Emergence of resistant microbes in critical care units is transient, despite an unrestricted formulary and multiple antibiotic trials

Resistance profiles in surgical-site infection

Surgical-site infections (SSIs) remain a common complication, affecting some 5% of patients undergoing surgical procedures and can sometimes present a major challenge after surgery with life-threatening septic illness. The appearance of organisms that are often resistant to common antibiotic treatment is of great concern. Staphylococcus aureus is the organism most commonly recovered from infected surgical wounds, and usually contaminates wounds from the patients own skin. SSIs occur despite appropriate skin disinfection, sterilization of instruments, use of gown and gloves, appropriate sterile technique and prophylactic antimicrobials. In fact, it is difficult to maintain a sterile field over time, and most wounds become contaminated throughout the course of surgery. Methicillin-resistant S. aureus (MRSA) first arose in the hospital setting, but have more recently evolved in the community. Such community-acquired MRSA are genetically different and seem to be even more virulent owing to genes that encode virulence factors, such as staphylococcal cassette chromosome mec type IV and Panton-Valentine leukocidin. The purpose of this review is to summarize characteristics of frequently isolated bacterial strains from SSIs. The focus will be on Gram-positive organisms because of their increasing prevalence in SSIs and their high potential to develop resistance against several antibiotic agents, including vancomycin.

Principles of antimicrobial therapy: what should we be using?

Although the use of antimicrobials has had an insurmountable impact on preventing patient morbidity and mortality, problems with antimicrobial resistance and antimicrobial-induced diarrhea are becoming more apparent in human and veterinary medicine. The mortality associated with nosocomial infection with antimicrobial-resistant bacteria in human patients is alarming. Similarly, in veterinary medicine, the morbidity and high cost of treatment of patients with postoperative infection, for example, are concerns. Specifically in equine medicine, the high morbidity and mortality associated with antimicrobial-induced diarrhea have been devastating in many equine practices. Misuse of antimicrobials is extremely common in human and veterinary medicine. All clinicians have the responsibility to consider the appropriateness of their antimicrobial use carefully and, whenever possible, to minimize antimicrobial administration to patients.

The driving force in hospital formularies: economics versus efficacy

The rising cost of pharmaceuticals has created a focus on hospital cost containment. From 1990 to 2000, spending on prescription drugs increased 200%. Through a variety of mechanisms and contracting, hospital formularies have become increasingly more restrictive. Physician choice with regard to antibiotics specifically is becoming more limited. The field of pharmacoeconomics looks at the cost effectiveness of the drugs we use. The pressures on the pharmaceutical industry and hospitals are reviewed here with a discussion of antibiotic prophylaxis, new expensive therapies, and physician responsibility. The driving force behind hospital formulary design is often economic, whereas the physician desires variety and efficacy. This review discusses some of the key issues related to drug costs and expenditures.