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A Global Declaration on Appropriate Use of Antimicrobial Agents Across the Surgical Pathway

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A Global Declaration on Appropriate Use of Antimicrobial Agents Across the Surgical Pathway SURGICAL INFECTIONS Volume 18, Number 8, 2017 Global Alliance Position Article ª Mary Ann Liebert, Inc. DOI: 10.1089/sur.2017.219 A Global Declaration on Appropriate Use of Antimicrobial Agents across the Surgical Pathway Global Alliance for Infections in Surgery Working Group Abstract This declaration, signed by an interdisciplinary task force of 234 experts from 83 different countries with different backgrounds, highlights the threat posed by antimicrobial resistance and the need for appropriate use of antibiotic agents and antifungal agents in hospitals worldwide especially focusing on surgical infections. As such, it is our intent to raise awareness among healthcare workers and improve antimicrobial prescribing. To facilitate its dissemination, the declaration was translated in different languages. ntimicrobial resistance (AMR) has emerged as one Antibiotic and Antifungal Resistance Aof the principal public health problems of the 21st century. This has resulted in a public health crisis of inter- Antibiotic resistance is one of the greatest threats to public national concern, which threatens the practice of modern health, sustainable development, and security worldwide. medicine, animal health, and food security. The substantial Its prevalence has increased alarmingly over the past de- problem of AMR is especially relevant to antibiotic resis- cades. In 2008, the acronym ‘‘ESKAPE’’ pathogens, which tance (ABR), although antifungal resistance is increasing at refers to Enterococcus faecium, Staphylococcus aureus, an alarming rate. Although the phenomenon of ABR can be Klebsiella pneumoniae, Acinetobacter baumannii, Pseudo- attributed to many factors, there is a well-established rela- monas aeruginosa, and Enterobacter species was proposed to tionship between antibiotic prescribing practices and the highlight those pathogens about which ABR is of particular emergence of resistant bacteria. concern and to emphasize which bacteria increasingly ‘‘es- This declaration, signed by an interdisciplinary task force of cape’’ the effects of antibiotics [1]. These organisms are in- 234 experts from 83 different countries with different back- creasingly multi–drug- (MDR), extensive–drug- (XDR), and grounds, highlights the threat posed by AMR and the need for pan–drug- resistant (PDR), and this process is accelerating appropriate use of antibiotic agents and antifungal agents in globally [2,3]. hospitals worldwide especially focusing on surgical infections. Although antibiotic-resistant infections are a widely rec- This declaration is promoted by the Global Alliance for Infec- ognized public health threat, less is known about the burden tions in Surgery and the World Society of Emergency Surgery of antifungal-resistant infections. The frequency of fungal (WSES). It is endorsed by the Surgical Infection Society (SIS), infections has increased in recent years, largely because of the Surgical Infection Society Europe (SIS-E), the European the increasing size of the at-risk population, which includes Society of Clinical Microbiology and Infectious Diseases cancer patients, transplant recipients, patients with human (ESCMID) Study Group for Antimicrobial stewardship (ES- immunodeficiency virus infection, and other patients who GAP) and Study Group for Infections in Critically Ill Patients receive immunosuppressive therapy. In addition, they are (ESGCIP), the European Confederation of Medical Mycology relatively common in critically ill patients and are associated Downloaded by Surgical Infection Society (SIS) from online.liebertpub.com at 11/09/17. For personal use only. (ECMM), the World Alliance Against Antibiotic Resistance with considerable morbidity and death. In this regard, anti- (WAAR), the British Society for Antimicrobial Chemotherapy fungal resistance is becoming increasingly problematic, (BSAC), the French Society of Anesthesia & Intensive Care particularly for Candida glabrata and Aspergillus fumigatus. Medicine (SFAR), the Italian Society of Anesthesiology, An- Recently, a new MDR species, C. auris, emerged causing algesia, Resuscitation and Intensive Therapy (SIAARTI), the persistent multi-regional outbreaks. While some species of South African Society of Clinical Microbiology (SASCM), the Candida are inherently resistant to certain antifungal agents, Italian Society of Anti-Infective Therapy (SITA), and the Italian in others, acquired resistance occurs via selection of muta- Group for Antimicrobial Stewardship (GISA). tions in existing genes, particularly in units with high Complete author list and author affiliations are in the Acknowledgment section, pages 849–853. 