328 Surgical Treatment
treated by implant removal, followed by a short
course of antibiotics. Gram-positive aerobic
bacteria have the capacity to produce polysac-
charide biofilm, making eradication without
removing the implant difficult (Jacqueset al.
2010; Singhet al. 2013). One study highlighted
the importance of implant removal by show-
ing that implant removal alone was just as effi-
cient as implant removal with antimicrobial use,
and more effective than antimicrobial adminis-
tration without implant removal (Savickyet al.
2013). In some situations, implant removal
is not always easy or possible. Despite the
general recommendation to remove implants
after infection, a successful resolution of infec-
tion without implant removal or after partial
removal has been achieved in several studies
(Fitzpatrick & Solano 2010; Savickyet al. 2013;
Yapet al. 2015). Risk of long-term recurrence in
such cases is unknown.
Prognosis and economic impact
Despite the high incidence of infection and the
incidence of MDR bacteria, infections of the
stifle joint generally carry a favorable prognosis
if treated appropriately. Resolution of infection
has been achieved in 95% of cases, and lame-
ness resolution can be observed around 38 days
(range 15–45 days) after initiation of treatment
(Fitzpatrick & Solano 2010; Savickyet al. 2013).
In many cases, treatment requires prolonged
antibiotic administration and results in addi-
tional client visits, hospitalization days, or
surgeries. The economic impact of SSI has been
evaluated after TPLO by Nicollet al. (2014), and
can represent a significant burden on the owner.
In this Canadian study, the average postopera-
tive cost for dogs that developed SSI was $1559,
compared to an average cost of $212 for dogs
that did not experience complications. Depend-
ing on the severity of the infection and treat-
ments required, the postoperative costs varied
between $145 and $5022. Presumably, the cost of
treating a MDR bacterium could be higher than
the cost of treating a non-resistant SSI ($2294
versus $1674). However, the difference was not
significant in this publication (Nicollet al. 2014).
In addition to the financial burden, postoper-
ative complications are also likely to decrease
client satisfaction and confidence in the
procedure.
Conclusions
Despite all the medical advances and the dis-
covery of antibiotics more than 60 years ago,
it is clear that surgical infections are here to
stay. Even though infections rates have dras-
tically decreased, the proportion of infections
caused by MDR bacteria continues to increase.
If the trend continues, there will soon come a
post-antibiotic era in which all currently known
antibiotics would be ineffective. Resistance to
each and every one of the currently known
antibiotic classes has already been observed
(Alanis 2005). Inappropriate use of antibiotics,
complacence, and the lack of discovery of new
antibiotics have been largely blamed for this
alarming trend (Overbye & Barrett 2005). Vet-
erinarians are not exempt from responsibility,
and the appropriate use of antibiotics is, more
than ever, of the upmost importance to reduce
or delay the development of bacterial resis-
tance. It is clear that accurate data on infection
rates and evidence-based guidelines for the cor-
rect use of antibiotics in veterinary surgery are
lacking and must be developed. While there
is a renewed push for the discovery of new
antibiotics (Clardyet al. 2006; O’Connellet al.
2013), current research has been focused on
understanding the mechanism of drug resis-
tance, its epidemiology, and the role of biofilm.
Understanding these may lead to new ways
of disrupting the bacterial defense systems to
increase the efficacy of the drugs currently
available. Meanwhile, another body of research
is already preparing for a post-antibiotic times,
evaluating novel strategies for fighting infec-
tions without the use of antibiotics (Kaufmann
2007; de Oca 2013). What the situation will be
in 5–10 years largely depends on the results of
these different research avenues.References
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