AvantGuard discusses the future of antimicrobial stewardship and infection prevention in a post-antibiotic world.
The current standard of care for preventing infections will have to shift in a world of reduced antibiotic efficacy. The Department of Defense’s evidence-based protocols for the treatment of wounds, codified in The Joint Trauma System Clinical Practice Guidelines, do not recommend the use of topical antiseptics in wounds to minimise infection risk. The only possible exception is the use of silver sulfadiazine in burn wounds, because the damaged tissue does not properly profuse systemic antibiotics and acts as a food source for pathogens. Most of the guidelines are dedicated to a discussion of which antibiotic to use, mainly prophylactically. Which leads to our first question: What if antibiotics lose their efficacy due to resistance?
Planning for antimicrobial resistance (AMR)
Antibiotics are a godsend – despite many calls for concern about resistance generation, they continue to save millions of lives every year, blinding us to a grave reality. The 2025 World Health Organization (WHO) Global Antimicrobial Resistance Surveillance report showed that one in six laboratory-confirmed bacterial infections worldwide are resistant to antibiotic treatments – an increase of 40% in the previous five-year period.¹ Today, 90% of Ukrainian casualties present themselves to healthcare facilities ~5-7 days post injury with polymicrobial infections of multidrug-resistant organisms (MDRO), of which 25-50% are pan-resistant to all antibiotics. If antibiotics lose their efficacy, we need to update the guidelines, and we need to consider now what those changes might be.
AMR and the battlefield
Battlefields are significant contributors to the rise of antibiotic resistance, as they breed unhygienic conditions with limited access to antibiotics, so maintenance of antibiotic stewardship is nearly impossible. To help determine the best approach to minimising infection, it is worth pondering a second question: Are antibiotic-resistant pathogens more likely to be acquired on the battlefield or in the hospital system?
During the Iraq war, carbapenem-resistant strains of Acinetobacter baumannii, ‘Iraqibacter,’ had mortality rates of up to 70%.² Recent data indicate that contamination of the environment of field hospitals and infection transmission in healthcare facilities played a major role in the acquisition of A. baumannii.³ Resistant organisms can be found in natural environments, but they often gain resistance at the cost of fitness, meaning resistant strains will get out-competed by non-resistant strains. Resistant strains get help from people taking antibiotics by eliminating susceptible pathogens and creating an environment where they can thrive. Where are people who have taken antibiotics? They are in the healthcare system. This creates the perfect environment for drug-resistant pathogens to spread in a possibly vulnerable population.
In the healthcare environment
Today, globally, healthcare-associated infections (HAIs) account for an estimated 136 million cases each year, with up to 3.5 million deaths attributed to HAIs annually.4-6 Prevalence rates can reach 25% in developing countries and 5-15% in developed countries, contributing to high morbidity and mortality rates.⁴ The number of deaths due to antimicrobial resistance is expected to rise by 70% by 2050.⁷ Over 2.8 million antimicrobial-resistant infections occur annually in the United States, resulting in more than 48,000 deaths.¹ This does not mean you should avoid hospitals. Infection rates have decreased in recent years since the Centers for Medicare & Medicaid Services put a spotlight on them. What’s worrying is that resistance generation puts us at risk of losing those gains.
If the healthcare environment is a location to make significant improvements in infection prevention, our third question is: What areas of that environment can yield the biggest gain? There are two areas for improvement: eliminating reservoirs of pathogen load and eliminating the spread of pathogens.
Environmental surfaces, aka high-touch surfaces, get significant attention as a reservoir of pathogens. A worst-case example is the rise of pathogens like Candida auris (now Candidozyma auris). C. auris has torn through hospitals recently, with up to a 40% mortality rate, and is hard to remove from skin and the environment, requiring our strongest disinfectants. C. auris is a slow grower and easily outcompeted but, when all other microbes are killed, C. auris biofilms thrive, easily shedding off patient skin into the environment in as few as four hours and then spreading back onto other patients’ skin. Small medical tools that get colonised often lead to multi-year outbreaks as they don’t get disinfected as often as high-touch surfaces and then spread C. auris throughout the hospital, compounding the issue.