846 ANTIMICROBIAL AGENTS ACROSS SURGICAL PATHWAY 847 antifungal consumption [4]. This can impact seriously the taining the effectiveness of current and future antibiotic outcomes of patients with invasive candidiasis. The problem agents specifically by: will likely continue to evolve unless greater attention is given Following locally developed customized antibiotic to measures to prevent and control the spread of resistant guidelines and clinical pathways Candida spp. Supporting and enhancing IPC including correct hand Combating resistance has become a top priority for global hygiene protocols policy makers and public health authorities. New mecha- Supporting and enhancing surveillance of ABR and nisms of resistance continue to emerge and spread globally, antibiotic consumption threatening our ability to manage common infections [5]. Prescribing and dispensing antibiotic agents only when Antibacterial and antifungal use in animal and agricultural they are truly required industries aggravates selective pressure on microbes. A One Identifying and controlling the source of infection Health approach is required urgently. The burden of ABR is Prescribing and dispensing appropriate antibiotic difficult to quantify in some regions of the world, because agents with adequate dosages—i.e., administration of enhanced surveillance requires personnel, equipment, and antibiotic agents according to pharmacokinetic- financial resources that are not always available [6]. The pharmacodynamic (PK-PD) principles worldwide impact of ABR is significant, however, in terms of Re-assessing treatment when culture results are avail- economic and patient outcomes, because of untreatable in- able fections or those necessitating antibiotic agents of last resort Using the shortest duration of antibiotic agents based (such as colistin) leading to increased length of hospital stay, on evidence morbidity, death, and treatment cost. Educating healthcare workers and staff how to use antibiotic agents wisely Misuse and Overuse of Antibiotic Agents Antibiotic agents can be lifesaving when treating patients Antibiotic Stewardship Programs with bacterial infections but are often used inappropriately, specifically when unnecessary or when administered for ex- Hospital-based programs dedicated to improving antibi- cessive durations or without consideration of pharmacoki- otic use, commonly referred to as Antimicrobial Stewardship netic principles. Large variations in antibiotic consumption Programs (ASPs), can both optimize the management of in- exist between countries, and while excessive use remains a fections and reduce adverse events associated with antibiotic major problem in some areas of the world, elsewhere there is use [8,9]. Of note, a recent systematic review and meta- lack of access to many antimicrobial agents. Antibiotic re- analysis demonstrated that ASPs significantly reduce the sistance is a natural phenomenon that occurs as microbes incidence of infections and colonization with antibiotic- evolve. Human activities have accelerated the pace at which resistant bacteria and Clostridium difficile infections in hos- bacteria develop and disseminate resistance, however. In- pital inpatients [10]. Therefore, every hospital worldwide appropriate use of antibiotic agents in humans and food- should utilize existing resources to create an effective multi- producing animals, as well as poor infection prevention and disciplinary team. The preferred means of improving anti- control (IPC) practices, contribute to the development and biotic stewardship should involve a comprehensive program spread of ABR. that incorporates collaboration between various specialties within a healthcare institution including infectious disease specialists, hospital pharmacists, clinical pharmacologists, Raising Awareness to Combat ABR administrators, epidemiologists, IPC specialists, microbiol- In line with a One Health approach, raising awareness of ogists, surgeons, anesthesiologists, intensivists, and under- ABR by education and dissemination of information to utilized but pivotal stewardship team members—the surgical, stakeholders is an important factor in changing behaviors. anesthetic, and intensive care nurses in our hospitals. Efforts must be aimed at the general public, healthcare pro- The ASP policies should be based on both international/ fessionals, food producing farmers, civil society organiza- national antibiotic guidelines and tailored to local microbi- tions, and policy makers. An effective and cost-effective ology and resistance patterns. Facility-specific treatment strategy to reduce ABR should involve a multi-faceted ap- recommendations, based on guidelines and local formulary proach aimed at optimizing antibiotic use, strengthening options promoted by the APS team, can guide clinicians in surveillance and IPC, and improving patient and clinician antibiotic agent selection and duration for the
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