Antimicrobial stewardship

In this section, I’d like to introduce you to antimicrobial stewardship. Essentially, antimicrobial stewardship is about using antimicrobial agents in an appropriate way, so that we can preserve their effectiveness for as long as possible. We know that using and abusing these agents promotes antimicrobial resistance. Antimicrobial stewardship is not about banning the use of these agents. It’s about using them in the right way. For a patient, we need to be confident that we can select the right antimicrobial agent, deliver it in the right dosage, and for the right duration. In some organisations, antimicrobial stewardship schemes have been introduced with the help of multidisciplinary teams.

To gain more knowledge on such schemes, I suggest you look at the publication on antimicrobial stewardship that was produced by NICE in 2015. It can be accessed in the See Also section below. Although not much has been published on antimicrobial stewardship in wound management, there is a good systematic review on the principles and practice of antimicrobial stewardship in the management of diabetic foot ulcers infections. You can find this in the See Also section below. There are many factors contributing to the misuse of antimicrobial therapy in clinical practice. The World Health Organisation has estimated that 50% of all medicines are inappropriately used. When it comes to wound care, several studies have suggested that care is sometimes ritualistic.

And it’s fair to say that there are variations in knowledge and not everyone has access to the same educational opportunities as others. A paper published in 2016 by a group headed by Professor Lipsky identified more contributing factors. This paper can also be found in the See Also section below. That paper goes on to emphasise the importance of administering antibiotics only when the wound is clinically infected. When the wound infection is spreading, you must start systemic antibiotic treatment on an empirical basis immediately. A sample must be sent to the path lab for testing so that you can later know the identity of the microorganism and what its antibiotics susceptibility is.

When you do prescribe an antibiotic, ensure that it is narrowly focused and administered for a short duration. It is always important to follow local guidelines on antibiotic use. Recommendations will vary from place to place, and I must emphasise that in many countries, the topical use of antibiotics on wounds is not allowed. Guidelines for using biocides are much sparser than those for using antibiotics. Biocides are important in clinical practice, but they have other uses– as pesticides in farming, in over-the-counter products like soaps and washes and detergents. In 2016, the FDA in America banned the incorporation of 19 biocides into over-the-counter products. Subsequently, around 200 scientists published their support towards that intervention by bringing out the Florence statement.

Personally, I think this is quite valuable. It states that you should avoid the use of chemicals except when they provide an evidence-based health care benefit and have proven to be safe to use. Such products should not pose risks to humans or to ecosystems. In the EU, we use about 400 tonnes of biocide every year. Certainly limiting their use in everyday products seems to be a good idea to me. The advantages of using antimicrobial agents sparingly are evident. If we are to survive in a post-antibiotic era, there are a whole range of interventions that are important. We need to focus on preventing wound infections so that we don’t have to face the risk of the emergence of further antimicrobial- resistant organisms.

We need to use antimicrobial agents judiciously and carefully. Antimicrobial stewardship techniques in the future are mainly dependent on technological advances. We have to find improved methods to diagnose infection in a shorter span of time, and we need to look into the development of new antibiotics, and perhaps re-evaluate some of the older ones, to see if perhaps we can repurpose them. Agents that interfere with efflux pumps will have to be introduced that confer resistance to a whole range of antibiotics and antiseptics. Quorum sensing inhibitors must be found because they will be important in tackling the formation of biofilms. Lastly, something that has worked successfully since the 1950s– we must think about new combinations of agents to acquire effective therapy.

So far I have covered the problems of antimicrobial resistance. To conclude, early diagnosis and selection of appropriate antimicrobial agents is crucial in antimicrobial stewardship and wound care.