br Conflicts of interest br Introduction

Conflicts of interest
Introduction When it comes to risk taking, surgeons and anesthesiologists show greater risk taking than other physicians. Surgical procedures carry several risks of which infection is one. Surgical site infections (SSI) are the most common hospital acquired infection and lead to a 3% mortality rate. Patients who develop an SSI have a 2–11 times higher mortality rate than those who do not. Rates of colon SSI range from 5.4% to as high as 23.2%. Administration of prophylactic 5,7-dihydroxychromone is a highly effective method to reduce the risk of SSI; however, this assumes that the prophylactic antibiotic is effective against the common pathogens associated with various surgical procedures. Performing colorectal surgery without antibiotic prophylaxis would place patients at an unacceptable risk of infection. Loss of effective prophylactic antibiotics due to escalating rates of antibiotic resistance requires surgeons to be responsible stewards of antibiotics. Antibiotics are a health care resource in which the current use or misuse will determine their future value. Tilliant et al. published the first study that estimates the potential effect of antibiotic resistance on the efficacy of antibiotic prophylaxis for a range of surgeries. For example they show that for transrectal procedures, the proportion of SSI caused by Escherichia coli and Pseudomonas aeruginosa that are resistant to recommended standard fluoroquinolones ranges from 50% to 90%. This increased antibiotic resistance threatens the safety and efficacy of many surgical procedures, as the risk of developing a postoperative SSI dramatically increases when the prophylactic antibiotic fails to provide effective coverage against common organisms. Similar to the risks associated with surgery, antibiotics also carry inherent risks and potential consequences such as the development of Clostridium difficile infection (CDI). The practice of prescribing antibiotics “just-in-case” there is infection puts the patient at risk of developing CDI and other antibiotic-associated adverse drug events (ADEs) in addition to contributing to the rise of multidrug resistance organisms (MRDO), which are estimated to cause 23,000 deaths per year. The purpose of this paper is to describe the risk and potential consequences associated with overprescribing antibiotics in surgical patients.
Clostridium difficile is a major threat to patients both in the outpatient setting and in hospitals. The most significant predisposition is the amount and duration of antimicrobial therapy. Patients who undergo surgical procedures are often at risk as they frequently receive antimicrobials either for wound prophylaxis or for postoperative infections. The emergence of the BI/NAP1 epidemic strain of C. difficile has led to sharp increases in morbidity and mortality. This strain demonstrates increased toxin production, contributing to a higher proportion of severe disease and reduced response to traditional therapy. The Centers for Disease Control and Prevention (CDC) estimates that there were roughly 500,000 cases of CDI and 30,000 deaths in 2011, with an increasing burden among nonhospitalized persons. Although any antimicrobial can predispose to CDI, the risk is especially great with the use of broad-spectrum antimicrobials, which disrupt normal enteric flora. Other factors that increase the risk of CDI include advanced age, presence of comorbidities, and prior hospitalization. Judicious use of antimicrobials in concert with effective infection control is vital to reducing the likelihood of CDI. The antibiotics most strongly associated with CDI are clindamycin, cephalosporins, and fluoroquinolones. Recently we have observed the fluoroquinolones as high-risk agents, a finding that is most likely related to increasing fluoroquinolone resistance among epidemic strains and some nonepidemic strains of C. difficile. We have observed that restricting use of fluoroquinolones at our institution has led to a reduction in the incidence of hospital-associated CDI (File T, personal observation); others have also observed this.