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Science, Practice and Education tive infections. This lack of information about chronic ulcers may contribute to the uncertainty among physicians regarding the use of antibiotic therapy in these cases. The National Guidelines for antibiotics issued by the Norwegian Health Directory for primary health services, which is assumed to be the primary reference point for doctors who are faced with a clinical uncertainty, should therefore provide further guidance about when the prescription of antibiotics is contraindicated. Conclusion The results of the current study suggest a significant excess use of antibiotics in patients with non-healing ulcers. Mounting evidence suggests that the use of antibiotics should be reduced significantly among this population because antibiotics do not treat the underlying cause of the ulcer. A reduction of antibiotic use among this patient population will significantly reduce antibiotic resistance and health care costs associated with the side effects of antibiotics. Although the guidelines for antibiotic use should be updated and improved for use by doctors in the primary health services, research suggests that the guidelines are not read or utilized. 33 This fact argues in favour of the creation of several specialized wound healing units in Norway. A rapid referral of ulcer patients to specialists will undoubtedly raise the standards in the diagnosis and treatment of non-healing ulcers and reduce the use of antibiotics. The primary message All non-healing ulcers will be influenced to various degrees by bacteria. There is therefore no reason to take routine bacteria samples from chronic ulcers. It is most important to find out the underlying cause of the ulcer and focus on its treatment. Table 1 provides an overview of the indications for antibiotic treatment of non-healing ulcers. In such situations, bacteria samples should be taken from the ulcer. In most cases, empirical treatment will be necessary and narrow-spectrum antibiotics should be utilized to the greatest possible degree. The knowledge of the bacterial flora in different types of non-healing ulcers is therefore highly decisive. The treatment may have to be adjusted when resistance is determined. References 1. Posnett J, Gottrup F, Lundgren H, et al. The resource impact of wounds on health-care providers in Europe. J Wound Care 2009;18(4):154. 2. Tammelin A, Lindholm C, Hambraeus A. Chronic ulcers and antibiotic treatment. J Wound Care 1998;7:435-7. 3. Edwards R, Harding KG. Bacteria and wound healing. Curr Opin Infect Sis 2004;17:91-6. 4. Wolcott RD, Rhoads DD. A study of biofilm-based wound management in subjects with critical limb ischaemia. J Wound Care 2008;4:145-55. 5. Cutting K, Cert E, White RJ. Criteria for identifying wound infection – revisited. Ostomy Wound Manage 2005;51:28-34. 6. Gjødsbol K, Christensen JJ, Karlsmark T, et al. Multiple bacterial species reside in chronic wounds: a longitudinal study. Int Wound J 2006;3:225-31. 7. Howell-Jones RS, Wilson MJ, Hill KE, et al. A review of the microbiology, antibiotic usage and resistance in chronic skin wounds. J Antimicrobial Chemotherapy 2005;55:143-9. 8. Hill KE, Davies CE, Wilson MJ, et al. Molecular analysis of the microflora in chronic venous leg ulceration. J Medical Microbiology 2003;52:365-69. 9. Bowler PG, Davies BJ. The microbiology of infected and noninfected leg ulcers. Int J Dermatol 1999;38:573-578. 10. Trengrove NJ, Stacey MC, McGechie, et al.Qualitative bacteriology and leg ulcer healing. J Wound Care 1996;5:277-80. 11. Ge Y, MacDonald D, Hait H, et al. Microbiological profile of infected diabetic foot ulcers. Diab Med 2002;19:1032-5. 12. Schmidt K, Debus ES, Jessberger S, et al. Bacterial population of chronic crural ulcers: is there a difference between the diabetic, the venous and the arterial ulcer? VASA 2000;29:62-70. 