Topical antimicrobial toxicity

Neonatal skin care: the scientific basis for practice

OBJECTIVE

To review the literature addressing the care of neonatal skin.

DATA SOURCES

Computerized searches in MEDLINE and CINAHL, as well as references cited in articles reviewed. Key concepts in the searches included neonatal skin differences; neonatal skin and care practices for skin integrity; neonatal skin and toxicity; permeability; and contact irritant sensitization.

STUDY SELECTION

Articles and comprehensive works relevant to key concepts and published after 1963, with an emphasis on new findings from 1993 to 1999. One hundred two citations were identified as useful to this review.

DATA EXTRACTION

Data were extracted and organized under the following headings: anatomy and physiology of the skin; physiologic and anatomic differences in neonatal skin; nutritional deficiencies; skin care practices; and care of skin breakdown.

DATA SYNTHESIS

Newborns' skin is at risk for disruption of normal barrier function because of trauma. In light of available evidence about differences in neonatal skin development, clinical practice guidelines are suggested for baths, lubrication, antimicrobial skin disinfection, and adhesive removal. In addition, basic care practices are suggested for maintaining skin integrity, reducing exposure to potentially toxic substances, and promoting skin health beyond the neonatal period. Preventive care recommendations are made for reducing trauma, protecting the skin's immature barrier function, and promoting skin integrity.

CONCLUSIONS

This review generated evidence with which to create a new and comprehensive practice guideline for clinicians. Evaluation of the guideline is under way at 58 U.S. sites.

The management of patients with venous leg ulcers: new guidelines

The RCN Institute, the Centre for Evidence-based Nursing, and the University of York have recently produced guidelines on the management of patients with venous leg ulcers. These guidelines make recommendations with regard to assessment, compression therapy, cleansing, debridement, dressings, contact sensitivity, training/education and quality assurance (Cullum et al, 1998). They are evidence-based (Effective Health Care Bulletin, 1997), have been informed by expert opinion and are reflective of current good clinical practice. It is envisaged that they will be updated every 2 years. This article provides an outline of these guidelines. However, healthcare professionals must note that guidelines can simplify clinical decision making and this must be acknowledged when the guidelines' recommendations for practice are being implemented.

Culture results in open wound treatment with muscle transfer for tibial osteomyelitis

Fifty-three patients who underwent a two-staged protocol of debridement and muscle flap coverage for chronic osteomyelitis of the tibia between 1991 and 1996 were evaluated. All patients underwent a thorough debridement of all nonviable tissue and bone at initial debridement. Multiple cultures were taken, including aerobic, anaerobic and fungal cultures from the pus, soft tissue, bone curettings and bone. All patients were treated with open wound management and dressing changes. Between 2 to 7 days, median 4 days, all patients underwent a second debridement with a complete set of identical cultures, and immediate soft tissue muscle transfer. There were 42 free vascularized and 11 local tissue transfers. The 53 patients were classified according to the Cierny-Mader classification for chronic osteomyelitis. Twenty-four patients had Stage IVA osteomyelitis, 10 patients had Stage IIIA osteomyelitis, nine patients had Stage IIIB osteomyelitis, eight patients had Stage IVB osteomyelitis, one patient had Stage IA osteomyelitis, and one patient had Stage IIB osteomyelitis. All 53 patients had positive cultures at the time of their initial debridement, and 14 of 53 (26%) had a positive culture at the time of the second debridement. Based on the results, it seems from a bacteriologic stand-point that the second debridement allows for the opportunity for redebridement and wound sterilization of organisms that still may be present.

Effect of povidone-iodine on wound healing: a review

For the purpose of providing a summary of current clinical trials to determine whether povidone-iodine is beneficial or detrimental to wound healing, an integrated review was completed. Clinical trials were defined as any study that uses some concentration and form of povidone-iodine in a comparison or evaluation with other products or treatments resulting in an impact of povidone-iodine on wounds. The use of povidone-iodine for cleansing, irrigating, and dressing wounds is controversial. Wound healing is complex and requires safe and effective treatment modalities. Numerous in vitro and in vivo studies have been done with conflicting results on bactericidal effects and cytotoxicity of this antimicrobial agent. Human and animal in vivo studies in the last 10 years were used for this review because often the relevance of in vitro data in clinical conditions are questioned. The varied studies provide evidence that in most instances, povidone-iodine did not effectively promote good wound healing; in fact, most studies showed either impaired wound healing, reduced wound strength, or infection.

