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Wound colonization and infection: the role of toDical antimicrobials - - - - - _ 1 -

Richard J Wbite, Rose Cooper, Andrew Kingsley

ntact skin provides a physical barrier to the ingress of microorganisms, but if dani- I aged by wounding, microorganisms from

the surrounding skin, other body sites, or from exogenous sources have access to a warm, nioist environment. Whether organ- isms survive and multiply depends on their ability to evade tlie body’s immune system, and whether essential chemical and physical requirements are met.

Wound contaminants may not persist, but those species that do grow and divide may establish either wound colonizzltion or wound infection, The outcome depends on the interac- tion of complex h a t and microbial factors (Emmerson, 1998). The size, Position and dura- tion of a wound, local Perfusion (dissolved oxy- gen levels) and host imniunocompetency are balanced against the number aiid type of invad- ing microbial species and thc preseiice of foreign bodies (jncluding necroric rissue sliid eschar).

The presence of niicroorgaiiisiiis in n wound is not iinusual, but not all wounds Support the Same range siid number of species (Cooper and Lawrence, 2996n). Elective wounds ure usunlly subjcct to preop- erative antisepric mensures and aseptic surgi- cal techniques, and tlierefore infection is min- imized and healing often proceeds within expected timeframes. Trauiiiatic wounds are niore likely to contain devitalized tissue and debris, and to be contaniinated with microor- ganistns from environmental sources; conse- quently, infection rates are higher.

Chronic wounds, i.e. of over 6 weeks dura- tion (Dale et al, 1983), such as leg ulcers or pressure ulcers are inevitably colonized with a mixture of species and rnany of these are potential pathogens. The developmeiit of infection in chronic wounds often reflects host susceptibility.

Wound infection is one of the most signifi- Cant factors that delay healing. Alrhough a Consensus on the impact of specific microor- ganisms On the healing process is not yet agreed, the development of infecrion causes

Abstract Infbctlon 8nd bacterial colonhatlon are i~portant ihctors In cmprmlsed wound healing, partlcularly in chronlc wounds. The c u m t ‘best practicel fbr controlllng these factors 1s still unclear. Systemic antiblotlcs are generally accepted 8s hing the pre&rred cholce for treatlng Infectlm, provlded that ISCh8efn&1 does not lnterfere. Howevq #wir wldespread systemlc and toplcal use is leading to the emergence of reslstant bacterial sfralns such 8s methicIllln=rdstant Staphylocmus aureus. Culon~atlon of wound3 presents a double Problem: posslble dtdayed heaiiqg if out of balance witlr ttm Immune System; and as a source ibr crass-intectlon.

valuabb In Inliecffon control and In ths case far taMng the antiseptic mute 8s part of the concerted approach to locai wound management and lnfedion control,

scrious delays in healing. Additional conse- quences for ehe Patient iiiay be increased pain snd discomfort, inconveiiieiice and possibly even life- tlirea tening illness. Advcrse conse- querices for the healthcare system may be cxtcndcd hospital stny, and incrcased treat- ineilt cnsts in ternis of extra aiitibioric and dressing iisage, together with extra stslff costs.

Contiiiued, aiid often inappropriare, iisc of systernic ancl topical antibiotim wer rhe last 50 years lins led to the eniergeiice of mtibiot- ic-resistanr stmins. Both colonized and infect- ed wounds act as a reservoir of potential pathogeiis thar niay contribute to incrensed risks of cross-infection. There is increasing concern ainong healthcare professionals about tlie risks associated with the presence of microorgsnisms in wounds: Do they represent a real risk for Cross-infection? Should antimi- crobial agents be used? If so, when and how? This article explores some possible answers.

DEFINITIONS

Definitions of commoiily used terrns in the field of infection control are required to ensure con- sistency of language, and hexe understanding, between audiors and readers. The definitions cited in Table 2 are offered for ciarification.

sd J White is Clinical Research Consultant and Medicat Writer, Rase

ia Senior Lccmcr in

Scienccs, Uaiversity ology, School ol

. of Wales~Institute Cacdiff, Oardi& and Andrew KingdQ is C b d Nurse Specialist, T i m e Viability annd bfectioo Control, No& Devon District Hogpital, Barnstaple

Accepted f i r pwblication: April2002

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PREVENTWE MEASURES

Measures to prevetit wound infection and delayed liealing Situations are based on sound tissue viability principles (F ipre I ) , which are:

Identify aetiology of wound Reinove any continuing intrinsic and extrin-

sic causative factors such as venous hyperten- sion aiid shearing pressure I. Eliminate or redwce any factors that may impair healing such as malnutrition, hypergly- caemia and anaemia among others * Iniciate most effective therapy a t outset; do not use holding o r 'wait and See' treatnients just because rhey are more convenient 0 Use universal infection control precautions to prevent Cross-contamination from the wound 0 Remove necrotic and foreign material 0 Allow drainage of wound exudatdpus, in particnlar from sinuses (this does not

preclude iise of occhsive dressings but does help to determine dressing frequency depeiident on the absorbency of the individual product 0 Observe closely for signs of Change at all dressing changes, in particular those repre- senting a delay in healing or infection

Construct a care plan tliat details expected Progress so that delays be detected at the earliest opportunity I, Use a framework to guide decision making for undesired events (Kingsley, 200 1)

Modem 'moist wound healing' dr-essings have been shown to be vduable in infection control. They form part of the non-nlicrobiological approach to control the wound bioburden.