13. James GA, Swogger E, Wolcott R, et al. Biofilms in chronic wounds. Wound Repair Regen 2008;16:37-44. 14. Cooper R, Okhiria O. Biofilms, wound infection and the issue of control. Wounds UK 2006;2:48-57. 15. Kirketerp-Møller, Gottrup F. Bacterial biofilms in chronic wounds. Ugeskr Læger 2009;171:1097. 16. Sun Y, Smith E, Wolcott R, et al. Propagation of anaerobic bacteria within an aerobic multi-species chronic wound biofilm model. J Wound Care 2009;18: 426-31. 17. Kirketerp-Møller K, Jensen PØ, Fazli M, et al. Distribution, organization, and ecology of bacteria in chronic wounds. J Clinical Microbiology 2008;46:2717-22. 18. Dowd SE, Sun Y, Secor PR, et al. Survey of bacterial diversity inn chronic wounds using pyrosequencing, DGGE, and full ribosome shotgun sequencing. BMC Microbiol 2008;8:43. 19. O’Meara S, Al-Kurdi D, Ovington LG. Antibiotics and antiseptics for venous ulcers. Cochrane Database Syst Rev 2008;23:CD003557. 20. O’Meara SM, Cullum NA, Majid N, et al. Systematic reviews of wound care management (3= antimicrobial agents for chronic wounds; (4) diabetic foot ulceration. Health Technol Assess 2000;4:1-238. 21. Percival SL, Woods E, Nutekpor M, et al. Prevalence of silver resistance in bacteria isolated from diabetic foot ulcers and efficacy of silver containing wound dressings. Ostomy Wound Manage 2008;54:30-40. 22. Merckoll P, Jonassen TØ, Vad ME, et al. Bacteria, biofilm and honey: a study of the effects of honey on “planctonic” an biofilm-embedded chronic wound bacteria. Scand J Infect Dis 2009;41:341-7. 23. Jaklic D, Lapanje A, Zupancic K, et al. Selective antimicrobial activity of maggots against pathogenic bacteria. J Medical Microbiology 2008;57:617-25. 24. Bowling FL, Salgami EV, Boulton AJ. Larval therapy: a novel treatment in eliminating methicillin-resistant staphylococcus aureus from diabetic foot ulcers. Diab Care 2007;30:370-1. 25. Cutting KF. Addressing the challenge of wound cleansing in the modern era. Br J Nurs 2010;19(Suppl.):S24-S29. 26. Horrocks A. Prontosan wound irrigation and gel: management of chronic wounds. Br J Nurs 2006;15:1224-8. 27. Leaper D. European Union antibiotic awareness day relevance for wound care practitioners. Int Wound J 2010;7:314-5. 28. Howell-Jones RS, Price PE, Howard AJ, et al. Antibiotic prescribing for chronic skin wounds in primary care. Wound Rep Regen 2006;14:387-93. 29. Eliassen KE, Fetveit A, Hjortdal P, et al. Nye retningslinjer for antibiotikabruk i primærhelsetjenesten [New guidelines for antibiotic use in primary health service]. Tidsskr Nor Legeforen 2008;128:2330-34. 30. Berild D, Haug JB. Fornuftig bruk av antibiotika i sykehus. [Beneficial usage of antibiotics in hospitals] Tidsskr Nor Legeforen 2008;128:2335-39. 31. Berild D. Hvordan få til riktigere bruk av antibiotika i allmennpraksis. [How to obtain more correct use of antibiotics in general practice] Tidsskr Nor Lægeforen 1998;118:1172. 32. Helsedirektoratet. Nasjonale faglige retningslinjer for antibiotikabruk i primærhelsetjenesten [The Health Directorate, National daily guidelines for antibiotic use in the Primary Health Service]. www.helsedirektoratet.no/vp/multimedia/archive/00078/ Nasjonal_faglig_retn_78639a. (04.01.2010) 33. Treweek S, Flottorp S, Fretheim A, et al. Retningslinjer for allmennpraksis – blir de lest og blir de brukt? [Guidelines for general practice – are they red and are they used?] Tidsskr Nor Lægeforen 2005;125:300-3. 22 EWMA <strong>Journal</strong> <strong>2014</strong> vol 14 no 1
Get pressure ulcers under control. See you at EWMA 14 – 16 May Caring for foot ulcerations with a clinically approved therapy programme. www.heelift.com www.darco.de www.molliter.it e.g. Heelift® Glide PREVENTIVE & ACUTE CARE PREVENTIVE CARE e.g. Claudio e.g. WCS e.g. OPTIMA Diab ACUTE CARE www.darco.de
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