Antibiotics in woundcare
Figure 1 Daily, we are witnessing an enormous abuse of antibiotics in wound care in Africa, and it is almost as if a chronic wound is synonymous with antibiotic therapy. We will focus a lot on this topic in newsletters and social media campaigns. Not only does this practice lead to the unnecessary development of resistant microbial strains, but it can actually harm the patients by causing antibiotic-related diarrhea and other side effects. credits Tima Miroshnichenko
Most chronic wounds will never need a course of antibiotics.
You can prevent infections from developing in chronic wounds by having clean procedures, rinsing the wounds with antibacterial solutions, applying antibacterial substances like honey, granulated sugar, silver-coated- or iodine impregnated dressings, to mention some. Critical wound colonization with pseudomonas aeroginosa can easily be treated topically with diluted vinegar ( see our separate chapter on the challenge with pseudomonas). Topical antibacterial substances are not the same thing as antibiotics!
If you have a patient with a chronic wound before you - take a step back and really think about whether antibiotics are necessary in this particular case. Never prescribe antibiotics routinely for patients with chronic wounds.
Pus-filled boils and abscesses most often do not need antibiotics. They need a scalpel to drain the pus out. After drainage, antibiotics are only necessary if the patient has a fever or shows other severe signs of systemic infection.
Foul smell alone from a chronic wound is not an indication for antibiotics. Instead, the wound should be debrided and cleansed, and topical antibacterial products, as mentioned above, can be used to prevent an infection from occurring.
Indications for using antibiotics are, for example, rapidly spreading local signs of infection, systemic signs of infection like high fever and malaise, erysipelas, diabetic foot infections, chronic wounds with exposed tendons or bone, infections in immune-deficient patients. Some types of tropical ulcers, like the Buruli ulcer, require a specific antibiotic regime to heal.
Always take a bacterial swab from the cleaned wound bed if you think of giving antibiotics. Make sure you have the routine to check the lab results when they come back after a few days to ensure that the antibiotic prescribed matches the bacteria found on the swab.
Never take a bacterial swab from a wound unless you consider prescribing antibiotics. It simply makes no sense to take a routine bacterial swab- you will definitely find a number of pathogenic strains in any way. This does not mean that the patient needs antibiotics.
Follow your national guidelines for which antibiotics should be prescribed for which condition. We also refer to the Pocket Guide for Prescribing Antibiotics for Adults in South Africa, which is available online on behalf of the South African Antibiotic Stewardship Program ( SAASP). We have a link to this pdf file below. This is also available as a free app for mobile phones, both IOS and android based.
Keep the course of antibiotics as short as possible. It may be sufficient to treat the infection for only 7-10 days in many cases. There are, of course, exceptions like infections in deeper tissues like, for example, osteomyelitis, which requires at least several weeks with antibiotics.
Get familiar with the term " antibiotic stewardship" - what it implies and how to implement this in your workplace.
Figure 2 None of these chronic ulcers need antibiotic treatment to heal. In the upper left image, the patient has a severe venous ulcer with an out-of-control superficial infection with pseudomonas aeroginosa. This infection was rapidly treated with twice daily diluted vinegar application, a topical antimicrobial dressing ( silver coated), and a good absorbent dressing to control the exudate. In the upper right image, we have a patient with an ulcer of mixed etiology - both venous and arterial. There are no signs of infection, and antibiotics are contraindicated. The lower-left image is a case of chronic ulceration after a trauma to the leg's shin. Everything looks peaceful- there is even some granulation tissue forming in the middle of the wound. We see a large pressure ulcer over the buttock area in the lower right image. The patient had no signs of systemic infection. The sloughy necrotic tissue was debrided, and topical antibacterial products were used to keep the bacterial levels under control. copyright upper right image: Shutterstock
Figure 3 As a rule of thumb, boils and carbuncles do not necessarily need antibiotic treatment. What they need is a scalpel to drain the pus out as soon as possible. Irrigate the abscess cavity thouroughly with saline or preferable an antibacterial solution on a regualr basis - if possible, daily. Some sort of tubing attached to a large syringe will make irrigation easier. Do not overstuff the cavity with gauze as this will block the outflow of purulent material!
