Consider this hypothetical case study. One week ago, you performed an elective distal metatarsal head osteotomy for a bunion in a 35-year-old otherwise healthy woman. During the first postoperative visit, after removing the dressing, you note moderate erythema, edema, superficial dehiscence, and serous drainage. Noting the clinical signs of infection, you prescribe an oral antibiotic, clean the area, redress it, and send the patient home. Three days later she’s back with fever, chills, and an ascending infection. She’s admitted to the hospital with a diagnosis of sepsis and placed on intravenous antibiotics, which do not stop the infection’s spread. Blood cultures have now grown out vancomycin-resistant staphylococcus aureus (VRSA). You bring her to the operating room for an emergent incision and drainage, take out the hardware, place an external fixator for tissue stabilization, and leave the wound open. Yet the next day she continues to worsen, antibiotics are changed, and she’s moved to the intensive care unit. Her sepsis becomes overwhelming and she dies in the ICU.

Sounds absolutely horrific, right? The true worst case scenario for every patient and doctor. Could this nightmare scenario become the norm? Unless you’ve been living under a rock, you’ve likely heard about the ongoing concern that we may be entering a “post-antibiotic era” in which previously treatable bacteria are now resistant to current antimicrobials. Is this just fear mongering, or are we truly entering a time when we will not be able to treat bacterial infections with our currently available antibiotics? Is this even worth considering? Whether you believe we are entering a time in which antibiotics will no longer be able to treat infections or not, the topic is worth considering. If we are, in fact, entering a post-antibiotic era, what would this mean for podiatry?

According to the Centers for Disease Control and Prevention, antibiotic resistant organisms are responsible for a minimum of over two million illnesses and 23,000 deaths per year.¹ At the same time, we’re seeing an ever-increasing number of antibiotic related complications such as Clostridium dificile colitis with 250,000 infections per year and 14,000 deaths.¹ It has been estimated that failure to act will lead to 10 million deaths per year from drug resistant organisms by 2050 with a world cost of $100 trillion.²

Consider also that we have been in an evolutionary arms race with bacteria since virtually the moment penicillin was discovered by Alexander Fleming in 1928 (if not for millions of years before that). Penicillin-resistant Staph aureus was identified in 1940, three years before it was introduced to the public.¹ In fact, for a selected list of 11 common antibiotics, the average time from market introduction to target bacteria resistance was 6.4 years.¹ Couple this with the fact that we severely decreased the number of new antibiotic production – the FDA’s approval of new antimicrobial drugs has decreased by 90% in the past 30 years^3-4 – and we have the perfect setting for a world in which we can no longer effectively battle infections.

It appears we are heading to a post-antibiotic era.

How Would a Post-Antibiotic World Affect Podiatrists?

Imagine this for a moment: in a post-antibiotic era, elective surgery would become vanishingly rare. This would destroy a good portion of podiatry and orthopedics, among other specialties, with a new emphasis on nonsurgical treatment. Who would do surgery with the looming risk of uncontrolled infection? No more bunionectomies, flatfoot reconstructions, Morton’s neuroma or hammertoe procedures. Charcot reconstruction? Good luck. Surgery would likely revert back to what it was before the 1940s: amputations, debridement, and trauma. How many otherwise easy-to-treat diabetic foot ulcers would end up as emergent major amputations? Would we have the leeway to attempt partial foot amputations?

We might see – at least at the beginning – a greater move toward minimal incision surgery and external fixation in an attempt to decrease incision size. However, if these procedures don’t prove safe in the face of potential infection, they too would go the way of elective surgery. Hospital-based podiatric treatment would likely become a greater percentage of our profession than it is now, and we would be obligated to take so many more patients to the OR for minor issues for fear of allowing a larger infection to brew.

The surgical supply and instrument industry would collapse, and we would likely see an explosion in the bracing and orthosis industries. In fact, there may be a new urgency to solve problems non-surgically and protect those at risk for infections. The wound care industry would likely become even larger since the push to heal wounds would have a more significant time component. Heal the wound faster would become the mantra, with an increased focus on any product that demonstrates the ability to close a wound fast.

Colleagues, It’s Time to Wake Up!

What this post-antibiotic world will look like is anyone’s guess, but we should be educated about the possibility. Physicians need to realistically consider what this could mean for us, and we should not fall prey to the optimism bias (where a person believes an adverse event is less likely to occur to them than someone else). This is already happening. In 2002 Wester and colleagues surveyed 490 Chicago-area internal medicine physicians about their beliefs and attitudes regarding antimicrobial resistance. Despite the 87% of physicians who felt this was a national problem, only 55% felt this was important in their own hospitals. While 97% believed inappropriate antibiotic use were important causes of resistance, only 60% favored restriction of broad-spectrum antibiotics⁵. These are dangerous attitudes to have.

Until there is some new revolutionary technological advance beyond antimicrobials, the primary cure for this potential disaster is the creation of new antibiotics coupled with appropriate stewardship and prescribing practices. This will require some hard decisions such as monetary incentives for drug companies to produce new antibiotics and controls over physician prescribing. Other methods, such as removing mandatory preoperative antibiotics from the SCIP surgical protocols, will also be beneficial. Without some significant changes to the current state of affairs, the bacteria will win the evolutionary war and the post-antibiotic era will have arrived – if it’s not already here.