The spread of MDROs throughout hospital systems is also often driven by hand hygiene. Common HAIs, such as surgical site infections, ventilator-associated pneumonia, and bloodstream infections, are often traced back to ineffective hand hygiene practices.8-10 Estimates put hand hygiene compliance at around 60%,11 with many barriers to overcome to reach higher levels.12 With the rise of antibiotic resistance, any transfer of pathogens on the hands of patients or healthcare workers (HCWs) becomes that much more dangerous.
Both hand hygiene and environmental disinfection would benefit from long-lasting protection – something that would prevent surfaces with infrequent disinfection from becoming colonised and reduce the likelihood of spread due to non-compliance.
Considering skin
However, we are still missing the real reservoir leading to our last question: What is the only surface in a patient’s room that is not cleaned every day? The answer is their skin. People on antibiotics unintentionally select for drug-resistant pathogens to colonise their skin by eliminating non-drug-resistant pathogens, creating a fertile environment for drug-resistant pathogens without competition. Attempts to target common skin-colonising pathogens like methicillin-resistant Staphylococcus aureus (MRSA) have shown little efficacy. However, universal decolonisation with broad-spectrum antiseptics has shown efficacy in decreasing MDRO prevalence by up to 26.7%, significantly decreasing transfers from nursing homes to hospitals due to infection, and reducing the chances of MDROs being present in a patient environment by 43%.13-15
So why hasn’t universal decolonisation been implemented in all hospitals? The same reason compliance with hand hygiene practices is at 60%, and some surfaces are not always disinfected – to do so takes precious time out of HCWs’ days and is expensive for the hospital. In the end, the cost outweighs the benefits. However, long-lasting efficacy would solve this issue too. Combined with residual efficacy in hand hygiene and disinfection, a long-lasting antiseptic would reduce MDRO prevalence, infection, environmental contamination, and the need for contact precautions far better than a transient one. The reduction in time spent on disinfection and hand hygiene would open the door for time spent on universal decolonisation, and the increased efficacy would only make it more worth the effort.
Despite the numerous disinfectant products available, i.e., bleach, hydrogen peroxide, peracetic acid, phenols, and quaternary ammonium compounds (QACs), none have residual efficacy at the level needed to combat HAIs. QACs are the only product to have any residual efficacy, but they are not effective against bacterial spores, mycobacteria, and are generating resistance to themselves.
The antiseptics available are also limited; chlorhexidine and povidone iodine are not safe for long-term and full-body use, benzalkonium chloride is a QAC with the limitations mentioned above, and alcohols would cause significant dryness and possibly damage the skin barrier in full-body use. None of the products show promising long-term efficacy.
Introducing AvantGuard’s AVA-003
AvantGuard’s novel antiseptic compound, AVA-003, meets the needs of the healthcare system and rises to the challenge of the post-antibiotic world. AVA-003 leverages the inherent biocompatibility of using the same chemical approach as our immune system, chlorine, to provide the broad-spectrum efficacy of chlorine-based disinfectants against all bacteria, fungi, spores, and viruses, but makes it safe enough for use on surfaces without corrosion, skin without irritation, or wounds without delaying healing. Even at sub-lethal doses where antibiotics develop resistance, AVA-003 is active against pathogens for the same reason we put chlorine in drinking water or swimming pools. Additionally, AVA-003 provides residual efficacy, almost like leaving the same level of chlorine in swimming pools on surfaces, including hands, for long-lasting protection. AVA-003 is a perfect biocompatible biocide.
The post-antibiotic world is almost here, and the future of antimicrobial stewardship and HAI prevention rides on innovations like AVA-003.
