Antimicrobial Challenge in Acute Care Surgery

Abstract

The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients’ morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.

Antibiotic Stewardship in Surgical Departments

“…In the study by Sawyer et al, it was proven that the outcomes in patients with intra-abdominal infections where source control was adequate and received a fixed short course (four days) of antibiotics did not differ in outcomes from those who received a more prolonged course of eight days [65,66]. This underlined the significance of source control, and it proved that the benefit of antibiotic administration is limited to the first few days after surgery [27,65]. If patients have signs of peritonitis after 5 to 7 days of antibiotic use, diagnostic investigation is warranted in order to address an ongoing uncontrolled source of infection [13].…”

“…AS initiatives in surgical wards should initially focus on surgical site infection (SSI) prevention and surgical antibiotic prophylaxis (SAP) [2,4]. SSIs are infections of the incision or organ or space, which occur in 1-3% of patients undergoing inpatient surgery, with the burden being worse in acute-care surgery [26,27]. They contribute the most to hospital care costs [28].…”

“…It could also be implemented through the rejection of unsuitable samples [88]. In surgery, the diagnostic pathway should involve the correct acquirement of tissue cultures via surgical debridement or peritoneal fluid culture in cases of peritonitis [27,88]. In addition to the rapid and correct identification of pathogens, the biomarkers that depend on the host's response to infection have offered a new perspective on infectious disease diagnoses in patients undergoing surgery [27].…”

“…In patients with sepsis in surgical ICUs, PCT has been found to be a useful biomarker to safely reduce antibiotic consumption in this setting [11,97,98]. CRP, overall, is considered a nonspecific but highly sensitive indicator of an inflammatory response [27].…”