Some occlusive dressings such as hydrocol- loids have both bacterial and viral barrier prop- erties. These can be used to 'contain' pathogens within the wound environment thus reducing the spread and Cross-infection (Bowler et al, 1993). Hydrocolloids have also been shown to reduce the airborne distribution of organisnis at dressing cliange tlirough aerosol formation (Lawrencc, 1994). In general, occlusive dress- ings are associated with a lower Overall wound infection rate tlian non-occlusive dressings (Hutchinson and Lawrence, 1991).

Dry dressings such as gauzes stick to tlie wound. O n removal, the traiiniatic detach- ment has been demonstrated to spread bacte- ria by aerosol formation (Lawrence et al, 1992). In hospital clinics this is likely to be a Eactor in the spread OE infectiorrs. While tkere is no evidence that traditionai dry dressings have any role in infection control and may even lead to an increased rare of infection, some modern dressiiigs have evidence to sup- Port their use in this context.

A hydrofibre dressing, Aqiiacel (ConvaTec), bas been found to bind bacteria and thereby 'contain' die spread of pathogens. In a study using an in vitro wouid iiiodel seeded with Staphylococcus aurcus, Bowler et al (1999a) have compared a number of fibrous dressings. Results Show Aquacel to be most effective in binding the bacteria (P<O.OOZ), followed by the alginates Algosteril (Beiersdorf) and Kaltostat (ConvaTec) . "HERAPEUTiC MEASURES

Active steps taken to reduce colonizarion or Counter-infecrion depend upon the nature of the wound, Status of the Patient md the patli- ogenicity of the organism(s) involved. An

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There is evidence C that the routine use of antibiotics in the management of clinically infected leg ulcers is of no benefit ... and there is some evidence that it may be harmful by encouraging the colonization by resis tant organisms . . .Topical antibiotics can provoke delayed hyp ers ensitivity reactions ... superinfections.. . and, more importandy,

resis select tance.. for . 9

Organ transplant Patient threatened with a methicillin-resistant S. aureus (MRSA) infec- tim in hidher surgical wound is at greater risk. This is because hisher immunosup- pressed Status puts him/her a t higher risk of life-threatening infection than a Patient with a long-standing leg ulcer known to be colo- nized but with minimal host reaction.

The bacterial loading, or bioburden, of the wound may influence the healing rate and is a particularly important factor in patients known to be ‘at risk’, e.g. those known to have campromised healing or host response, diabetes or ischaemia.

Antibiotics Appropriate systemic antibiotics are consid- eted to be essential for the treatment of

Severlty

clinically infected wounds (ßowler et al, 2001). The use of topical antibiotics is not justified for the routine treatment of colo- nized or infected wounds (Drug and Therapeutics Bulletin, 1991). There is evi- dence that the routine use of antibiotics in the management of clinically infected leg ulcers is of no benefit (AIinovi et al, 1986) and there is some evidence that it may be harmful by encouraging the colonization by resistant organisms (Huovinen et al, 1994).

Topical antibiotics caii provoke delayed hyperseositivity reactions (Zaki et al, 1994), superinfections (the itifection by resistant bac- teria) and, more importantly, select for resis- tance (British Medical Iournal, 1977). This is particularly evident with those antibiotics that are used both topically and systemically,

Crltlcal Sterlllty Contamination Colonltation colonizatlon lnfectlon

Acute Acute wounds Acute and Acute and Acute and wounds chronic c hron ic chronic

wounds wounds wounds

Absence of Presence of Ba1 anced Host defences Host defences microbes microbes but growth and unable to overwhelmed,

little active death of maintain local spread of growth microbes hea I t hy cellulitis (may

bacteraemia, septlcaemia and death)

balance lead to

Very brief Present soon Sltuatlon Delay in Exacerbation period after woundlng, normal healing of wound following Progresses initial surgical quickly to incision or colonization thermal trauma

No action Action ~

Action Action Action

Situation will No need to not persist in artificially wounds prevent healing by colonization secondary Wound healing intention by secondary

intention (wlth the possible exce ption of burns)

Do not disturb Consider using Systemic balance (wlth antiseptic antibiotics +/- the possible dressings to antiseptic exception of return wound dresslngs diabetic foot to colonization ulcers)

Rgum I. The Infection continuum (Klngsiey, 2001).