In Africa and globally, we see an alarming abuse of antibiotics in the treatment of chronic ulcers. Often broad-spectrum antibiotics are administered, which makes the issue even more serious. Studies from the USA show that up to 25% of patients with chronic ulcers use antibiotics right now, and that may be up to 60% of patients with chronic ulcers have received antibiotics at some point in time as a part of the wound treatment regime. To set things in perspective: the chief editors of WoundsAfrica work at a tissue viability clinic at a government hospital where most of our patients have complicated chronic wounds demanding advanced treatments. Yet only about 5-10% of our patients need antibiotic treatment. We have adopted an antibiotic stewardship approach which over time has yielded results.
Most chronic wounds do not need antibiotic treatment, and it is a misconception that these wounds will generally heal faster if the patient is given antibiotics.
You will most likely already have heard the term " antibiotic stewardship" but may not know what this really means. Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance. It involves educational awareness programs for clinicians and patients. You will find a lot of information about such programs on the internet.
Figure 4 If you are interested in antibiotic stewardship programs, we recommend this publication by the Center for Disease Control and Prevention (CDC): The Core Elements of Human Antibiotic Stewardship Programs in Resource-Limited Settings. It has relevant information for both national and hospital levels. Click on the image above to get to a pdf file of the document. copyright:CDC
Many healthcare workers still do not understand that when you take a bacterial swab from a chronic wound, and the results show staphylococcus aureus or enterococci ( or other pathogenic bacteria), this should not automatically translate into a prescription for antibiotics. All chronic wounds are colonized with bacteria. Staphylococcus aureus, for example, is a very common guest in most chronic wounds and only rarely poses a real threat. Most bacteria in chronic wounds behave quite well as long as the numbers are kept under control. As long as the tissue is adequately perfused and there is not too much necrotic tissue, the bacterial load of chronic wounds keeps a good balance by itself. If we suspect a bacterial imbalance - for example, if there is increased inflammation or odour, we should try topical antibacterial solutions or dressings first. Superoxodized water, polyhexanide solutions, or diluted vinegar are examples of antibacterial rinses that can keep bacterial numbers in check. All these solutions have in common that the antibacterial effect is not long-lasting - probably only a few hours. Therefore it is ideal if the dressing choice also has some antibacterial effect. You could use honey or granulated sugar to limit bacterial growth. Silver or iodine impregnated dressings can be used before even considering antibiotics. Please also refer to the chapter about "topical antimicrobials."
Of course, there are situations where we definitely have to use antibiotics to save limbs and lives. If the patient is systemically affected with fever or general malaise, or rapid deterioration of the wound area, there will be a strong indication for using antibiotics. We also have a lower threshold for starting with antibiotics in patients with diabetic foot problems as these ulcerations quickly deteriorate when there is a bacterial infection. If the patient has a comprised immune deficiency due to, for example, HIV, then this may also warrant a more aggressive approach towards antibiotic treatment. As a rule of thumb, we also consider antibiotic treatment in most cases where we see exposed bone or hardware. However, keep in mind that there is a general trend internationally towards shorter treatment periods. Previously we were taught to treat, for example, diabetic patients with infected foot ulcers on antibiotics for at least 2-3 weeks. Today, we use much shorter treatment periods, sometimes only a week unless bone or tendon involvement warrants longer treatment periods. Many countries have devised national recommendations for antibiotics in both the primary and secondary healthcare systems.
Another misconception is that pus-filled boils and abscesses always need antibiotics. What these conditions need is a scalpel to drain the pus out. Once this has been done, antibiotics are rarely necessary unless the patient has a high fever or shows other signs of systemic infection. Antibacterial solutions can be used to rinse the abscess cavity afterwards.
