IN POSTOPERATIVE PATIENTS 1

In Postoperative Patients, how Does Antibiotic Adherence

Affect Multidrug-Resistant Organisms

Hannah Braley, Laura Christiane, Victoria Johnson, Brittany Swafford, and Julia Waite

James Madison University School of Nursing

IN POSTOPERATIVE PATIENTS 2

Abstract

Antibiotic resistance is a growing issue in the realm of healthcare. Antibiotic resistance

occurs when bacteria evolves and is no longer affected by the antibiotic used to treat it, creating a

new multidrug resistant organism. This problem needs to be addressed because it has the

potential to make antibiotics used to treat dangerous infections useless and may create problems

that medical professionals have worked for many years to eradicate. Various research studies

have demonstrated that much of the general public and even health care professionals are

unaware of the importance of this issue. It is important to address the reasons for poor adherence

to antibiotics as well as the potential consequences to patients, particularly in postoperative

patients, to prevent further resistant organisms. Throughout the nine different articles addressed

in this literature synthesis, the severity of the problem at hand is clear. There are discrepancies

about how to rectify the issue for both prescribers and patients. However, all sources agreed that

education and increased antibiotic research are two main keys to potential success.
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In Postoperative Patients, how Does Antibiotic Adherence

Affect Multidrug-Resistant Organisms

Introduction

The presence of multidrug resistant organisms is a hot topic in today’s medicine.

Antibiotic resistance refers to the ability of bacteria and other microorganisms to resist the

effects of antibiotics that they were once sensitive to (Centers for Disease Control and

Prevention, 2018). Resistance often occurs when an antibiotic regimen is not completed, the

antibiotic is not effective against the proper organism, or the antibiotic is not necessary to treat

the patient’s condition. When this occurs, the organisms that were killed by the original

treatment have a chance to proliferate, creating a potential to adapt to the initial antibiotic

treatment. This is extremely important because as more organisms are becoming resistant, health

care providers have increased difficulty treating these infections. There is an evident need for an

investigation regarding the effects of antibiotic stewardship and multidrug resistant organisms.

Looking specifically at postoperative patients, how does adherence to the prescribed antibiotic

regimen affect the rates of multidrug-resistant organisms in the hospital and how can these rates

be decreased (Mayo Clinic, 2018)?

Synthesis of Literature

An effective way to combat antibiotic resistance in postoperative patients is through

education. Overprescribing is a significant cause of resistance and studies suggest that

educational courses outside of the undergraduate curricula are necessary to better medical

professional’s understanding of antibiotic stewardship. These educational programs will be most

effective if they are multifaceted and extend beyond the medical community to include the

general public (Lee, C.-R., Lee, J. H., Kang, Jeong, & Lee, S. H., 2015). Public and patient
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education is also key in hindering the progress of antibiotic resistance. In the West article, which

took place in Malta, the most effective teaching theory used was The Normalization Process

Theory. This encompasses a teaching method that explains antibiotic information in a way the

patient will understand while supplying a regimen that is easily applicable to the patient’s

lifestyle. The usage of educational intervention significantly advanced adherence to short term

antibiotics (West, 2018).

Postoperative infections are the most common cause of health-care acquired infections in

surgical patients and the correct use of antibiotic prophylaxis in perioperative care may reduce

these rates (Gouvêa, Novaes, Pereira, Iglesias, 2018). Surgical antibiotic prophylaxis (SAP),

which includes any dose given one hour before the first incision until end of the operation is

often used to prevent these infections. According to a study by Cohen et al., the correct usage of

SAP is not associated with risk of postoperative antibiotic-resistant infections, suggesting that

SAP is effective. However, the adherence rates of providers to SAP guidelines is highly variable

and many use it without proper indication (Cohen et al., 2017). In addition, improper use of SAP

does not protect patients from postoperative infection and may cause more harm, creating a

multidrug resistant organism (Gouvêa, Novaes, Pereira, Iglesias, 2011). Various studies indicate

a greater need for a better adherence for SAP by providers, due to the lack of policies and

universality regarding antibiotic prophylaxis (Gouvêa, Novaes, Pereira, Iglesias, 2011).

In a study by Caffrey et al., preoperative patients were followed, who tested positive for

Methicillin-resistant Staphylococcus aureus (MRSA) and were prescribed a prophylactic

antibiotic treatment to be completed prior to their surgery (Caffrey et al., 2011). Of those

patients, only about 30% completed the treatment correctly. The low percentage of compliance

was largely due to a misunderstanding of how and when to complete the treatment. Only one
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patient contracted MRSA post operatively; however, eighteen patients tested positive for MRSA

the day of their operation. This study suggests that the lack of education and communication

between provider and patient about antibiotics contributes to the misuse of surgical antibiotic

prophylactic treatment and can ultimately decrease the effectiveness of the treatment.

