Antimicrobial stewardship is becoming an increasing concern for nearly all clinical professionals. Antimicrobial resistance is often considered one of the most serious health threats of the 21st century. It is estimated that currently approximately 700,000 people die each year of drug-resistant infections,¹ and experts predict that this figure could increase to 10 million deaths each year by 2050.² On a global scale, antimicrobial resistance compromises the ability of clinicians to treat infectious diseases and thereby undermines many of the recent advances in modern medicine.

Antimicrobial Stewardship and Wound Care

Wound care represents one area of use for antibiotics and antimicrobials. Although all open wounds are colonized with bacteria, antibiotic therapy is required only for those wounds that are clinically infected.³ Antibiotic misuse in wound care occurs for many reasons, including diagnostic uncertainty concerning the presence of a bacterial infection, insufficient clinician knowledge about when antibiotics are necessary, clinicians' fear of achieving unfavorable patient outcomes, and patient demand.⁴ For these reasons, antimicrobial stewardship programs generally focus on the following four key strategies for antimicrobial use⁴:

1. Not prescribing antimicrobials when they are not indicated, such as for a non-infectious problem (i.e., a non-bacterial infection)
2. Prescribing the appropriate antimicrobial treatment when therapy is indicated
3. Ordering the appropriate antimicrobial duration, at an optimal dose, administered through the most appropriate route for the indicated condition and patient status
4. Using an agent that has the least risk for adverse effects for the patient and community

Antimicrobial stewardship programs also focus heavily on patient and clinician education concerning when antibiotics are necessary and when alternative treatment is a better option.

Advances in Antimicrobial Stewardship

In addition to increased education efforts, there have been many technological advances and clinical strategies that can help achieve the goals outlined in antimicrobial stewardship programs. Microbial stewardship can be especially difficult in wound care because infection is one of the most frequent complications encountered.

Alternative Therapies

Antibiotic administration is often inappropriate as part of a wound management treatment plan, and alternative therapies may be much more aligned with the care necessary. There is strong and growing evidence that antiseptic use for wound cleansing and for surgical skin preparation is not being given proper consideration by infection control and microbiology experts. Antiseptics can be powerful agents with huge potential in attempts to reduce antimicrobial resistance, particularly in the fields of wound care and surgical site management.⁴ In addition to antiseptics, a dressing treated with antiseptics can be a powerful ally in achieving the goals of antimicrobial stewardship programs. Silver is very effective because silver ions have broad-spectrum antimicrobial potential that can kill microorganisms such as bacteria, fungi, and viruses. Understanding when these dressings should be used can help wound care professionals be better antimicrobial stewards while still promoting positive patient outcomes.

Technological Tools

Technological tools can also serve as a strong ally in enhancing the ability of health care professionals to use antibiotics with greater discretion. Early identification of pathogens and of their antimicrobial susceptibility has been shown to have a tremendous effect on selecting the most appropriate treatment; however, traditional testing has usually taken 24 to 48 hours for pathogen identification.⁵ Within the last several years, there has been a marked improvement in the available techniques for pathogen identification, such as for susceptibility testing and DNA amplification assays.

There has also been the introduction of emerging technologies, such as matrix-assisted laser desorption/ionization-time of flight (MALDI-ToF) mass spectrometry, next-generation sequencing, and accelerated phenotypic methods, that can further assist with the identification of specimens.⁶ This information is crucial in making treatment decisions. These data can also be combined with emerging decision-making technologies that can further inform clinicians about the most appropriate treatment course. These tools are highly accurate and can also provide advanced data, such as future growth projections of the specimens with and without identified infection management interventions.⁶

The Role of Wound Care Professionals in Antimicrobial Stewardship

Wound care professionals are on the front lines in the quest to achieve better, more discretionary use of antibiotics to prevent the spread of drug-resistant infections. Increasing educational efforts and the ability to adequately apply the principles of antimicrobial stewardship (strategies for administration of antibiotics) will be increasingly essential for wound care clinicians. These professionals may also want to explore the ability to incorporate advanced tools and technologies to help inform treatment plans, whenever possible. These strategies will not only assist with the goal of enhanced antimicrobial stewardship, but will also often lead to better patient outcomes. Further, antimicrobial stewardship will reduce the risks associated with prescribing antibiotics to patients who do not truly need them.

References

1. McLeod M, Ahmad R, Shebl NA, Micallef C, Sim F, Holmes A. A whole-health-economy approach to antimicrobial stewardship: analysis of current models and future direction. PLoS Med. 2019;16(3):e1002774.

2. United Nations meeting on antimicrobial resistance. Bull World Health Organ. 2016;94(9):633-708.

3. Lipsky BA, Dryden M, Gottrup F, Nathwani D, Seaton RA, Stryja J. Antimicrobial stewardship in wound care: a position paper from the British Society for Antimicrobial Chemotherapy and European Wound Management Association. J Antimicrob Chemother. 2016;71(11):3026-3035.

4. Roberts CD, Leaper DJ, Assadian O. The role of topical antiseptic agents within antimicrobial stewardship strategies for prevention and treatment of surgical site and chronic open wound infection. Adv Wound Care (New Rochelle). 2017;6(2):63-71.

5. Maurer FP, Christner M, Hentschke M, Rohde H. Advances in rapid identification and susceptibility testing of bacteria in the clinical microbiology laboratory: Implications for patient care and antimicrobial stewardship programs. Infect Dis Rep. 2017;9(1):6893.

6. Muller M, Seidenberg R, Schuh SK, et al. The development and validation of different decision-making tools to predict urine culture growth out of urine flow cytometry parameter. PloS One. 2018;13(2):e0193255.