When we administer antibiotics, we usually do this systemically. This means we either give the antibiotics orally, intravenously or by intramuscular injection. The antibiotic will then travel through the entire body and eventually reach the infection area. Although systemic antibiotic therapy is seen as the standard of care, we must remember that our normal bacterial flora will also be affected by this and can cause antibiotic resistance. It is, therefore, relevant to ask whether topically applied antibiotics directly into the wound can be utilized. The consensus was previously that topical antibiotics lead to antibiotic resistance problems. But is the danger of resistance not actually worse when we use systemic antibiotics- when all the bacteria of our body come into contact with the given antibiotic? This is a highly relevant discussion, and we do not have a definite answer to this. Keep in mind that some infections will not respond adequately to topical antibiotics because the bacterial infection already has spread far away from the wound bed into other tissue regions where a topically applied antibiotic will not reach.
At a recent congress, a microbiologist explained that topically applied antibiotics actually lead to fewer resistance issues - when used correctly. The problem is that many caregivers see topical antibiotics as something relatively harmless and have a surprisingly low threshold to applying them into wounds, whether they seem infected or not. In Norway, where we work, we see confirmation of this daily. A majority of our patients report that their GPs prescribed some form of topical antibiotic during the course of the wound treatment. Furthermore, many patients believe that every wound requires a topical antibiotic, and since some of these products can be obtained without a prescription, their use is widespread. So, in conclusion: topically applied antibiotics theoretically will pose less of a risk for resistance- as long as they are used with restrictions. When they, however, are used without discrimination, they pose a significant threat for developing resistant bacterial strains.
We mentioned earlier that we rarely need antibiotic treatment at our wound clinic, and we never (very rarely) use topical antibacterials. When we see a need for controlling a bacterial imbalance in the wound, we use antibacterial products- this is not the same as antibiotics - and reserve the need for systemic antibiotics for the more severe cases.
There is also some misconception about when to give intravenous antibiotics and when we can switch to oral antibiotics. Intravenously administered antibiotics in general work quicker as they bypass the digestive tract. They are warranted in severe infection and when the patient is in poor condition and may not be able to swallow oral antibiotics. Some health workers ( and almost all patients) think that intravenous antibiotics are at least twice as effective as oral antibiotics. That is a misconception - the efficacy of oral antibiotics is usually around 80-90% of the intravenous form. The biggest advantage of administering an antibiotic intravenously is that it works more rapidly at the start. Once the body has been "saturated" with the intravenous antibiotic, we can switch to the oral form. Note that there is an international trend towards switching from intravenous to oral antibiotics earlier than before. Sometimes only a single intravenous dose may be required before the patient can be changed to oral antibiotics. This can save many resources and be a helpful workaround at rural dispensaries with no possibility of hospitalizing the patient. The patient can receive a single dose of antibiotics intravenously as an out-patient, then return home with a prescription for oral antibiotics.
On a side note: some healthcare workers still believe that crushing antibiotic tablets and sprinkling them into a wound can outperform systemic antibiotic therapy. Do not use that method - it is considered even worse in terms of developing resistant strains than using systemic or other topical antibiotics! It can even have adverse effects on the healing of the wound. Many years ago, it was not uncommon to crush metronidazole tablets and sprinkle the resulting powder onto malignant ulcerations ( for example, breast cancer ulcerations) to control odour and superficial infections. This method is seen as obsolete and should not be utilized anymore. There are excellent antibacterial solutions instead that we should use. For example, odour control can be achieved by several different products like activated charcoal.
Remember: Always take a bacterial swab BEFORE starting the patient on antibiotic treatment. This is important to ensure that the patient receives the correct type of antibiotics. Before taking the bacterial swab, you have to clean the wound bed properly and irrigate it thoroughly with saline to remove the irrelevant bacteria present in any chronic wound. We are interested in the bacteria that adhere to the bottom of the wound bed - they are usually the ones relevant to the patient's infection. You need not worry about washing away too many bacteria - we guarantee you that you will get growth of bacteria on your swab even though you have cleaned the wound well beforehand! Do not use antibacterial solutions ( like super oxidized water or polyhexanide) when cleaning the wound before taking a bacterial sample, as this may interfere with the results. The standard procedure is as follows: We take a good bacterial swab and start the patient on a course of antibiotics.
