This article is more than 5 years old. Information may no longer be current.
Continuing resistance to antibiotic prophylaxes gaining worldwide attention
Despite low rates of infection, surgeons are considering the benefits of national databases.
Click Here to Manage Email Alerts
The continued resistance of certain organisms to standard antibiotic prophylactic agents is an issue that must be addressed by the orthopaedic community, according to researchers in Europe and the United States.
And although there is widespread agreement on how to prevent perioperative infection, monitoring the incidence and prevalence of these infections is more controversial. One way to track the emergence of the antibiotic-resistant organisms would be through an orthopaedic infection database.
Surveillance systems of this type are in place in Europe and can be beneficial in reducing the rates of nosocomial infections, according to Geert H. I. M. Walenkamp, MD, associate professor, Academic Hospital in Maastricht, Netherlands.
Wound infection registry
Walenkamp is a member of the advisory committee of the Dutch wound infection registry program and the organizer of data collection in his own department. “The National Surveillance program has collected data on more than 100,000 surgeries since 1997, which includes data from orthopaedics as well as other surgical specialties,” he said. “What is striking is that more than half of these patients are from orthopaedic surgeries,” he said. “The same percentages exist in Germany and the United Kingdom.”
Advantages to these systems include the ability to track infection rates and geographic or institutional differences; the analysis of data on a mass scale, which allows for a better statistical significance; and taking away the burden of data storage and analysis from the institutions and centralizing it at a data collection organization.
Walenkamp told Orthopaedics Today that organizing an infection-tracking registry is difficult. Initially, it comes down to defining an infection and the organism responsible.
Following detection, the next issue is recording and submitting the data. “According to studies, doctors are very bad people to fill in forms,” he said. “Doctors have simply too many forms to fill out.”
Putting the data to use
How this type of data may be used or not used by people outside the profession is also an issue. In the Netherlands, the infection registry is not open to the public.
“We feel that if they become public, the doctors will not fill the records out accurately and no one will be helped by this,” Walenkamp said. “The most important part of these registries is for the profession itself. All data that come out of these registries must then be explained to the public. If we have a deep infection rate of 0.8%, for example, for total hips and another institution has a higher rate, we will know that there is a problem. It will be important for the profession to know where there is a problem and then to solve it.
“The dispute is always in how far these kind of registers are able to compare hospitals. Our national medical journal has published articles that suggest that it is difficult to use these kinds of registers, since they are not always able to compare hospitals because it is very difficult to have a uniform data registration.”
Under certain government-supported medical systems data collection on perioperative infections may be possible, but in a more market-driven system like that in the United States, it may not be feasible.
“I don’t want to be pessimistic, but the problem with establishing a voluntary database is that it is voluntary. Doctors are like other humans and don’t want to show their faults,” said Paul A. Lotke, MD, professor of orthopaedic surgery at the University of Pennsylvania in Philadelphia.
Lotke believes there should be a database tracking infections, “but I don’t believe that it could work as a voluntary system. It would have to work through the hospitals or insurers.”
Seeking better drugs
On the treatment front, the decreasing effectiveness of standard prophylactic regimens, like the cephalosporins, has to be recognized, he added. “The problem is that there isn’t any other drug on the horizon that can take over their function.”
Lotke told Orthopaedics Today that vancomycin could fill the void. “However, everybody is reluctant to use it because it is such an important drug and we don’t want to develop a resistance to it. So, this really puts the medical community in a quandary at the moment as to what to do.”
The American Academy of Orthopaedic Surgeons (AAOS) issued an advisory statement in 1998 concerning the spread of antibiotic resistant organisms. It states that vancomycin “should be reserved for the treatment of serious infection with beta-lactam-resistant organisms or for treatment of infection in patients with life-threatening allergy to beta-lactam antimicrobials.”
Prevention is key
Lotke said it is important for surgeons to remember all the perioperative infection prevention techniques, such as proper skin preparation, proper draping techniques and air filtration to augment the drugs. “There is a constellation of techniques. We should not think that antibiotics solve all our problems and [that] we don’t have to worry about infection. You have to worry about clean air and clean skin, clean techniques and clean wound closure. The entire constellation of techniques contributes to maintaining low infection rates. We shouldn’t solely depend on antibiotics.”
According to data from the U.S. National Nosocomial Infections Surveillance of the Centers for Disease Control and Prevention (CDC), the overall surgical site infection rate in the United States is 2.6%. Reports in the literature have noted a perioperative infection rate for orthopaedic surgery between less than 1% and 8%. The low overall incidence of perioperative infection, however, may be setting the medical community up for many future problems.
“The current thinking is that the infection rates are relatively low and so it is not an issue at this moment in time,” Lotke said. “However, it is apparent that the infections that we are seeing are more resistant than what we are used to. We are going to have to address this sooner or later.”
Antibiotic cement
One alternative antibiotic prophylaxis is drug-impregnated cement for arthroplasty surgeries. Lotke said this is gaining popularity, but the increased cost of the antibiotic cement may make it unobtainable. “To go from a cheap cement to a very expensive antibiotic-laced cement is not cost effective.”
The AAOS claims that orthopedists are among the heaviest users of prophylactic antibiotics. Further recommendations from the advisory statement include stressing the importance of hand washing, isolating patients infected with vancomycin-resistant strains, and reporting any strain of Staphylococcus aureus that demonstrates a reduced sensitivity to vancomycin to state and local health departments and the CDC.
Please see the print edition for more coverage of infection news.