Arrowsmith Revisited

Martin Arrowsmith, MD was the fictitious character from a novel, first published in 1925, by the Nobel Laureate, Sinclair Lewis [1]. The young Dr. Arrowsmith becomes disenchanted with the practice of family medicine, attempts to find satisfaction in a public health career, and finally pursues laboratory research. In his research effort, he discovers bacteriophage and was able to demonstrate in-vitro activity against the plague bacillus. Plague was rampant on a Caribbean island and Dr. Arrowsmith and his wife went to the island to test the hypothesis of improved outcomes with the bacteriophage treatment. As the plot unfolds, Dr. Arrowsmith's wife contracts the plague and dies, the experimental design to prove effectiveness of the treatment has problems of protocol violations, and at the end of the investigation it is unproven that the bacteriophage therapy made any difference. As the novel concludes, despite all of the setbacks of his effort to treat plague bacilli with bacteriophage, he is committed to continuing his research activities to identify effective treatments for the future as a private enterprise with a colleague rather than in the commercial or academic institutions of his day. It is truly remarkable that nearly 100 years ago and before the emergence of conventional antibiotics, bacteriophage was proposed as potential treatment for human bacterial infection.

Bacteriophage were discovered in 1915–17 [2,3], antimicrobial peptides in 1922 [4], and the prototypical antibiotic of contemporary clinical practice in penicillin was identified in 1929 [5]. Conventional antibiotics were rapidly developed and alternative potential treatments for human infection were not investigated. Technology has generated a plethora of modified and substituted antibiotic molecules, which have extended the activity of currently available drugs to meet the challenge of resistance that has been the consequence of earlier generations of anti-microbials. The generalized deployment of systemic antibiotic therapy has now left clinical medicine with the dilemma of rapidly evolving microbial resistance. Pathogens that are pan-resistant to all available antibiotic therapy are being identified with increasing frequency, and the evolution of microbial resistance even during a course of treatment is being reported. Combining this evolution of resistant bacterial strains with the increased cost and detailed administrative procedures required in the development of new drugs have resulted in concern that the post-antibiotic era is upon us. Old strategies need to be revitalized and new approaches need to be developed.

In the current issue of Surgical Infections, publications are presented to illustrate some alternative ideas for the prevention and treatment of surgical infections in the post-antibiotic era. It is the expectation that these concepts that either have laid fallow for many years or have not been pursued at all can be rejuvenated and find clinical applicability in management of the surgical patient. The content of this special issue brings forward the concepts of active and passive immunity that Pasteur and many others have envisioned as treatments of infection [6]. Can the microbial environment be manipulated to the advance of the host? Can local antiseptics and wound management avoid the need for systemic antibiotics? Can bacteriophage be used as primary treatment of infection? These and other potential therapies will be explored in this issue.

Hopefully, there will be a continued evolution of current antibiotic therapy as new drugs are developed. Nevertheless, the alternative management strategies presented in this theme issue of Surgical Infections will inspire new and rejuvenated treatment plans to supplement and potentially supplant current antibiotic strategies. Like Dr. Arrowsmith, research into alternative methods for treating infection must continue lest the day arrive when our current dependence upon systemic antibiotics will prove ineffective.

The timing of this publication is designed to coincide with the Antibiotic Awareness Week by the World Health Organization [7], Centers for Disease Control and Prevention in Atlanta [8], and the National Collaborating Centre for Infectious Diseases in Canada [9]. Amplification of the need for appropriate antibiotic prescribing habits, specifically in surgery, has been a major focus of the Global Alliance for Infections in Surgery [10]. The goal of these initiatives is to promote antibiotic stewardship practices among all clinicians in the reduction of antibiotic use in clinical scenarios where there are no clinical merits, and avoid prolongation of antibiotic therapy beyond the point of effectiveness. With effective antibiotic stewardship and the development of alternative treatment strategies it is hoped that the post-antibiotic era can be avoided.