After a few days, the results should be back from the lab, and we have to check that the strain(s) of bacteria found match the antibiotics we have prescribed. This is something that is often overlooked - very often, the antibiotic treatment is not adjusted after the microbiological test results are back. This also has to do with some challenging logistics in rural parts of Africa. The patient may have travelled half a day to get to the dispensary and may not be easy to reach after the lab report comes back. Please refer to our separate chapter on taking a good bacterial swab which you find under "Tools" in the menu.
Figure 5 The South African Antibiotic Stewardship Program (SAASP) has published a pocket guide for antibiotic prescribing for adults in South Africa. The version we found online is from 2015, but the recommendations for infections in soft tissues are still valid today. If you are aware of a more recent online version, please send us an email. This pocket guide is also available free of charge as a smartphone app, and you will find this app on iTunes or GooglePlay. Click on the image above to get to the pdf version—the relevant pages for wound care are from page 50 and onwards.
Figure 6 Futurelearn.com has a free-of-charge online course on antimicrobial stewardship for Africa. This is relevant for wound care specifically and a valuable course for all health workers. Click on the image above to get to the course registration. copyright futurelearn.com
Figure 7 The European Wound Management Association ( EWMA) and the British Society for Antimicrobial Therapy have an ongoing project on this topic. The link above leads to several useful publications.
Figure 8 The WHO AWaRe (Access, Watch, Reserve) antibiotic book provides concise, evidence-based guidance on the choice of antibiotic, dose, route of administration, and duration of treatment for more than 30 of the most common clinical infections in children and adults in both primary health care and hospital settings. Click on the image above to get to the downloadable document.
I work as a nurse at a GP office in Harare. I see daily that our GP prescribes local antibiotics whenever he sees a chronic wound - for example, Fucidin or Bacymycin. I have learned that there are no indications for such topical antibiotics. What alternatives can I suggest here?
Answer: Most chronic wounds need antibiotic treatment - neither systemic nor topical. Both forms of administration increase the chance of antibiotic resistance. Suppose there are clear signs of serious infection, the patient should receive a course of systemic antibiotics. Sometimes topical antibacterials ( these are not antibiotics!) may be useful when we suspect an increased amount of bacteria present in the wound- for example if there is a foul smell. Examples of these are honey, sugar, silver-coated dressings, or iodine impregnated dressings. Superoxidized water or PHMB solutions can be used to rinse the wound when a bacterial imbalance is suspected.
In the dispensary where I work as a medical assistant in western Tanzania, we routinely use a silver-sulfadiazine cream in chronic wounds. We feel that this is a practice that works very well. However, is this something you recommend? Can we cause bacterial resistance with this practice?
Answer: Silver-sulfadiazine is a topical antibacterial cream with an active ingredient that belongs to the group of antibiotic medicines called sulphonamides. So, in reality, it is more than an antibacterial - it has an antibiotic component, and therefore, yes, you will cause resistance when you use it routinely. There have also been some issues with local allergic skin reactions when using this product. Initially, the product was developed to prevent and treat superficial infections in burn patients. We are aware of its widespread use in many other areas of wound care. The general consensus is that we should limit the use of this product to burn care and only rarely use this for other wounds. In most cases, you will achieve the same results if you use an antibacterial product like honey, granulated sugar, vinegar products, silver-coated dressings, or iodine impregnated dressings. Please also refer to our chapter on topical antibacterial products.
I work as a GP in Johannesburg. I am aware of the problem with antibiotic resistance. However, I hardly find it an issue when I prescribe antibiotics to my patients when the agricultural/ veterinary sector uses much more antibiotics than we do in human medicine. I believe that they are the true culprit of antibiotic resistance. Could you comment on this?
Answer: You are correct in stating that the use of antibiotics in livestock ( and even fish farming!) is alarmingly high and most certainly contributes to the global challenge of resistant bacteria. However, it is not just a simple case of blaming the agricultural sector. We see the highest incidence of resistant strains of bacteria in countries with an all too liberal antibiotic policy for human use. We see the highest incidence of multiresistant strains in hospitals where antibiotic policies have been handled poorly over decades. Take the Netherlands as an example. They have a very active agricultural sector where antibiotics are routinely used in livestock as well. However, they have had a stringent antibiotic policy in the human health care sector, which has resulted in the fact that it is one of the countries with the least resistance problems in the world. In other words- we have proof that antibiotic awareness programs help to fight resistance. Every time you use an antibiotic without proper indication, you sabotage these global efforts.