The evaluation of a cadexomer iodine wound dressing on methicillin resistant Staphylococcus aureus (MRSA) in acute wounds

BACKGROUND

Many bacteria have become resistant to commonly-used antibiotics.

OBJECTIVE

The purpose of this study was to examine the effect of a cadexomer iodine wound dressing on methicillin resistant Staphylococcus aureus (MRSA).

METHOD

Partial thickness wounds were made on the backs of three pigs and inoculated with a known amount of MRSA. Wounds were treated with either cadexomer iodine dressing or vehicle dressing (without iodine), or they were left untreated. Three wounds from each treatment group per animal were cultured using quantitative scrub techniques after 24, 48, or 72 hours of treatment.

CONCLUSIONS

The cadexomer iodine dressing significantly reduced MRSA and total bacteria in the wounds as compared to both the no treatment control and vehicle. No significant differences were observed in the number of bacteria recovered between the no treatment control and cadexomer (vehicle) treated wounds. Cadexomer iodine may be an effective agent for preventing proliferation of MRSA in wounds.

Opportunities for mupirocin calcium cream in the emergency department

Mupirocin calcium cream is a newly reformulated topical antibiotic with a bactericidal spectrum specific for the pathogens that frequently cause secondary infections in superficial wounds. Both the calcium cream and ointment formulations have demonstrated efficacy in the treatment of secondarily infected traumatic lesions and dermatoses, including eczema, burns, wounds, bites, and ulcers. Mupirocin has a low risk of systemic and topical complications. To date, antimicrobial resistance is rare among target pathogens. The use of mupirocin to treat secondary wound infection has a profile of high efficacy and does not impair the normal healing in traumatized skin.

Nonselective debridement and antimicrobial cleansing of a venting ductal breast carcinoma

A woman with a moderately differentiated carcinoma that erupted through the skin and amputated her breast was treated with whirlpool, topical antimicrobials, radiation, and chemotherapy. The draining, necrotic, and septic wound was treated for 5 months with a whirlpool containing dilute povidone-iodine solution and intravenous chemotherapy. Wet bandages, necrotic tissue, and softened eschar were removed by whirlpool agitation or mechanically debrided. To start treatment the wound was dressed with Debrisan crystals and sterile gauze for 1 week. Afterwards, wet-to-dry dressings wetted with Dakin's solution were applied. Tissue ingrowth at the wound margin started after 2 weeks, with whirlpool treatments effecting a tissue-reddening hyperemia. Wound drainage ceased after 2 months, with granulation and revascularization resulting. Eleven months later the wound was closed, aseptic, and undergoing dry flaking. The patient was cancer free with a completely healed wound 2 years after treatment. In this case, nonspecific debridement using whirlpool and topical antimicrobials promoted healing of an open fungating wound from a breast carcinoma.

A rational approach to the outpatient management of lacerations in pediatric patients

Lacerations are a frequent reason for pediatric health care visits. Many are referred to EDs or to surgical specialists but may be treated by the pediatrician who has the time and interest in maintaining wound care skills. Although skin closure is often viewed as the primary event in wound care, local anesthesia and wound toilet are equally important aspects in which expertise is often undervalued. On occasion, patient anxiety and resistance complicates wound care, and a variety of sedative techniques facilitates completion of procedures that otherwise would require general anesthesia. Adherence to basic principles and the occasional use of innovations in wound care enable the clinician to bring about optimal outcomes.

Comparison of normal saline with tap water for wound irrigation

This study compared irrigation with tap water versus saline for removing bacteria from simple skin lacerations. The study was conducted in an animal model with a randomized, nonblinded crossover design using 10 500-g laboratory rats. Two full-thickness skin lacerations were made on each animal and inoculated with standardized concentrations of Staphylococcus aureus broth. Tissue specimens were removed before and after irrigation with 250 cc of either normal saline from a sterile syringe or water from a faucet. Bacterial counts were determined for each specimen and compared before and after irrigation. There was a mean reduction in bacterial counts of 81.6% with saline and 65.3% with tap water (P = .34). One tap water specimen had markedly aberrant bacterial counts compared with others. Excluding this specimen, the mean reduction for tap water was 80.2%. In this model, reduction in bacterial contamination of simple lacerations was not different comparing tap water with normal saline as an irrigant.