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The Consensus c on eusol, especially among nurses, is that it has no place in wound care, regardless of the concentration used.,.This view is based on evidence that it is rapidly deactivated in the presence of pus, is painful to the Patient and delays healing by damaging cells arid capillaries.. .

e.g. gentamicin (Genticin and Cidomycin), metronidazole (Flagyl and Metrotop), sodi- um fusidate (Fucidin), chlortetracycline (Deteclo and Aureomycin) and others. Resistaiice to aiiribiotics has become a serious Problem for tliose involved in wound care. The situation has been described as ‘crisis’ in the USA (Colsky et al, 3.996).

Antiseptics For many, the use of antiseptics in wound carc is biased by the ‘bad press’ given to eusol and the confusion over iodine compounds. The value and use of eusd has led to vigorous debate and polarization of healthcare profes- sioiials into a majority that vehemently oppose its wse under any circunstances (Leaper, 1992) and a ininority tliat still regard it OS useful. The value and use of topicsll antiseptics in wound care has been debated for many years. In the UK in particular, the use of hypochlorites such as eusol is controversial (Moore, 1992).

The Consensus on eusol, especially among nurses, is that it has no place in wound care, regardless of the concentration used (Roe et al, 1994). This view is based on evidence that it is rapidly deactivated in the presence of pus, ,

is paiiiful to the Patient and delays heeling by damaging cells and capillarics (Leaper, 1988).

Iodine compouncls have also attracted criti- cism (Rodeheaver, 1990). The main argument against the use of such agcnts is their potential toxicity (Lawrence, 1998a) - a factor related to coticentratioti nnd exposure - and the attendant delay in healing compared to untreat- ed controls (Brennan and Leaper, 1985).

CLlNlCAl EVlDENCE TOR THE USE OF TOPICAL ANTISEPTICS

Careful and objective review of the literature reveals that the iise of many antiseptics in wound management miw be subject to a risk- benefit assessment of possible local toxicity with beneficial antibacterial action (Kaye, 2000). Brennan and Leaper (1985) advise balancing the beneficial antimicrobial effects and bioavail- ability with possible cellular toxicity before use.

In solution form, antiseptics are used to irri- gate or cleanse the wound. This, by definition, means a short period of contact with the tis- sues. Solutions are, therefore, concentrated in Order to luve tlie desired effect - this increas- es the likelihood of tissue toxicity and delayed healing. Antisep tic agents incorporated i rito

dressings are in contact for much longer and can, therefore, be more dilutc, less toxic aiid exert a proloiiged antimicrobial effect.

The ideal antiseptic will have the following key attributes (Morison, 1990): broad spec- trum of activity; low potential for resistance; non-toxic; rapid acting; not irritant or a sen- sitizer; and effective, even in the presence of exudate, pus, slough, etc.

Xodine Iodine, particularly in the safe, modern iodophor povidone-iodine (polyvinyipyrroli- done iodine complex, or PVP-I) and the cadexomer is a very useful bacteriostatic and bactericidal agent being active against MItSA and other pathogens (Mertz et al, 1999). The use of PVP-I as a preswgical Skin aiitiseptic is unquestioned although its value in wound antisepsis is subject to debate (Thoinas, 1988; Rodeheaver, 1990; Goldenheim, 1993; Lawrence, 1998a,b; Gulliveq 1999).

Concerns about toxicity and impaired heal- ing relate mainly to products that contain ele- mental iodine, although PVP-I is also impli- cated (Kramer, 1999). The newer products, e.g. Ioban (3M Health Care), Inadine (Johnson & Johnson Medical), Iodosorb (Smitli & Nephew Mealthcare), appear to be safer and have a very wide spectrum of nctiv- ity (Gilchrist, 1997a; Sundberg and Meller, 1997). In ehe USA, the Food and Drug Administration maintains that PVP-I in 5-10% solutiotis does not adversely affect heding (Fcderal Register, 1994), although a later review of published data by Kramer (1 999) disputes tliis view.

l o b e iodophor is available in a range of con- cetitrations as medicated dressings (e.g. Inadine, Johnson 8c Johnson Medicd, Iodoflex, Smith & Nephew Healthcare), solutions and oint- ments (e.g. Betadine, SSL International), pow- der and Spray (e.g. Savlon Dry powdeq Novartis Consumer Health), and incise drapes (Ioban, 3M Health Care). PVP-I gradually releases free iodine, which has a broad spectrum of antimi- crobial activity, including MRSA (McLure and Gordon, 1992; Lawrence, 1998b). The slow release from the iodophor is intended to opti- mize activity and to reduce toxicity.

The cadexomer is a Polysaccharide starch lattice contilining 0.9% elemental iodine that is released OLI exposure to exudate (Lawrence, 1998a) and has antimicrobial activity for LIP

to 3 days (Mertz et al, 1999). It has been

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Figure 2. The role of sllver- and iodine-impregnated dressings In toplcal antiSepsis of critlcally colonlzed and infected wounds. 71re arro w lndicates the thought/declslon-m8~ing pathway.

extensively evaluated in B variety of aciite and chronic wouiids and €ound to be safe atid effective (Sundberg and Meller, 1997).

