Antibiotics & Treatment of Wound Infection

As described last week, the use of antibiotics in the management of wounds generally falls into two categories: treatment of infected wounds and prophylaxis in vulnerable wounds. This week, we will briefly consider the use of antibiotics to treat wounds that already show signs of colonization or infection.

It is thought that approximately one in four patients with a chronic wound is being treated with antibiotics at any one time, while 60% will have received systemic antibiotics within the previous 6-month period.(1) As the prophylactic use of antibiotics in most chronic wounds is discouraged because of the danger of building host resistance, it must be assumed that most of these prescriptions are for the treatment of existing infections.

As there are limited trial data available concerning the effectiveness of topical antibiotics to reduce bacterial burden, current treatment protocols tend to be based on an empirical approach. In general, the principal indications for initiating topical antibiotic therapy include superficial compartment infections or critical colonization, while use of systemic agents is recommended if the colonization progresses to infection.(1) The NERDS and STONEES mnemonics can be used to differentiate  critical colonization and infection and to direct treatment strategies (see Table).(2) In most cases, and in the absence of microbiological data, a broad-spectrum antibiotic is used in the first instance.

The selection of the specific antibiotic treatment used depends very much on the preferences and previous experiences of the clinician involved.(3) Many innovative antibiotic dressings and creams are now being developed, adopting different approaches in the battle against wound infection. For example, a new wound dressing being developed at Tel Aviv University is based on biodegradable fibers impregnated with antibiotics. After two days, infection-causing bacteria are eradicated, before the dressing biodegrades to avoid common problems associated with dressing removal.(4) This product, as well as many other antibiotic wound care innovations, are currently in clinical trials.

Management of wound infection is a fundamental part of wound care practice, and is a significant area of study in the wound care certification program.

Table. Use of topical or systemic antibiotics in wound critical colonization or infection(2)

Level of colonization	Mnemonic	Recommended agent
Critical colonization	NERDS:    Non healing wound; presence of inflammatory Exudate; friable or Red granulation tissue; tissue Debris, and Smell	Topical agent
Infection	STONEES:    Increased wound Size; Increased local wound Temperature; Extension of the wound to bOne; New wound breakdown; Exudate/ Edema/ Erythema; Smell or odor	Systemic agent

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References

1. Landis SJ. Chronic Wound Infection and Antimicrobial Use. Adv Skin & Wound Care 2008; 21: 531–540.
2. Sibbald RG, Woo K, Ayello EA. Increased bacterial burden and infection: the story of NERDS and STONES. Adv Skin Wound Care 2006;19:447–63.
3. Bates-Jensen BM, Ovington LG. Management of exudate and infection. In: Sussman C and Bates-Jensen B. Wound Care: A Collaborative Practice Manual for Health Professionals. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

4.              ScientistLive. Antibiotics laced dissolving dressing. 20th April 2012. Available from http://www.scientistlive.com/European-Science-News/Pharmacology/Antibiotics_laced_dissolving_dressing/23716/ (Accessed 20 April 2012).