Journal_1_2014_final_WEB

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30 25 20 15 Figure 2: Number of patients treated with antibiotics per ulcer diagnosis. 10 5 0 number of patients per diagnosis number treated with antibiotics Antibiotic treatments were administered in 78.3% of patients with traumatic or postoperative ulcers, 66.6% of patients with venous ulcers of the legs, 36.4% of patients with pressure ulcers, and 30% of patients with arterial ulcers (Figure 2). A bacteriological examination was conducted in 33 (31.4%) of patients. Staphylococcus aureus was found in 43% of these patients. Normal skin flora was found in 13% of these patients (Figure 3). VLU TRAUMA / POST PRESSURE ARTERIAL HYDROSTATIC DIABETIC FOOT CANCER MIXED ULCER RADIATION BURN SKIN DISEASE VASCULITIS OTHER STAPH. AUREUS STREPTO GRAM NEG. MIXTURE GRAM NEG RODS PROTEUS Antibiotics were administered in 84.5% of the cases in which bacteriological samples had been taken. Dicloxacillin, which is a beta-lactamaseresistant penicillin, was prescribed in 41% of these cases (Figure 4). Figure 3: Detected isolates from ulcers PSEUDOMONAS ENTERCOCCI E. COLI NORMAL SKIN FLORA NO GROWTH The personnel at the wound healing unit agreed with the indication for antibiotic therapy in only one case (0.9%). However, the Wound healing unit identified a need for systemic antimicrobial therapy in 6 (5.4%) patients who had not received this treatment from primary health services. Five of these 6 patients (83.3%) had an undiscovered and untreated cases of either osteitis or osteomyelitis, which is a clear indication for antibiotic treatment. Discussion Microbiology of chronic ulcers Conditions such as chronic venous insufficiency, arterial insufficiency, and pressure over time, can lead to the reduced reparation capacity of skin injuries, which can lead to non-healing ulcers. A non-healing ulcer, however, should not be regarded as a disease, but rather as a symptom of an underlying state. Bacteria will colonize within the ulcer if the protective barrier of the skin is broken. Therefore, the appearance of a chronic ulcer depends on several factors (Table 1). These Figure 4: Antibiotics prescribed for ulcer treatment 18 EWMA Journal 2014 vol 14 no 1
Science, Practice and Education Table 1. Factors that enhance the risk of development of ulcer infections Systemic factors n Metabolic diseases, such as diabetes mellitus n Systemic diseases, such as rheumatic diseases n Other forms of chronic disease, such as HIV infection n Old age n Malnutrition / poor diet n Alcohol / narcotics abuse n Medicines, such as steroids, oestrogens, and vitamin K antagonists n Smoking Local factors n Size of the ulcer n Age of the ulcer n Location of the ulcer n Local circulation n Necrosis n Suppuration and maceration n Edema n Exposed bones or capsules factors also contribute to the development of infections in the ulcer. 3 As Louis Pasteur (1822-1895), the father of modern microbiology, said: “The germ is nothing. It is the terrain in which it is found that is everything.” There are various hypotheses regarding the interactions between ulcers and bacteria. The contamination–infection continuum hypothesis is based on the fact that chronic ulcers are contaminated or colonized by planktonics, i.e., free bacteria. 4 In such situations, the healing of an ulcer takes place undisturbed, despite the fact that bacteria are present. Critical colonization, however, occurs when microorganisms begin to negatively affect the healing process. In such cases, subtle signs of infection can be observed, such as friable granulation tissue, lack of epithelial growth, and increased suppuration. 5 Infection is present when at least three of the following classical signs of infection have been observed clinically: n Redness (due to vasodilation) n Local heat (due to vasodilation) n Pain (due to the stimulation of nociceptive nerve fibres by cytokines) n Swelling (due to increased vascular permeability) This contamination-infection continuum hypothesis adequately explains the inflammation observed in acute ulcers, e.g., in cases of postoperative infection. Bacteria are always found in chronic ulcers. There are often multiple types of bacteria observed within a single ulcer. For example, the flora usually found in cases of venous ulcers of the legs include Staphylococcus aureus (90.5%), Enterococcus faecalis (71.7%), and Pseudomonas aeruginosa (52.2%). 6 The bacterial flora found in a non-healing ulcer change as the ulcer ages. Staphylococci and streptococci bacteria are normally found in new ulcers, while gramnegative mixed flora are often found in older ulcers. In addition, different types of ulcers are influenced by different types of bacteria. For example, a clinical infection will develop in 60% of diabetic foot ulcers but only 20% of venous leg ulcers that are colonized by Staphylococcus aureus. 12 Other systemic and local factors also influence the development of an ulcer infection. Between 1.6 and 4.4 species of bacteria are found per ulcer by conventional culturing methods 7 . However, molecular biological methods suggest that even more species of bacteria are present in the average ulcer. 8 The number of ulcers with anaerobic bacterial growth is estimated to be between 25% and 82%. The most common anaerobic bacterial species are Peptostreptococcus and Prevotalla. 9,10,11 However, many ulcers heal despite the fact the presence of these microorganisms. The presence of anaerobic bacteria is therefore not necessarily a sign of an ulcer infection. Recent research has indicated that the presence of bacterial biofilm contributes to the development of chronic ulcers. Biofilm, which is a well-known cause of periodontitis, has also been observed in cases of infection that involve medical implants and catheters. Studies performed by James et al. have shown that biofilm is present in 60% of chronic ulcers but only 6% of acute ulcers. 13 This supports the view that biofilm probably plays an important role in the formation of chronic ulcerations. In contrast to planktonic, i.e., free bacteria, the bacteria in biofilm are organized into a layer that consists of proteins, nucleic acids, and polysaccharides. The biofilm is affixed to the surface of the ulcer. 14 The physical properties of the biofilm protect the bacteria against most forms of chemical, biological, and physical stress. These properties also protect the bacteria against antibiotics and the immune response (e.g., neutrophil granulocytes). In addition, the biofilm assures the maintenance of a chronic inflammation in the ulcer. The bacteria in the biofilm release proteases. These proteases contribute to the breakdown of growth factors and tissue proteins that are responsible for repair processes in the tissue. The breakdown and decomposition products from the neutrophil granulocytes Killed by bacteria play a role in the inhibition of the “search and destroy” capabilities of the macrophages. This breakdown and decomposition also leads to the destruction of tissue EWMA Journal 2014 vol 14 no 1 19
Page 1 and 2: Volume 14 Number 1 May 2014 Publish
Page 3 and 4: BeneHold TASA The future of wound
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