Tlie PVP-I containing dressings such as Inadinc (a sterile knitted viscose dressing imptegnated with 10% PVP-I in a water-solu- ble base) and Ioban (iodophore incorpora ted onto a film) provide sustained release of low levels of free iodine. Consequently, this and other modern iodinated dressings sliould oiily be used on exuding wounds for best effect.

Iodine is also available as the alcoholic tinc- ture aiid as Iodoform, neither of which is regarded ns being valuable in wound manage- ment because of pain and limited bacterial activity respectively.

Siluer Silver and silver compouiids have been rou- tinely used as bactericidals for over a century. It is generally recogiiized as a safe, broad spectruni agent witli only irritation and Skin discolouration (argyria) reported for the inor- ganic nitrate Solution (Wright et al, 1998a).

Silver acts czs a heavy meta1 by impairiiig the bacterial electron transport system and some of its DNA functions (Russe11 atid Hugo, 1994; Cervantes and Silver, 1996). To da this, the ‘active’ agents - silver ions - have EO be bioavailslble (i.e. to be able to mter the cell), at the correct concentration in solu- tion (Demliiig and DeSanti, 2001).

Silver iiitrate was probably tlie fitst silver compouiid used on wounds where it has aii astringent aiid irritatiiig effect. As a tesult of these Problems it is rnrely used today except for the occasional use in teducing hypergran- ulation. The esterification (chemical bonding) of silver witli a sulphonamide antimicrobial - sulphadiazine - (SSD) has resulted in a

I I

I lncreasing bacterial resistance to antibiotics and evidence against toplcal antiblotics

lnfection control by alternative means?

Silver and iodine are potent antimlcrobials with broad spectrum and little resistance

Silver or iodine in a sustalned, slow-release delivery system for application to wounds

- ~ ~~

Steady release of antlmicrobial agent over a period of days, or until removal of dresslng

Continuous antimicrobial effect

very safe, broad-spectrum agent for topical use. Silver is released slowly from tlie oil-in- water cream formulation in concentrations that are selectively toxic to m icroorgaiiisnis such as bacteria (MRSA, gentamicin-rcsistant Pseudomonas spp. and Enterococcus spp.) and fungi (Goodman and Gilnian, 1990).

Best known as the Flamazine 1% cream (Smith & Nephew Healthcare), SSD hsls been a mainstay of topical turns therapy (Pruitt, 1987) and hs been used successfully in acute (Buckley et al, 2000) and chronic wouiids (Bishop et al, 1992) to treat infection. Resistmce to SSD has been reported (Modak and Fox, 1981) but is rare. A variety of topical silver preparations have been evaluated on chronic wounds (O’Meara et al, 2000,2001) in controlled trials witli favourable results,

Recently, a number of silver-containing dressings have become available (Adams et al, 1999; Furr et al, 1994; Williams, 1994, 1997; Wright et al, 1998a,b; Yin et al, 1999). In any formulation, the way in whicb silver is incor- porated and how it interacts with microorgan- isms, i.e. its bioavailability in Solution, is criti- cal in deterniining its antimicrabial efficiency atid its safety (Demling and DcSanti, 2001).

Actisorb Plus (recently renamed Actisorb Silver 220, Johnson & Johnson Medical) con- tains silver impregtiared onto an activated charcoal Cloth (Williams, 1994). It is claimed to be effective against sl wide range o€ microorganisms, nlthough there is only oiie stibjective published report of coinparative clinical datn (Millward, 1991). Arglaes (Maersk Medical) is avslilable as a slow- release filiii dressing polymer with silver ions (Williams, 1997). Acticoat Antimicrobial Barrier dressing (Westaim Co. -not yet avail- able in the UK) is an antimicrobial barrier dressing which has also been shown to be effective against a wide range of organisms (Yb et al, 1999). Although the delivery sys tems vary, the mode

of action prhciple is the sanie in each case. There is currently very little clinical evidence available to suipport these products. Their ratio- nale is based On in vitro studies (Furr et al, 1994; Wright et al, 1998b). Preliminary find- ings from an in vitro wound model (Bowler et al, 2000) suggests that not all can be expected to be equally effective. In heavily exuding wounds, the presence of proteinaceous materi- al in wound Buid is likdy to bind to the char- coal layer in Actisorb Silver 220, thus reducing

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The value C of cleansing wounds rests with the removal of excess exudate, foreign b odies, including dressing residues, necrotic tissue, loose slough

. and wound edge crusting (which is fibrin, dehydrated exudate and dressing residue). Removal of all these and leaving the wound moist will enswe that healing will be assisted to Progress unhinder ed.

the release of silver and thereby reducing the antibacterial activity. These in vitro findings question the capacity of this dressing to inhibit wound bacteria in clinical practice*. Prodwts that can sustain the interaction of silver with microorganisms in the exuding wound are like- ly to be More effective in controlling infection.

