Potential burden of antibiotic resistance on surgery and cancer chemotherapy antibiotic prophylaxis in the USA: a literature review and modelling study.
BACKGROUND
The declining efficacy of existing antibiotics potentially jeopardises outcomes in patients undergoing medical procedures. We investigated the potential consequences of increases in antibiotic resistance on the ten most common surgical procedures and immunosuppressing cancer chemotherapies that rely on antibiotic prophylaxis in the USA.


METHODS
We searched the published scientific literature and identified meta-analyses and reviews of randomised controlled trials or quasi-randomised controlled trials (allocation done on the basis of a pseudo-random sequence-eg, odd/even hospital number or date of birth, alternation) to estimate the efficacy of antibiotic prophylaxis in preventing infections and infection-related deaths after surgical procedures and immunosuppressing cancer chemotherapy. We varied the identified effect sizes under different scenarios of reduction in the efficacy of antibiotic prophylaxis (10%, 30%, 70%, and 100% reductions) and estimated the additional number of infections and infection-related deaths per year in the USA for each scenario. We estimated the percentage of pathogens causing infections after these procedures that are resistant to standard prophylactic antibiotics in the USA.


RESULTS
We estimate that between 38·7% and 50·9% of pathogens causing surgical site infections and 26·8% of pathogens causing infections after chemotherapy are resistant to standard prophylactic antibiotics in the USA. A 30% reduction in the efficacy of antibiotic prophylaxis for these procedures would result in 120,000 additional surgical site infections and infections after chemotherapy per year in the USA (ranging from 40,000 for a 10% reduction in efficacy to 280,000 for a 70% reduction in efficacy), and 6300 infection-related deaths (range: 2100 for a 10% reduction in efficacy, to 15,000 for a 70% reduction). We estimated that every year, 13,120 infections (42%) after prostate biopsy are attributable to resistance to fluoroquinolones in the USA.


CONCLUSIONS
Increasing antibiotic resistance potentially threatens the safety and efficacy of surgical procedures and immunosuppressing chemotherapy. More data are needed to establish how antibiotic prophylaxis recommendations should be modified in the context of increasing rates of resistance.


BACKGROUND
DRIVE-AB Consortium.
Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA.
Aude
A
Teillant
Center for Disease Dynamics, Economics & Policy, Washington, DC, USA.
Sumanth
S
Gandra
Center for Disease Dynamics, Economics & Policy, Washington, DC, USA.
Devra
D
Barter
Center for Disease Dynamics, Economics & Policy, Washington, DC, USA; School of Medicine and VA Maryland Healthcare System, University of Maryland, Baltimore, MD, USA.
Daniel J
DJ
Morgan
Center for Disease Dynamics, Economics & Policy, Washington, DC, USA; Princeton Environmental Institute, Princeton, NJ, USA; University of Strathclyde, Glasgow, UK. Electronic address: ramanan@cddep.org.
Ramanan
R
Laxminarayan
D000900:Anti-Bacterial Agents / Q000191:economics* / Q000627:therapeutic use; D000970:Antineoplastic Agents / Q000191:economics / Q000627:therapeutic use; D024841:Fluoroquinolones / Q000191:economics* / Q000627:therapeutic use; D006801:Humans; D007166:Immunosuppressive Agents / Q000191:economics / Q000627:therapeutic use; D015233:Models, Statistical; D009369:Neoplasms / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality / Q000601:surgery; D009894:Opportunistic Infections / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality / Q000601:surgery; D016032:Randomized Controlled Trials as Topic; D013530:Surgical Wound Infection / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality / Q000601:surgery
D000900:Anti-Bacterial Agents; D000970:Antineoplastic Agents; D024841:Fluoroquinolones; D007166:Immunosuppressive Agents