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Our goal: Change the face of infection
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![Douglas W. Jackson, MD [photo]](images/content/ot/commonart/jackson1.jpg)
--- Douglas W. Jackson,
Chief Medical Editor
As a young child I was hospitalized with pneumonia and apparently was not responding well to the treatment. Our family physician told my parents that he wanted to try what was considered a new miracle drug. It was penicillin. My parents recounted that my response was dramatic and, of course, there are many stories from that period of far more dramatic applications and responses to the administration of penicillin.
That particular experience instilled in my family unrealistic expectations from penicillin and antibiotics in general. This was further reinforced by our family doctor. I recall the standard treatment for my usual childhood illnesses and colds was a "penicillin shot." Usually no cultures were taken and no laboratory tests were done. Most of those penicillin injections probably did not alter my recovery.
The color of orthopedics
When I started my orthopedic residency and spent time working on the wards at the county hospital, there were many patients with infections. An older attending at that time would tell us stories of patients he had treated before effective antibiotics were available. He said during those times the color of orthopedics was "salmon" — the color you got when you mixed blood, pus and tears.
During my training my great confidence in antibiotics caused me to undertake a study to document that frequent use of a triple antibiotic irrigation during surgery would significantly decrease postoperative infections in our institution. The study was far from a sophisticated research project but was designed simply to compare using triple antibiotic irrigation vs. saline in cases done by the house staff.
After reviewing the data at the end of the study, the only significant change in the OR infection rate documented was around the time of the change in house officers in July and August. Other explanations could have accounted for these increased infections in July and August that I did not record or even think to document. That study made me realize more then ever that controlling infection involved multi-variable factors and we could not depend on antibiotics as our main means of preventing postoperative infections. [And just last month Orthopedics Today reported on a new study by Jeffrey Anglen, MD, chairman of orthopedics at Indiana University, showing that antibiotics proved no better than soap in helping to treat open fracture wounds in the lower extremity.]
Genetic, biologic advances
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Since then we all have come to realize, more the ever, the incredible genetic and biologic factors at play that allow the agents responsible for infections to invade, change, adapt and spread. We all are seeing the need for newer generation antibiotics because of increasing drug resistance to the old stand-by antibiotics we used in our training. Pretty much as fast as pathogens have selected out resistance, researchers have brought on another line of defense — at least in my patient population. However, this approach is no longer the one we can count upon. The rising cost of research and development of new agents, the years involved in clinical trials and the liability issues that can arise when mass usage is undertaken have all slowed the enthusiasm for new antibiotics. Other major factors: The impact of too little return on the risk of investment required for the preclinical trials and the regulatory hurdles pharmaceutical companies face in developing new antibiotics and vaccinations. This has placed us in a position of possibly not keeping pace in the arms race with these changing microbials.
Future challenges
What does this mean in our patient care? The challenges for the future continue to include the need to develop new approaches to risk assessment and to prevent operative infections. This will result in new assessments of our patients' underlying, intrinsic, individual risk factors by doing the following: (1) boosting host factors to enhance their immunological response; (2) identifying exogenous risk factors even if small [ie, reducing the use of blood transfusions]; and (3) obtaining more insight into the complex social issues that predispose to infection.
Such measures will be added to new techniques for cleaning and preparing the OR environment, the role of prophylactic antibiotics and identifying the specific organism early in the infection process.
Scientists are learning more about the passive immune responses that often, in themselves, protect us or alert our active traditional immune responses [Scientific American, January 2005, Luke A.J. O'Neill, PhD] Given that these factors were unheard of just seven years ago, investigators have made enormous progress in understanding what role these proteins play in the body's first line of defense. This innate immunity serves as a rapid response and hopefully will provide new options for treating patients prone to develop infectious and abnormal inflammatory responses. Recognizing patients with over- or under-active responses presents opportunities to reduce some more risk factors.
Hopefully these and other aspects of understanding and using the body's recognition and response to infection will enter the practice of orthopedics soon. The future applications of gene expressions and the proteins they encode will help us enhance protection with early detection, and help suppress or activate the body's individualized responses.
Bottom line
The bottom line is that the days of depending totally on antibiotics as our main approach to staying a step ahead of microbials has to change. Our support of the ongoing research in this area will only speed us along to these new understandings and approaches in our orthopedic patients.