Figure 2 illustrates the rationale for iodine and siIver dressings in the treatment of criti- calIy colonized and infected wounds.

Proflavine Proflavine is an acridine derivative (a com- pound originally used in the manufacture of dyes) available as Proflavine Cream, British l'harmaceutical Codex (BPC), solution BPC and as the hemisulphate, which has been in use for niany years as a slow-acting mildly bactetiostatic (i.e. inhi bits bacterial growth) agent in wound management. In particulal; proflavine is still widely used prophylacticaily as a gauze soak for wound packing even though it has been found to be inferior to an alginate dressing in this respect (Gupta et al, 1991). There is no reliable evidence that it is effective in this context, or that it has any clin- ical benefits. Indeed, there are reports of mutagenicity - gene and chromosomal muta- tions - of proflavine on bacterial (Iwamoto et al, 1992) and cell cultures (DeMarini et al, 1988), raising questions about its safety.

Chlorhexidine compouncls These are useful antiseptics for skin and are highly effective for hand washing and surgical scrub. They bind to the Stratum corneum and have a persisting activity, remaining active for at least 6 hours after application (Kaye, 2000). The acetate, Chlorsept (Baxter Heal thcare), is intended for wound irrigation. The gluconate is active against Gramnegative organisms such as P. aeruginosa and Gram-positive organisms such as S. aureus and Escherichia coli. Their toxicity and use on wounds has not been esta blished categorically, although they may be a useful therapeutic Option as an agent for topical use (Scott Ward nnd Saffle, 199.5).

Hydrogen Peroxide Usually used as a 3% (10 volumes) or 6% (20 volumes) aqueous solution to clean necrotic infected wounds, hydrogen Peroxide is anti- *

ohnron and ohnson Medial statc that Actisorb &er 220 is ekectiuc for wet or dry wounds (Da& On file,]ohnson and]ohnron Medial, Ascot, Berks)

sepric due to the release of oxygen, an oxidiz- ing agent, on contact with the tissues. There are safety concerns about using hydrogen Peroxide solutions on Open wounds because of reports of tissue embolism (Scott Ward and Saffle, 2995). Hydrogen Peroxide is also available as a 1.5% creain (Hioxyl, Quinoderm) for desloughing wounds.

Potassium permangatrate Weak solutions of this oxidizing agent (1 part in 5000, 1 part"Jn 10000) are used ns soaks to cleanse aiid deodorize eczeinatous wounds and leg ulcers. Although favoured by derma- tologists, there is no evidence published to supporr their use (Roe and Cullum, 1995).

WOUND CLEANSING

The value of cleansing wounds rests with the removal of excess exudate, foreign bodies, including dressing residues, necrotic tissue, loose slough and wound enge crusting (which is fibrin, dehydrated exudate and dressing residue). Removal of all these and leaving the wound moist will ensure that healing will be assisted to Progress unhindered. Cleaning that does not seek to achieve any of these aims is uiilikely to be of vnliie nnd is niorc likely to cnuse hnrm by damaging frngile new tissue growth, thereby delnyitig Iiealitig.

However, if one considcn wouiid cluaning to include the periwouiid skin, t h ~ i reinavnl of exiidate and dressing adliesive residues should reduce the likelihood of mncerntion, which can extend wouiids and excoriation from exudate, eiizynies, bacterial roxins and Skin pH disturbance (Cutting, 1999).

The ideal method of cleansing deyends on the individual circumstances of the case. Some inay require rapid sharp debridement under anaesthetic, while in others this inay not be suirablc and more conservative approaches are needed. Though debridemen t is technically cleansing, it is usually consid- ered separately.

Normally cleansing is achieved through irri- gation with a fluid, or mechanically with a moistened wipe. For wounds healing by sec- ondary intention, the fluid used can be sterile normal Saline as it is isotonic but this is expen- sive in comparison to tap wate4 which is the fluid of first choice. Studies on traumatic wounds by Hall Angeras et al (1992) suggcst there is no quantifiable infection risk with tap

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Micr obial c coloniza t io n of Open wounds is inevitable and cleansing can lower the bioburden transiently. The purpose of cleansing (whether pressurized or not and with whatever fluid) is to aid removal of necrotic tissues and foreign bodies which provide the medium for overgrowth, a phenomenon which can cause delay in healing.

water. The use of tap water makes cleansing convenient as it can be done in a sink under run- ning water, in the batli or shower, or in a buck- et for leg ulcers. These processes have die added advantage of ease of cleaning surrounding skin.

