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Module 4.4: Infection
Topic Progress:

Antimicrobial Stewardship

Antibiotics have been widely used since the 1940’s. Initially revolutionary in the war on infection, saving countless lives, the reliance on antibiotics has led to over prescribing and overuse that reaches far outside the health care. This has led to the emergence of microbial strains being resistant to one or more antibiotics, such as methicillin resistance staphylococcus aureus (MRSA). The continued resistance, in combination with no new classes of antibiotics for over thirty years, suggests there is an increased risk of a health crisis. The United Nations, WHO and other international agencies estimate that if left without action, antimicrobial drug-resistant diseases could cause 10 million deaths each year by 2050, costing approximately £66 trillion. (Wounds UK, 2020; IWII, 2022)

Within wound care, topical antimicrobials are on the rise, their use driven by antibiotic/antimicrobial resistance (AMR). They are typically utilised for infected or open wounds healing by secondary intention (Wounds UK, 2020). The prevalence of non-healing wounds is increasing, potentially escalating the problem, with studies suggesting excessive use of antibiotics in these individuals (Probst, 2022; IWII, 2022). In addition, the understanding that non-healing/chronic wounds have a high probability of containing biofilm amplifies the overuse.

Antimicrobial stewardship (AMS) can be defined as: ‘The supervised and organised use of antimicrobials in order to decrease the spread of infections that are caused by multidrug-resistant organisms and to improve clinical outcomes by encouraging appropriate and optimised use of antimicrobials.’ (IWII, 2022)

Clinicians have a significant role in AMS, with robust prevention and management of wound infection.

Clinical level antimicrobial stewardship initiatives:

  • Educate patients, their families and health care professionals regarding AMR and responsible use of antimicrobial agents.
  • Avoid use of antimicrobials as a prophylactic therapy, except for wounds identified at high risk of infection.
  • Use non-medicated options (e.g. non-medicated wound dressings) to manage infection when possible.
  • Only use antimicrobials when a wound has been clinically identified as infected.
  • Base antimicrobial selection on identification of the infecting organisms.
  • Select antimicrobial agents with narrow-spectrum activity where possible.
  • Reserve broad-spectrum agents for more resistant bacterial infections where possible.
  • Continue the use of antimicrobial therapy for an appropriate duration to prevent development of resistance.
  • Monitor therapeutic response to guide ongoing selection and use of antimicrobials.

An holistic assessment can identify if a wound has signs and symptoms/is clinically infected (Wounds UK, 2020). If there are no indications of infection, antimicrobials would be an inappropriate requirement. Following on as part of AMS, prophylactic antimicrobial use should only be considered for exceptional circumstances, such as immunocompromised patients, those with poor vascularity or following high-risk surgery. Other potential risk factors include wounds with large areas of necrotic tissue and high-risk anatomical sites, e.g. the sacral area. (Swanson et al., 2014; IWII, 2022) (Wounds UK, 2020)

Two-week challenge

The length of use of a topical antiseptic/antimicrobial should be individualised and centred on regular wound assessment. A two-week challenge is recommended and should allow enough time for the antimicrobial agent to exert some observable activity.

When using antimicrobials, it is recommended that the effects of the product on the wound should be monitored at every dressing change and then reviewed after two weeks:

  • If there are signs of progression and a reduction in the signs and symptoms of infection or critical colonisation, discontinue the antimicrobial dressing.
  • If the wound shows signs of progression and of infection, continue with the antimicrobial dressing for a further two weeks unless the wound deteriorates earlier.
  • If the wound deteriorates, fully reassess to exclude contributing causes (other than infection) that might indicate an alternative approach or the addition of systemic therapy.

(Nair et al., 2023)

It has been noted in the IWII 2022 guidelines that in the stepdown/step-up approach to biofilm-based wound care it may be up to 4 weeks to attain results. It also notes that alternating or rotating topical antiseptic treatments is popular. The premise for this being that suppression of a range of microorganisms is attained through the application of different antiseptics/antimicrobials in 2- or 4-week rotation. In conjunction with therapeutic cleansing and debridement, alternating the type of antiseptic/antimicrobials may assist in restoration of microbial balance; however, further research is required to support this clinical practice. (IWWII, 2022)

Guide on management of a wound’s infection risk applying the principles of antimicrobial stewardship

Adapted from (Wounds UK, 2020)