Although the rates of antibiotic resistance are growing, new antibiotics are not being

rapidly created. Mahesh Patel, director of drug discovery research at Wockhardt, says the biggest

barrier for companies creating antibiotics is the regulatory burden. The cost of trials are high, and

unfortunately society is not willing to pay for this, which causes a paradox (Sukkar, 2018).

There is a lack of incentive for drug companies to research antibiotics due to lack of tax cuts and

return on investments associated with this type of research. It is important to note that antibiotics

are used only when needed in short intervals so patients are not using antibiotics regularly as

they are with other medications, thus it is not on the forefront of their priorities. One proposed

fix for this problem is using smaller clinical trials to decrease the cost of the research. Another

solution could be to incentivize drug companies to conduct research through tax cuts (Sukkar,

2018).

In the literature reviewed, there were some areas of weakness and inconsistencies. One

weaknesses is that many of the studies were localized to one region, which was true in the West

article where the research was done in Malta (West, 2018). This could skew the consistency of

the findings when applying them to other cultures or areas. In addition, the study by Cohen et al.

was contained to one specific hospital. Although the sample size was large, the specificity of the

area studied makes the findings less reliable. Another weakness is found in the study by Caffrey

et al., where the size of the group tested is small, most subjects were male, and the mean age was

57 years old. Although using the same types of subjects provided consistency for the study, the
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results became less generalizable to the public (Caffrey et al., 2011). Overall, we found that the

biggest issues regarding consistency within the articles is found within the realm of their

generalizability.

Recommendations

Practitioners must learn how to effectively educate their patients about the importance of

adhering to prescriptions. Patients need to understand the importance of completing the

antibiotics as well as taking them as instructed. Educating those both in and out of the healthcare

industry about the crippling issue of drug resistance that could lead to a global health crisis is an

important solution. In addition, creating standardized guidelines for practitioners regarding

surgical antibiotic prophylaxis can be an effective way to decrease the incidence of this issue,

and will provide consistency. Researching new types of antibiotics is another recommended

solution. Creation of policies that promote the funding of new antibiotics by the government

could be helpful to make this an effective solution. Through patient education, appropriate

antibiotic prescription and use, fixed hospital policies about preoperative antibiotic treatment,

pharmaceutical research, and global education, the antibiotic resistant crisis can be dramatically

reduced world wide.

Conclusion

Commonly used antibiotics such as Penicillin and Tetracycline are becoming less

effective due to the increasing incidence of antibiotic resistance, which is creating a global health

issue. Overall, this problem is something that could benefit from more research. Both health

care providers and the general public need to be educated about antibiotic resistance. If there is

not a solution created for this crisis, the livelihood of mankind could be at stake.
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References

Caffrey, A. R., Woodmansee, S. B., Crandall, N., Tibert, C., Fielding, C., Mikolich, D. J.,

LaPlante, K. L. (2011). Low adherence to outpatient preoperative methicillin-resistant

Staphylococcus aureus decolonization therapy. Infection Control and Hospital

Epidemiology, 32(9), 930-932.

Centers for Disease Control and Prevention. Antibiotic/Antimicrobial Resistance (AR / AMR).

(2018, September 10). Retrieved from https://www.cdc.gov/drugresistance/about.html

Cohen, M. E., Salmasian, H., Li, J., Liu, J., Zachariah, P., Wright, J. D., & Freedberg, D. E.

(2017). Surgical antibiotic prophylaxis and risk for postoperative antibiotic-resistant

infections. Journal Of The American College Of Surgeons, 225(5), 631–638.e3.

doi:10.1093/ofid/ofx163.1728

Gouvêa, M., Novaes, C. D., Pereira, D. M., & Iglesias, A. C. (2015). Adherence to guidelines for

surgical antibiotic prophylaxis: A review. The Brazilian Journal of Infectious Diseases,

19(5), 517-524. doi:10.1016/j.bjid.2015.06.004

Lee, C.-R., Lee, J. H., Kang, L.-W., Jeong, B. C., & Lee, S. H. (2015). Educational

effectiveness, target, and content for prudent antibiotic use. Biomed Research

International. doi:10.1155/2015/214021

Mayoclinic. Antibiotics: Are you misusing them? (2018, January 18). Retrieved from

https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/antibiotics/art-

20045720?p=1

Medlineplus. Antibiotic Resistance. (2018, August 06). Retrieved from

https://medlineplus.gov/antibioticresistance.html#summary
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Sukkar, E. (2013, November 13). Why are there so few antibiotics in the research and

development pipeline? Retrieved from https://www.pharmaceutical-journal.com/news-

and-analysis/features/why-are-there-so-few-antibiotics-in-the-research-and-development-

pipeline/11130209.article?firstPass=false

West, L. M., & Cordina, M. (2018). Educational intervention to enhance adherence to

short-term use of antibiotics. Research In Social & Administrative Pharmacy: RSAP.

https://doi.org/10.1016/j.sapharm.2018.04.011