Pressurized irrigation can be achieved notably with commercially available acrosol spray cans. The pressure must be adequate eiiough to dislodge loose debris and sIough without causing tissue damage. Whirlpool baths, for exaniple, niay ca~ isc daniage to tis- sues in leg wounds (Oliver, 1997). Spray mns deliver a pressurized stream of saline at 8 Pounds per Square inch (55 kPa), which is considered Optimum for effectiveness. However, such delivery onto the flat surface. of most wounds generates aerosols which must offer a high risk for cross-contamina- tion of the practitioner and surrounding envi- ronment, making them inadvisable for use anywhere but the home (avoids nosocomial infection risk) with suita ble protective cloth- ing. To improve diese devices, a disposable splash guard would make them more viable.

Microbial colonization of Open wounds is inevitable and cleansing can lower the bioburden transiently. The purpose of cleans- ing (whether pressurized or not and with whatever fluid) is to aid removal of necrotic tissues and foreign bodies which provide ehe medium for overgrowth, a phenomenon which can cause clelay in healing.

As For the use of antiseptic solutions as cleansing agents, Thomlinson (1997) notes that tlie duration of contact is generally too short to be effective.

WOUND DRESSINGS

Malodour is common in chronic wounds. It is associated with aerobic and anaerobic bacteria colonizing or infecting the wound (Bowler et al, 1999 b). The use of odour-Controlling dressings such as those containing charcoal, e.g. Actisorb Silver 220 Wohnson & Johnson Medical), CarboFlex (ConvaTec), Lyofoam C (SSL Iiiternational), can be very helpful (Thomas et al, 1998a). Indeed, of this category only CarboFlex currently has the capacity to man- age exudate (Thomas et al, 1998a) and still control odour effectively (Thomas et al, 1998b). This is atrributable to an absorbent wound contact layer thnt manages the exudate, restricting exudate access to the charcoal adsor- bent layer. While odour control alone does not

eradicate infection or, indeed, alter bacterial growth, it does have substantial Patient quality of life benefits and should, tlierefoore, be an adjunct to any topical andor systeinic antibac- terial therapy (Haughton and Young, 1995).

The use of modern dressings in infectioli control shows great promise. Medicated (silver and iodine complexes) dressings can be useful in the local control of bacterial biaburden pro- vided the active ngents - silver ions and ele- mental iodine - are available in Solution at an appropriate concentration over time. Such dressings will, in tun, assist in infection con- trol by reducing the iiuinbers of wound pathogens available for Cross-infection.

Dressings containing antibiotics generally have a diminishing place in wound treatment primarily because of antibiotic resistance. However, a case can be made for the use of topical metronidazole gel in the palliative treatmen t of malodorous malignant (fungat- ing) wounds where odour is a major Problem and, because of the terminal nature of the disease, antibiotic resisrance is not an issue (Rice, 1992).

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CHRONIC WOUNDS

Tlie detailed reviews condiicred by O’Meara et al (2000, 2001) and the Scotrisli Intercollegiate Guideliiies Nctwork (SIGN) (1998) have fouiid little cvicleiicc to support tlie routine use of systemic antihiorics in patients with chronic wounds. Acutc infec- tions in chronic waunds shoulcl, Iiowevei; I)e treated with systeinic antibiotics.

Topical dressing crectms or ointments thnt provide a sufficient delivery of an aiitiseptic agent (e.g. silver or iodine) niny be useful. However, the use of povidone-iodine in solu- tion as a wound cleanser is not justifjed (Leaper, 1994; Burks, 1998). Solutions used as rinses do not have sufficiently long contact time to be of much effect. Cleansers that rely on pressure, as in aerosol Sprays of normal saline or containing Liocompatible surfac- tants to help remove necrotic material are effective, but infection control measures niust be carefully considered before use.

SURGICAL WOUNDS

Clean surgery carries a small (1-5%) risk of postoperative wound infection, whereas ‘dirty procedures’ such as those involving the

BRITISH JOURNAL OP NUHSINC, 2001, VOL 10, No 9 SI4

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In “critical” colonization,

the numbers of organisms and of species increases above the levels found in the colonized wound. Clinical signs for critical colonization may be apparent, although primarily it is a microbiological criterion tbat may only become app ar ent retr o sp ec tivel y on ce infection is 9 diagnosed.

large intestiiies hss a much higher risk (up to 27% (Nickols, 1998).

Minimizing the iiicidence of infection relies on adequate asepsis, antisepsis and preservation of local host defences (Hunt, 1981). Asepsis involves effective infection coiitrol to minimize exogenous contamination during surgery. Aiitisepsis involves the use of skin antiseptics and prophylactic antibiotics before surgery (Hansis, 1996). Recent guidelines on the pre- vention of surgical site infection have been pub- lished (Mangram, 1999). The emphasis on sur- gical wound healing is rapid Perfusion, as ischaemic tissue beals poorly and is easily infect- ed (Hunt and Hopf, 1997). Healing and resis- tance to infection improves with increased local blood supply, and hence tissue oxygenation. Delivery of antibiotics, systemically dosed, to the infected wound also depeiids on perfusion. Antibiotics given at the time of injury will reduce, but not eliminate, the risk of infection.

