistance, toxicity, and selection of pathogenic organisms.⁴ Most human antimicrobial use occurs in the outpatient setting, with over 260 million prescriptions annually.⁵ Most antibiotic courses are longer than recommended,⁶ including those prescribed for skin and soft tissue infections. This contributes to over 50 million excessive days of therapy per year^6,7 and makes the outpatient wound clinic a key environment for active implementation of antimicrobial stewardship.

How Can Wound Care Clinicians Help?

Wound care clinicians should educate themselves on diagnosing and treating organisms, and those that prescribe should follow proper recommendations. If using topical antibiotic ointments, clinicians should know why they are used and what organisms are being targeted. The use of topical antibiotic ointments can increase the amount of gram-negative bacteria in the wound bed8 and have been associated with allergic reactions that can cross over to oral and intravenous antibiotics in the same class.^9-11 Some topical antibiotic creams are associated with increased infection rates.^12-14 If you use a topical antibiotic ointment to maintain a moist environment, consider an antimicrobial hydrogel or non-antibiotic ointment. Clinicians should maximize clinical exams to improve diagnostic accuracy. Identifying conditions that mimic cellulitis and wound infection, like venous stasis dermatitis, deep vein thrombosis, pyoderma gangrenosum, and vasculitis, can decrease total antibiotic usage.

Patient Communication

Clinicians should also take the time to talk to patients about why they think the patient does not need an antibiotic and what would change with them or their wound that would make the clinician consider antibiotic use. Patients are not necessarily expecting antibiotics. One study found that 54% of prescribers thought patients expected an antibiotic prescription, but only 26% of patients did.¹⁵

Using Antimicrobials Versus Antibiotics

In addition, adhering to good wound management principles can decrease the need for antibiotics and antifungals. Wound cleansing products and dressings come with a host of antimicrobial options. Antimicrobials have a broader spectrum of activity than topical antibiotics. Some commercially available options can also be cytotoxic.¹⁶ For many antimicrobial products, the evidence for clinically meaningful cytotoxicity is not clear, but there are plenty of other products for wound care professionals to choose safely from where it is. Antimicrobials are an important intervention to kill, inhibit, or reduce the number of bacteria within a wound and decrease the need for topical, oral, and intravenous antibiotics.

Telemedicine and Technology

Antimicrobial stewardship can be assisted through the use of technology and telemedicine. With the multitude of methods available to reach patients, clinicians should feel increased comfort in following up with patients to delay or extend antibiotic courses based on necessity. This has the potential to reduce the number of antibiotic days prescribed substantially. Innovative point-of-care technology can also help differentiate between some microbial species at the bedside to guide antibiotic coverage, debridement, and culturing techniques. Antimicrobial stewardship at the systems level can involve projects to identify high-priority conditions where antibiotic usage is not optimally prescribed by tracking and reporting clinician antimicrobial prescription rates. This can be prescribing unnecessarily, too little, or not prescribing the correct antibiotic. Examine the issues to identify barriers that prevent providers from adhering to best practices. Providing individualized feedback to high prescribers of antibiotics and comparing their prescribing practices to their peers is effective.¹⁷

Conclusion

While hope remains for new antibiotics through research in under-explored environments and genome mining,¹ clinicians must be continually mindful of their role in preventing antimicrobial resistance. References

1. Hutchings MI, Truman AW, Wilkinson B. Antibiotics: past, present and future. Curr Opin Microbiol. 2019;51:72-80. doi:10.1016/j.mib.2019.10.008
2. O'Neill J. Tackling Drug-Resistant Infections Globally: Final Report and Recommendations. United Kingdom: Review on Antimicrobial Resistance; 2016.
3. Biggest threats and data. Centers for Disease Control and Prevention. https://www.cdc.gov/drugresistance/biggest-threats.html. Published March 2, 2021.
4. Society for Healthcare Epidemiology of America; Infectious Diseases Society of America; Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol. 2012;33(4):322-327. doi:10.1086/665010
5. Hicks LA, Bartoces MG, Roberts RM, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis. 2015;60(9):1308-1316. doi:10.1093/cid/civ076
6. Holubar M, Deresinski S. Antimicrobial stewardship in outpatient settings. Uptodate. https://www.uptodate.com/contents/antimicrobial-stewardship-in-outpatie….
7. King LM, Hersh AL, Hicks LA, Fleming-Dutra KE. Duration of outpatient antibiotic therapy for Common Outpatient Infections, 2017. Clin Infect Dis. 2020;72(10):e663-e666. doi:10.1093/cid/ciaa1404.
8. Bryant RA, Nix DP. Acute & Chronic Wounds: Current Management Concepts. 4th ed. Elsevier/Mosby; 2012.
9. Delves, PJ, Roitt, IM. Encyclopedia of Immunology. Academic Press; 1998.
10. Sasseville D. Neomycin. Dermatitis. 2010;21(1):3-7. doi: 10.2310/6620.2009.09073
11. Neomycin Sulfate. (2020). Contact Dermatitis Institute. https://www.contactdermatitisinstitute.com/neomycin-sulphate.php
12. Barajas-Nava LA, López-Alcalde J, Roqué i Figuls M, Solà I, Bonfill Cosp X. Antibiotic prophylaxis for preventing burn wound infection. Cochrane Database Syst Rev. 2013;(6):CD008738. doi:10.1002/14651858.CD008738.pub2
13. Nímia HH, Carvalho VF, Isaac C, Souza FÁ, Gemperli R, Paggiaro AO. Comparative study of Silver Sulfadiazine with other materials for healing and infection prevention in burns: A systematic review and meta-analysis. Burns. 2019;45(2):282-292. doi:10.1016/j.burns.2018.05.014
14. Nešporová K, Pavlík V, Šafránková B, et al. Effects of wound dressings containing silver on skin and immune cells [published correction appears in Sci Rep. 2021;11(1):4369]. Sci Rep. 2020;10(1):15216. doi:10.1038/s41598-020-72249-3
15. Francois Watkins LK, Sanchez GV, Albert AP, Roberts RM, Hicks LA. Knowledge and attitudes regarding antibiotic use among adult consumers, adult hispanic consumers, and health care providers--United States, 2012-2013. MMWR Morb Mortal Wkly Rep. 2015;64(28):767-770. doi:10.15585/mmwr.mm6428a5
16. Punjataewakupt A, Napavichayanun S, Aramwit P. The downside of antimicrobial agents for wound healing. Eur J Clin Microbiol Infect Dis. 2019;38(1):39-54. doi:10.1007/s10096-018-3393-5
17. Hallsworth M, Chadborn T, Sallis A, et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. Lancet. 2016;387(10029):1743-1752. doi:10.1016/S0140-6736(16)00215-4