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Thursday, March 16, 2000

Fear overuse of antibiotics as infections increase

It's been more than 30 years since the problem of multiple-drug-resistant (MDR) bacteria was first highlighted, and the problem is more pressing than ever, said Arlen D. Hanssen, MD, Associate Professor of Orthopaedics at Mayo Clinic, Rochester, Minn.

Speaking at an instructional course on emerging viral and bacterial infections, Dr. Hanssen described a "vicious cycle" of bacterial resistance in which physicians, fearing MDR bacteria will develop, use antibiotics inappropriately, thus increasing the likelihood of bacterial resistance. In turn, this leads to the use of even more antimicrobials and new patterns of resistance.

"We, as orthopaedists, need to figure out what we can do to prevent this," he said. "We need to understand how to properly use antibiotics and pay attention to the standards and restriction policies in place."

Don't count on drug companies to solve the problem with newer and more expensive agents. Pharmaceutical manufacturers are becoming disenchanted with the prospect of developing drugs when resistance could quickly render them obsolete. Instead, Dr. Hanssen said, physicians themselves need to adopt quality standards and learn to avoid mistakes.

Some of the common misuses of antibiotics include: prolonged prophylaxis, failure to narrow the spectrum of antimicrobial activity after establishing diagnosis, and prolonged empiric treatment of a patient who is febrile but not clearly infected.

Yet another common problem leading to resistance is the overuse of certain drugs. Dr. Hanssen decried the widespread administration of vancomycin, which he termed a "very weak" antibiotic compared to others. "There is a huge misconception in the orthopaedic community that this is the big gun," he said. "It's not-it's a water pistol."

At Mayo Clinic, Dr. Hanssen and colleagues have aggressively reduced use of vancomycin, favoring other antimicrobials instead. "We have very few reasons to use it anymore," he said.

Using antibiotics properly is not the only way orthopaedic surgeons can reduce the risk of infection for their patients. When using bone and tissue allografts, orthopaedists should take care that they were acquired following guidelines and standards that have evolved, said Gary E. Friedlaender, MD, Professor and Chair of Orthopaedics at the Yale University School of Medicine.

Retrospective studies have found rates of allograft-related infections approaching 4 percent, and in massive bone grafts, bacterial infection rates of nearly 12 percent have been reported, according to data presented at the AAOS instructional course.

The American Association of Tissue Banks has evolved guidelines that focus on consent, past medical history, examination, and a variety of lab tests.

"Musculoskeletal allografts are safe for our patients if they are obtained using guidelines," said Dr. Friedlaender, a former president of that association. "I would urge you to obtain them from banks that follow them. One way to do that is to make sure they are inspected and accredited."

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Last modified 16/March/2000 by IS