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Emphasizing The Importance Of Antimicrobial Stewardship

As per the “Standards and Requirements for Approval of Podiatric Medicine and Surgery Residencies” published by the Council on Podiatric Medical Education (CPME), every podiatric resident is required to complete an infectious disease rotation to graduate residency.1

Although this is a rare requisite among surgical specialties, the pertinence is clear. Of all hospital-acquired infections, surgical site infections (SSIs) are the most common and costly.2 Surigical site infections account for 20 percent of hospital-acquired infections, requiring an average increased hospital stay of 9.7 days, and cost billions of dollars.

The Infectious Diseases Society of America (IDSA) has world-renowned clinical practice guidelines that provide valuable information for surgeons, including podiatric surgeons. These guidelines include recommendations on antimicrobial prophylaxis in surgery, diabetic foot infections (DFIs), laboratory diagnosis of infectious disease, methicillin-resistant Staphylococcus aureus (MRSA), prosthetic joint infection, skin and soft tissue infections, and outpatient antimicrobial parenteral therapy.3

With antimicrobial resistance on the rise, harnessing and applying these important principles contribute to preventing overuse of antibiotics, thus combating antimicrobial resistance. The threat of antimicrobial resistance has dire implications on global health. Earlier this year, the United Nations Interagency Coordination Group on Antimicrobial Resistance (IACG) published a report stating that without action, the current global death toll of nearly 700,000 people per year from resistant infections has the potential to grow by as many as 10 million deaths per year by the year 2050, according to the World Bank.4

While infectious disease teams have become common in most hospital systems, antimicrobial stewardship begins far before an infectious disease consult or referral. For example, proper utilization of IDSA guidelines regarding outpatient oral antibiotic therapy for mild soft tissue infections can make the difference between a resolved infection or inadequate therapy leading to hospitalization. If hospitalization occurs, the patient may possibly require more aggressive therapy due to acquired resistance. This cycle contributes to the production of multi-drug resistant organisms (MDROs) and, in turn, suboptimal antimicrobial stewardship outcomes. This phenomenon directly impacts patients, especially those who are immunocompromised and have a history of recurrent infections, such as the diabetic patient population, whom are often treated by podiatrists.

In addition to clinical applications, understanding laboratory diagnosis can be very valuable for decreasing hospital stay lengths and swiftly achieving targeted therapy. Even if one anticipates an infectious disease consult, understanding new diagnostic tools and their advantages can help expedite the process and potentially contribute to lesser financial burdens and better health outcomes.

Furthermore, given the rapid development of new antibiotics, getting involved in collaborative research projects as well as joint grand rounds sessions with infectious disease teams is very important. Of particular interest to the field of podiatric surgery, the Oral Versus Intravenous Antibiotic Treatment for Bone and Joint Infections (OVIVA) trial is a great example of a project that holds great potential value to the podiatric patient population.5

The IDSA recommends four or more weeks of antibiotic therapy for residual osteomyelitis after bony resection.6 Conventionally, physicians have administered long-term treatment for osteomyelitis intravenously. The OVIVA trial sought to explore how oral therapy fared in comparison to intravenous therapy. While the researchers believed there was little evidence to prove oral antibiotic therapy is worse, the authors did not believe they had enough evidence to formulate a clinical recommendation.6

The development of an alternative oral antibiotic regimen for osteomyelitis in DFIs may have great potential benefits. However, this will require diligent efforts of both infectious disease physicians and podiatric surgeons. With the CPME mandating an infectious disease rotation, podiatric surgeons are well equipped to work with their colleagues in the infectious disease community toward the goal of greater antimicrobial stewardship.

Dr. Basatneh is a first-year podiatric surgery resident at the Detroit Medical Center. One can find Dr. Basatneh on social media via Instagram ( @_podiatry ) and Twitter (@RamiBasatneh ).

Dr. Velasco is an Infectious Disease Fellow at  Wayne State University-Detroit Medical Center.

Forum
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By Rami Basatneh, DPM, and Jon Velasco, MD
References

1. Council on Podiatric Medical Education. Standards and requirements for approval of podiatric medicine and surgery residencies. Available at: https://www.cpme.org/files/CPME%20320%20final%20June%202015.pdf . Published 2015. Accessed September 26, 2019. 

2. Loyola University Health System. Surgical site infections are the most common and costly of hospital infections: Guidelines for preventing surgical site infections are updated. ScienceDaily. Available at: www.sciencedaily.com/releases/2017/01/170119161551.htm . Published January 19, 2017. Accessed September 26, 2019.

3. Infectious Diseases Society of America. IDSA practice guidelines. Available at:  https://www.idsociety.org/practice-guideline/practice-guidelines/#/date_na_dt/DESC/0/+/ . Accessed September 26, 2019. 

4. Interagency Coordination Group on Antimicrobial Resistance. No time to wait: securing the future from drug-resistant infections.  Available at: https://www.who.int/antimicrobial-resistance/interagency-coordination-group/IACG_final_report_EN.pdf?ua=1. Published April 2019. Accessed September 26, 2019.

5. Li H-K, Scarborough M, Zambellas R, et al. Oral versus intravenous antibiotics for bone and joint infections (OVIVA): study protocol for a randomised controlled trial. Trials. 2015;16:583. doi: 10.1186/s13063-015-1098-y.

6. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):132-173. 

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