Iri one-third of wound infections, bacteria cultured from the wound are susceptible to the prophylactic antibiotic provided. The key factors involved here are patients with hypox- ia and local Perfusion Problems (Hunt nnd Hopf, 1997). In such instances, it is easy to make a case for prophylactic and therapetitic antiseptics, particularly tliose provided by sustained dosing from ‘medicated’ dressings.

The risk assessnient for surgical wounds has been defiried by the Americcln SENK study of tlie effect of nosocomial infection (Study of the Effect of Nosocomisll Infection Control) (Haley et al, 1985), This and other factors liave beeil sunimarized by Kingsley (2001).

DlSCUSSlON

Antiniicro bial agents have been applied to wounds for thousands of years (MoeUering, 1995), but the relentless emergence of resis- tant strains has forced the continued search for novel agents. As each new type of antirni- crobial agent has been introduced into clinical practice, changes in niicrobial sensitivity have been observed, At the outset, there are always some strains that art not inhibited by a new agent (i.e. possess intrinsic resistance), and some species that are susceptible.

Use of a new antimicrobial agent iimits the growth of susceptible strains, but eventually ‘resistant strains always emerge. These agents do not iiiduce the formation of resistance genes, but merely provide an environment in

wliicli sensitive species are curtailed and resis- tant species flourisli. The eniergence of wound pathogens with Patterns of niultiplc antibiotic resistaiice is having serious coiisequences in the hospital environment (Morgan, 2000), nursing homes (Fraise et al, 1997), and in the coinmii- nity (Cookson, 2000). The Situation is com- pounded by the increasing costs of senl-cliing for new antimicrobials aiid tlie decreasing rate of discovery of new agents (Moellering, 1995).

At one time it was considered thnt the cievel- opment of resistance to antiseptics aiid disin- fectants was remote, Bu t tliis Iias been shown to be incorrect (McDonnell m d Russell, 1999). Certain species, such as bacterial Spores, mycobacteria and Gram-negative bac- teria possess intrinsic resistance, but plasmid- mediated acquired resistance to antiseptics and disinfectants in several bacteria has been reviewed (McDonnell and Russell, 1999).

The presence of different species of inicroor- ganisms in the wound has been linked to delayed healing and wound odour. Trengove et al (1996) have found a significantly greater Chance of impaired healing when four or inore species are present. WhiIe the definition of wound infection itself is not acceyted unani- moiisly (Gilchrist, 1997b; Lmper, 1998), the consensus is tlint the signs are recognized as s u p piirntion, cellulitis, lymphaiigitis, and hacter- aemia. Maiiy rexts refer to c? figure of 109 organ- isnis per grain of tissue as n criterion for infec- tion (Thoinpson and Smitli, 1994). This growth density, in isolation, has no confirmed connec- tioii to tlie threshold or degcee of immune respoiise or to healing (Cooper nnd Lawrence, 1996b) and none at all if no acciirate sanipling hes been conducted (Robsoii, 1999).

In ‘critical’ colonization, ehe niimbers o€ organisms and of species increases above tlie levels found in tlie colonized wound. Clinical signs for critical colonization may be appar- ent, although primarily it is a micro biological criterion that may only become apparent ret- rospectively once infection is diagnosed.

There is evidence that delayed healing or die f a h r e to heal in a chronic wound which has no signs of cliaical infection, suggestive of critical colonization, is directly related to the microbial bio burden, notably haemolytic streptococci and anaerobes (Halbert et al, 1992). In this study, the implications for wouiids colonized with these organisms were that they had been present for longer, were larger, and had a significantly delayed healing

576 BRITISH JOURNAL 01: NURSING, 2001, VOI. 10, No 9

time. One iniplication of these findings is that early nnd appropriate intervention caii avoid Progression to critical colonizntion and to infection, thus potentinlly iinproving healitig rates aiid reducing the risk of Cross-iiifection.

Where overt infection exists, systemic antibiotics are usually appropriate for first- line treatnient witli topicnl treatiiieiits being usefiil adjuncts, pnrticularly in the case of poor Perfusion. Non-hcnling wounds where critical colonization is suspected or confiriiied may also be appropriate for such treatment.

In the case of silver as an antiseptic, the antibacterinl action and effects on indolent wounds and burns (Wright et al, 1999) have been established (Demling and DeSanti, 2001). It has been stated that silver can 'pro- vide a disinfected surface in the immediate environment of the wound, thus preventing bacterial infection' (Williams, 1997).

For iodine as iodophor or cadexomer prepa- rations, the consensus is in favour of its use in non-healing and infected chronic wounds (Gilchrist, 1997a; Sundberg and Mcller, 1997). Once the infection or critical colonization is reduced and the wound Shows signs of healing, it is advisable to chniige the dressing for one appropriate to the iieeds of thc wound.

