Dr Chindu Kabir is the Founder and CEO of Post Op postop.ai
In 2022 at a London teaching hospital, I came across a patient who'd come to A & E with pus pouring out of his knee. It was 3 days after his knee joint surgery and his wound was infected. The doctor did what was required of them - cleaned up the infection, prescribed flucloxacillin and gave him an outpatient appointment. The patient was treated correctly and this is not a criticism of the doctor or the A & E department, rather a reflection on how we as doctors could be contributing to antimicrobial resistance by the processes we follow or the approach we take.
Let's imagine that the same doctor requested an on-call orthopaedic consult for this infected knee wound. That assessment could have checked whether the infection had spread to the joint, prompting further damage to the patient even as his knee wound was healing, to avoid another invasive operation a year later. Many patients are seeing a break in routine pathways after major surgical procedures because our current system works in silos. Treating patients in isolation, in order to deal with the issue at hand, rather than making a thorough assessment, is potentially jeopardising patient care and causing antimicrobial resistance and we should be concerned, particularly as research by WHO shows below.
The global challenge and significance of antimicrobial resistance
Antimicrobial resistance (AMR) is a global health challenge with predictions that infections caused by antimicrobial resistance bacteria will kill up to 10 million people a year, by the year 2050 . To put this into context that is more deaths caused by cancer (7.2 million) and diarrhoeal disease (1.4 million) combined. There is an urgent need to tackle the AMR crisis, highlighted by the UK’s National Action Plan (NAP) on AMR. The latest update in May 2024 to the UK NAP places emphasis on infection prevention and control (IPC) to reduce exposure to antimicrobial medicines via informed interventions, as well as the need for active surveillance.
What is antimicrobial resistance?
AMR occurs when the medicines used to treat infections caused by bacteria are no longer effective. Antibiotics have come a long way since the discovery of penicillin in 1928 by Dr Alexander Fleming. The purification and mass production of penicillin the 1940s revolutionised the way infections were treated. It meant infections such as pneumonia and blood poisoning (which were a significant cause of mortality), could now be treated and cured. Since the discovery of penicillin, the development and optimisation of newer and more powerful antibiotics have revolutionised medicine and the treatment of bacterial infections. However, the misuse of antibiotics and the ability of bacteria to rapidly evolve resistance to antibiotics has resulted in a global looming AMR crisis. A recent analysis of global health records from 204 countries published in the Lancet estimated that in 2019, 1.27 millions deaths were directly attributable to infections caused by AMR bacteria. With this in mind the World Health Organisation has called for the need to accelerate the implementation of NAPs on AMR and proposed the development of a WHO strategic and operational framework to address AMR bacterial infections.
How can infection prevention and control help to reduce the impact of antimicrobial resistance?
IPC plays a pivotal role in reducing the risk of people contracting infections, whether it is keeping patients picking up infections in hospital or keeping our families safe at home. There is a wealth of evidence which shows that simple measures such as washing our hands or ensuring we stay up to date with vaccinations, can reduce the spread of infections and disease impact. However, challenges to IPC are always evolving and there will always be ways in which bacteria and viruses can find a new way to cause infection and disease. The COVID pandemic and the evolution of new ‘variants’ of SARS-CoV-2 demonstrated first hand how quickly microorganisms can evolve and adapt, presenting new challenges such as increased transmission risk or reducing vaccine efficacy. IPC will be crucial in the fight against AMR, as highlighted by the UK NAP on AMR. Preventing infections reduces the need for the use of antibiotics, which directly reduces the risk of resistance to antibiotics developing. In contrast a high incidence of infection results in increased demand for antibiotics, a catalyst to rising drug resistance. Patients can also carry AMR bacteria on their skin or in their gut and be ‘colonised’ without an active infection. Screening and decolonising of patients prior to hospital admission (for surgery for example) reduces the risk of patients developing infections from the AMR bacteria they are colonised with.
How can surgical site surveillance and SSI prevention reduce the risk of AMR
Infections resulting from surgical operations (known as surgical site infections (SSIs)) place a significant burden on patients and healthcare organisations. Patients who develop an SSI are frequently readmitted to hospital for additional treatment and it some cases operations may have to be re-performed. Compared to patients without SSIs, those with SSIs remain in the hospital approximately 7 to 11 days longer. Additionally, one study involving 177,706 postsurgical patients reported that SSI was the cause of 78% of all readmissions. This places additional requirements on the healthcare organisation, increasing the number of patients visiting accident and emergency. As part of the additional treatment, antibiotics are required to treat the infection which can increase the risk of AMR developing. Educating patients pre surgery (as part of so called pre-habilitation) can help support a reduction in SSIs, aiding patients to take the correct measures (such as skin preparation and or de-consolidation) prior to their surgery. Proper wound care techniques including regular dressing changes and monitoring for signs of infection (as part of the post-surgery pathway), are essential in preventing SSIs. Ultimately reducing the incidences of SSIs will lower the need for antibiotics to be used, reducing the risk of AMR and tackling the AMR crisis head on.
Introducing Post Op, aiding patient recovery, reducing AMR risk and saving hospitals money
Post Op is a smart phone app which connects patients and healthcare professionals before and after surgical procedures. Features within Post Op have been designed in collaboration with healthcare professionals to help support patient recovery and prevent SSIs. Post Op has been successfully adopted within general surgery at Kettering General Hospital (KGH) in the East Midlands and the implementation has resulted in benefits to patients and the hospital. A Lancet study discussed 300 million surgical procedures being completed every year, with 4.2 million patients dying from complications and surgical site infections in the first 30 days. This costs the global economy approximately $12.3 trillion in lost GDP, borne mainly by low middle income countries. Without a standardised method for detecting SSI, and no global database for wound infection monitoring, the Post Op platform can be a game changer - offering patient reported surveillance, and AI powered surgical site infection analytics. As I see it, no surveillance can truly be successful without patient engagement and buy in. A study in collaboration with KGH published in the Journal of Surgery showed that 77% of patients who used Post Op felt more confident in their recovery following surgery. Additionally 73% of patients reported avoiding an unnecessary visit to hospital or their GP due to the ability to be able to communicate directly with healthcare professionals via Post Op.
The future
With the AMR crisis looming the focus needs to be on the prevention of infections, such as SSIs. Digital platforms such as Post Op can promote best practise, aid surveillance and support a reduction in SSI rates, whilst all the time support patients in their recovery. We are facing a global health emergency where infections may no longer respond to any of the antibiotics available, due to bacterial resistance. Prevention is always better than cure, especially when we may be in the position where there is no effective cure. Let us refocus and consider better recovery pathways and procedures that put the patient first.
References
Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis [published correction appears in Lancet. 2022 Oct 1;400(10358):1102. doi: 10.1016/S0140-6736(21)02653-2]. Lancet. 2022;399(10325):629-655.
Gov.uk, UK 5 year plan for antimicrobial resistance 2024-2029.
Moore, M., Monteiro, S., Al-Thani, M., Raicu, A., Rayan, F., & Kelkar, A. (2023). Patient’s Perspective on ‘Post Op’Experience. Journal of Surgery
Vlazaki, M., Sajjad Raja, M., Gomaa, A., & Rayan, F. (2024). Cost effectiveness unlocked: Redefining clinical outcomes augmented by 'Post Op' Digital Care Platform. Journal of Surgery and Research.
World Health Organisation, WHO strategic and operational priorities to address drug-resistant bacterial infections in the human health sector.