I work as a registered nurse at a rural wound care clinic in Nigeria. Sometimes I find it very obvious that a patient with a chronic wound needs antibiotics; at other times, I find it really hard to determine whether antibiotics are required. Do you have any advice here?
Answer: We understand your dilemma. Even for us who work with wound care daily at an expert level, we sometimes scratch our heads and wonder if antibiotics may be needed after all. Of course, we have some situations where it is evident that antibiotics are indicated- for example, if there are signs of a quickly spreading infection of the wound, in cases of erysipelas, if the patient is systemically affected like a high fever, etc. However, in many cases, we are ourselves quite unsure whether we should start up with antibiotics - it is not always a clear-cut case. It always makes the decision easier when we can have a patient's follow-up the next day or within a few days. If we are unsure about giving antibiotics, it is usually a very good idea to ask the patient to come back the next day or after two days. In the meantime, you can use topical antibacterial products to see if this is sufficient. You can mark the area of redness with a marker and check if the redness has spread. Has the patient noticed any improvement like less pain, less swelling, etc.? Then probably antibiotics are not needed. If you are working at an off-the-grid clinic where the patient has traveled to by hitchhiking for several hours, a re-visit to the clinic is not always a realistic option. Most patients today have access to a mobile phone, and in that case, you could have a telephone consultation with the patient to check on how it is going.
Another issue is that the classical signs of infection may be harder to spot in African skin than lighter skin. Be aware that signs of infection may be completely absent in patients with diabetic ulcers.
I am a nurse working at a nursing home in Cairo. We currently have a patient who knocked the shin of her leg on a bedpost and developed a chronic leg ulcer. It seems infected - we took a bacterial swab which showed a mix of bacteria- staphylococcus aureus, streptococci, and escherichia coli. Which of these bacteria should we treat? No antibiotic covers all three bacteria alone. Should we give a combination of antibiotics? The patient is otherwise in good shape- she has slight fevers in the nights but has no other signs of serious systemic infection.
Answer: Firstly, from the little information we have about the patient, we cannot determine whether she really needs antibiotics - maybe all the wound needs is a good debridement and topical antibacterial products? You state that she has a slight fever at night - this does not necessarily mean that the infection is severe - the natural inflammation processes of the wound itself can cause a slight fever. But for the sake of argument, let us assume that the wound indeed warrants the use of antibiotics. You took a bacterial swab that shows an unhappy mix of three pathogenic bacteria. Should we give antibiotics to treat all three strains? That may involve using three different types of antibiotics, at least two types.
Your bacterial swab result tells us that it most likely was not taken correctly. Was the wound bed properly cleaned/irrigated before taking the swab? Most likely, only one of these bacteria is the true culprit of the infection. If the clinical condition of the patient allows it, it can be wise to withhold antibiotic treatment for a few days ( use antibacterial products in the meantime) and do another swab- this time in the correct way. If you are lucky, you will only end up with one strain of bacteria, which is most likely the one you need to focus on with your treatment.
If you, however, feel that the patient needs antibiotics straight away, we would advise you to do another swab first and then start with the antibiotic. You will have to make an educated guess for which bacterial strain is most relevant for the infection. Sometimes the appearance of the infection can give us a hint about which bacteria is the true culprit. For example- if the area of redness is rapidly ascending in the leg as is typical of erysipelas, then we may assume that the streptococci are the troublemakers here. If there is a foul-smelling exudate, we probably should focus on the escherichia coli. We also have to remember the aggressiveness of different bacterial strains. As a rule of thumb, it is very common to find Staphylococcus aureus and e.coli in chronic wounds in Africa. Streptococci, however, is a less common part of the " normal" wound flora, and they more often cause trouble. That was a long answer to your question. Most likely, we would have taken a new swab and started the patient on penicillin against the streptococci while attempting to control the e.coli and staphylococci by using topical antibacterials and debriding as much necrotic tissue as possible.
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