Preparing the Wound Bed – Debridement, Bacterial Balance, and ...

Safe and Effective
Selected Use
Caution
Cadexomer iodine
Ionized silver
Silver sulphadiazine
Polymyxin B sulphate
– Bacitracin
zinc
Mupirocin
Metronidazole
Benzoyl peroxide
Gentamicin
Fucidin
Polymyxin B sulphate
– Bacitracin
zinc neomycin
+ = effective against bacteria
strong enough for cytoxicity. It should be used with caution
in patients with thyroid disease and iodine allergy. If cadexomer
iodine is used on large areas or for long periods, monitoring
of thyroid function is advised.
Ionized silver dressing (Acticoat ; Westaim Biomedical,
Exeter, NH, Fort Saskatchewan, Alberta, Canada) has a slow
release of silver, combined with an absorptive polyester pad.
The silver has a broad spectrum of antibacterial coverage
and can be used very successfully to decrease friable exudative
tissue on the wound surface. Acticoat must be used
with sterile water because the chloride in saline precipitates
the silver to inactive silver chloride. Acticoat contains no
sulfa, which may be present in other silver preparations.
Topical antibacterials will only treat the wound surface
and not deeper infection. Their use should be re-evaluated
after 2 weeks or if symptoms or signs of deeper infection
occur. 40
Recommendation 10
Use Systemic Antibiotics if Symptoms or Signs of
28 OstomyWound Management
TABLE 7
CHOOSING APPROPRIATE ANTIMICROBIALS
Staphylococcus
aureus
+
+
+
+
Weak
+
+
+
MRSA Streptococcus Pseudomonas Anaerobes
+
+
+
+
+
Weak
+
+
+
+
+
Weak
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Weak
+
Comments
Good autolytic debridement;
limited potential for bacterial
resistance. Caution with
thyroid disease
Use with water, not saline.
Limited potential for bacterial
resistance
Not for use in sulfa–sensitive
patients
Reserve for MRSA and other
resistant Gram-positive
organisms
Reserve for anaerobes and
odor control
For use on large wounds. Can
cause irritation/allergies
Reserve for oral/IV use
Ointment contains lanolin,
which can sensitize to cause
allergic contact dermatitis
Contains neomycin, which
causes an allergic contact
dermatitis, may cross sensitize
to aminoglycosides
Infection Extend Beyond Wound Margin or the
Ulcer Probes to Bone
Systemic antibiotics should be used if infection extends
beyond the ulcer margin. Ulcers of less than 1-month duration
require primary Gram-positive coverage primarily for at
least 2 weeks or until clinical symptoms and signs resolve. If
immunosuppression is an issue, broad spectrum agents,
including Gram-negatives and anaerobes, should be included.
A semiquantitative swab is often helpful when patients
fail to respond to the initial therapy. In complex cases, an
infectious disease consult is advised.
If an ulcer probes to bone, osteomyelitis must be suspected.
Antibiotics for longer periods are necessary, usually for at
least 4 to 6 weeks. Treatment progress can be monitored
with x-rays, erythrocyte sedimentation rate, C reactive protein,
and, rarely, nuclear scans. Nonhealing ulcers may
require surgical debridement. For a more detailed discussion
on this topic, see Recommendation 8 of Best Practices for the
Prevention, Diagnosis, and Treatment of Diabetic Foot Ulcers
by Inlow et al on page 63.