References
World Health Organization. Global antibiotic resistance surveillance report 2025: WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS). Geneva, 2025
Brady, M.; Jamal, Z.; Pervin, N. Acinetobacter; StatPearls Publishing, 2023
Dijkshoorn, L.; Nemec, A.; Seifert, H. An increasing threat in hospitals: multidrug-resistant Acinetobacter baumannii. Nat Rev Microbiol 2007, 5 (12), 939–951. DOI: 10.1038/nrmicro1789 From NLM
Raoofi, S.; Pashazadeh Kan, F.; Rafiei, S.; Hosseinipalangi, Z.; Noorani Mejareh, Z.; Khani, S.; Abdollahi, B.; Seyghalani Talab, F.; Sanaei, M.; Zarabi, F.; et al. Global prevalence of nosocomial infection: A systematic review and meta-analysis. PLoS One 2023, 18 (1), e0274248. DOI: 10.1371/journal.pone.0274248 From NLM
World Health, O. Global report on infection prevention and control 2024; World Health Organization, 2024
Balasubramanian, R.; Van Boeckel, T. P.; Carmeli, Y.; Cosgrove, S.; Laxminarayan, R. Global incidence in hospital-associated infections resistant to antibiotics: An analysis of point prevalence surveys from 99 countries. PLOS Medicine 2023, 20 (6), e1004178. DOI: 10.1371/journal.pmed.1004178
Naghavi, M.; Vollset, S. E.; Ikuta, K. S.; Swetschinski, L. R.; Gray, A. P.; Wool, E. E.; Robles Aguilar, G.; Mestrovic, T.; Smith, G.; Han, C.; et al. Global burden of bacterial antimicrobial resistance 1990-2021: a systematic analysis with forecasts to 2050. The Lancet 2024, 404 (10459), 1199–1226. DOI: 10.1016/S0140-6736(24)01867-1 (acccessed 2025/10/13)
Kampf, G.; Löffler, H.; Gastmeier, P. Hand hygiene for the prevention of nosocomial infections. Dtsch Arztebl Int 2009, 106 (40), 649–655. DOI: 10.3238/arztebl.2009.0649 From NLM
Kumar, A.; Keri, V. C.; Khan, M. A.; Ranjan, P.; Rastogi, N.; Sahu, M.; Wig, N. Assessment of healthcare worker’s hand hygiene and infection prevention practices of their personal belongings in a healthcare setting: a survey in pre COVID-19 era and literature review on standard disinfection practices. J Prev Med Hyg 2021, 62 (1), E104–e109. DOI: 10.15167/2421-4248/jpmh2021.62.1.1742 From NLM
Armstrong-Novak, J.; Juan, H. Y.; Cooper, K.; Bailey, P. Healthcare Personnel Hand Hygiene Compliance: Are We There Yet? Curr Infect Dis Rep 2023, 1–7. DOI: 10.1007/s11908-023-00806-8 From NLM
Mouajou, V.; Adams, K.; DeLisle, G.; Quach, C. Hand hygiene compliance in the prevention of hospital-acquired infections: a systematic review. J Hosp Infect 2022, 119, 33–48. DOI: 10.1016/j.jhin.2021.09.016 From NLM
Afework, A.; Tamene, A. Uncovering the obstacles: a comprehensive analysis of barriers to hand hygiene adherence among healthcare providers: a systematic review. BMC Infect Dis 2025, 25 (1), 502. DOI: 10.1186/s12879-025-10924-4 From NLM
Mody, L.; Gontjes, K. J.; Cassone, M.; Gibson, K. E.; Lansing, B. J.; Mantey, J.; Kabeto, M.; Galecki, A.; Min, L. Effectiveness of a Multicomponent Intervention to Reduce Multidrug-Resistant Organisms in Nursing Homes: A Cluster Randomized Clinical Trial. JAMA Netw Open 2021, 4 (7), e2116555. DOI: 10.1001/jamanetworkopen.2021.16555 From NLM
Miller, L. G.; McKinnell, J. A.; Singh, R. D.; Gussin, G. M.; Kleinman, K.; Saavedra, R.; Mendez, J.; Catuna, T. D.; Felix, J.; Chang, J.; et al. Decolonization in Nursing Homes to Prevent Infection and Hospitalization. New England Journal of Medicine 2023, 389 (19), 1766–1777. DOI: doi:10.1056/NEJMoa2215254
Gussin, G. M.; McKinnell, J. A.; Singh, R. D.; Miller, L. G.; Kleinman, K.; Saavedra, R.; Tjoa, T.; Gohil, S. K.; Catuna, T. D.; Heim, L. T.; et al. Reducing Hospitalizations and Multidrug-Resistant Organisms via Regional Decolonization in Hospitals and Nursing Homes. Jama 2024, 331 (18), 1544–1557. DOI: 10.1001/jama.2024.2759 From NLM
Please note, this article will also appear in the 25th edition of our quarterly publication.
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