Antiseptics nnd disinfectmts have long been die coriierstonc of effective infection control and the preveiitioti of hospitnl-nccluired infec- tion. Wie iise of topical silver aiicl iodine con- taining sustained releiise forniulatioiis on infected and criticdly colnnized wo~inds can, as pair of an tiolistic approach, bc supportccl. There are several indicntioiis for use of a topi- cal an tiseptic sustaiiied clelivery System, whether it be dressing, creatn 01' ointment: 0 If one oc moce overt sigti of infection, or

any less obvious signs such as increased exudate Ievels, are preselit Increased local yain

0 Cessation of Progress in healing, tlien intervention is indicated to return the wound to health.

The use of appropriate topical products .will also assist in the reduction of odour and local bioburden, thus reducing the risks of Cross-infection. rmSp

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Ayton M (1985) Wounds that won't heal. Nurs Tinrcs 81(46): 16-19

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Bowler PG, Delarv 13, Princc D et al 19h) The viral bilrrier properhes of some wouni dressings and their role in infcction control. Wouncls 5: 1-8

Bowler PG, Joacs SA, Davics BJ, Coyle E (1999a) Infection control properties of some wound dress- in s, ] Wound Care 8(10): 499-502

Bowkr PG, Davies BJ, Jones SA (1999b) Microbial involvcincnt in chronic wound malodour. Wound Cnre 8( 10): 2 16-1 8

Bowler PG, Joncs SA, I-Iollnnd A (2000) 1s silver incor- porttted h t o nctivated charcoal Cloth likely to he tough on wound infcction? Poster resentatioii nt 'Wouiids 2000' Harrogate, 12-14 Xovernber

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Where overt C infection exists, systemic antibiotics are usually appropriate for first-line treatment with topical treatments being useful adjuncts, particularly in the case of poor perfusion, Non-healing wounds where critical colonization is suspected or confirmed may also be appropriate for such treatment.

577 BRITISH JOURNAL OF NURSING, 2001, VOL 10, No 9

CLINICAL

KEY POINTS All wounds should be assessed at each dressing c h ange . I Where wounds are

static, or exudate levels high, critical colon izatio n a nd infection should be suspected,

II Wounds should be cleansed with tap water or saline to remove pus, tissue arid dressing debris. Rinsing with antiseptic solutions has no proven clinical value. Pre-treatment of the Skin with appropriate antlseptlcs is effective in reducing the risk of surgical wound infection. I Toplcal antibiotics

are of limited vaiue in treating infected wounds. They shouid be used only where there 1s no alternative. Systemlc antibiotics, dosed appropriately, are indicated for overt infection with signs of spreading celluliis. Dressings and other delivery Systems that deliver sustained doses of effective antlmicrobials have been shown to be valuable In the treatment of critical colonization and infection.

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Lawience JC (1994) Dressin s and wound infection. Am J Srrrg 167(Suppl 1A):%IS-4S

Leaper D (1988) Antiseptic toxicity in Open wounds. N w s dnes 84(25): 77-9

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578 BRmSr-1 JOURNAL OF NURSING, 2001, Vor 10, N O 9

Betaisodona@ Nr. 29

Wound colonization and infection: the rote of topical antimicrobials Richard J. W hite, Rose Cooper, Andrew Kingsley British Journal of Nursing, 2001, Vol 10, No 9

Das ideale Antiseptikum im Wundmanagement hat folgende Eigenschaften: Breites Wirkspektrum, kaum Resistenzentwicklungen, nicht-toxisch, Soforhuirkung, nicht irritierend und nicht sensibilisierend, effektiv in der Anwesenheit von Exsudaten.

PVPJod Die Anwendung von PVP-Jod ist sehr sinnvoll durch seine bakteriostatische und bakterizide Wirkung gegen MRSA Stämme. Unbestritten ist der Einsatz von PVP-Jod bei der Hautantiseptik wie auch sein Wert in der Wundantiseptik

In den USA empfiehlt die FDA - the Food and Drug Administration - den Einsatz von PVP-Jod 5-1 0%, da es offensichtlich die Wundheilung nicht hemmt.

Silber und Silberpräparate Silbernitrate können zu Irritationen führen. Deshalb sollte es nur zur Reduzierung von H yperg ra n u la t ion eingesetzt werden. Die Kombination von Silber und Sulfonamid ist bekannt als Flammazine? Hauptgebiete sind Verbrennungen, akute und chronische Wunden um Infektionen zu behandeln. 1981 wurden iedoch bereits Resistenzen auf Flammazine@ festgestellt.

Wundauflagen Wundauflagen mit PVP-Jod sind empfehlenswert bei nicht heilenden und infizierten chronischen Wunden. Wenn die Infektion oder die kritische Kolonisierung der Wunde reduziert ist und die Wunde Heilungstendenzen zeigt, ist es Zeit zum Wechsel auf wundheilungsfördernde Maßnahmen

Indikationen für Antiseptika auf Wunden Infektion Lokaler Schmerz Wundheilungsstörung