Pressure ulcers

Pressure ulcers are localized areas of tissue necrosis that result from unrelieved pressure. They are graded or staged according to the degree of tissue damage observed. The main etiologic factors include pressure, shearing forces, friction, and moisture. The clinical course may be complicated by several conditions including infection, sepsis, osteomyelitis, fistulas, and carcinoma. Preventive measures in persons at risk can significantly reduce the incidence of pressure ulcers. Successful management should address the four etiologic factors as well as the general condition of the patient.

Dressing the part

Wound care after cutaneous surgery can play an integral role in wound healing. Wound care regimens have changed dramatically over the last 35 years as the physiology of wound healing has become better understood. Foremost is the improvement in wound healing achieved by keeping the wound occluded and moist. This observation has led to an explosion of a whole new category of occlusive dressings at the surgeon's disposal in healing postoperative wounds. These dressings have numerous applications as discussed previously. Generally, for acute surgical wounds, occlusive dressings are most useful for split-thickness wounds, such as graft donor sites and after dermabrasion, chemical peel, or laser treatment, and full-thickness wounds allowed to heal by secondary intention. Occlusive dressings may have greater benefit for the treatment of chronic ulcers of varying etiologies. The different categories of dressings share the common disadvantage of being relatively expensive. For routine sutured wounds, the authors prefer the readily available and inexpensive Telfa-type dressing combined with a topical antibiotic ointment. Topical antiseptics are useful for reducing bacterial counts on intact skin in preparation for surgery. Povidone-iodine (Betadine) and chlorhexidine gluconate (Hibiclens) have emerged as the two agents of choice. However, antiseptics have been shown to be toxic to healing tissue, and should not be used on open wounds. In contrast, topical antibiotic ointments are safe to use on open wounds, effective in preventing wound infections, and promote wound healing by maintaining a moist wound environment. The authors prefer the combination antibiotic ointment Polysporin for routine postoperative wound care. Antibiotic prophylaxis in dermatologic surgery to prevent wound infection is appropriate in certain cases. Surgery performed on grossly contaminated or infected skin requires a full 7 to 10 day course of antibiotics. Procedures in anatomic areas considered contaminated as well as in clean areas with significant environmental or patient risk factors may benefit from antibiotic prophylaxis. The choice of antibiotics should be based on the organism most likely to cause wound infection at the particular surgical site. Evidence supports giving a single preoperative dose 1 hour before surgery with a second dose possible 6 hours later if the procedure is prolonged or delayed. The risk of bacterial endocarditis after dermatologic surgery is not known. Antibiotics are indicated for any procedure on obviously infected skin, but are not routinely required for very minor procedures, such as small biopsies, on intact skin. Antibiotic prophylaxis may be prudent for those patients classified as high risk by the (AHA). The antibiotic chosen should again cover the organism most likely to cause infection. One dose can be given 1 hour before surgery and repeated 6 hours postoperatively. Finally, wound healing can be greatly impacted by what the patient does or does not do after leaving the office. Therefore, wound care instructions should be clear, detailed, and provided in both oral and written form. Information should also be provided about what to expect as the wound heals.

Interactive wound dressings. A practical guide to their use in older patients

The properties of an ideal wound dressing do not change with the introduction of new types of wound dressing, but the range of effects on wound healing increases. The number of dressings available is enormous, and the choice between them is often bewildering. Because there is still no ideal dressing for all wound types, it is necessary to get to know a few well, and to avoid switching to new therapies solely on the basis of anecdotal reports. The adoption of novel dressings should be based on scientific evidence. At present, dressings are still chosen on the basis of local traditions and personal empirical experience, together with evidence from the few double-blind, placebo-controlled trials that have been performed. In the management of ulcers, a particular wound management plan should not be changed if the ulcer being treated is decreasing in size and the patient is comfortable. The dressing should be chosen with care. The type of chronic ulcer and its appearance, the amount of exudate and the presence or absence of pain all assist in the selection of an appropriate wound dressing product. Quality-of-life aspects are important. In the elderly, good quality of life may not necessarily require complete ulcer healing, although this is naturally desirable. Dressing changes should be minimised and the ulcer should be kept moist and the surrounding skin dry. The high cost of interactive dressings is a potential disadvantage of their use. However, if the wound can be re-dressed at longer intervals and if healing occurs more quickly, their use may be cost effective and associated with less pain and a better quality of life.

Wound healing and wound infection. What surgeons and anesthesiologists can do

Wound healing can be enhanced and wound infections prevented, often by simple, inexpensive, readily available means. Preoperative evaluation for impediments to healing, such as malnutrition, vasoconstriction, hyperglycemia, and steroid use, allows correction prior to operation. Intraoperatively, the surgeon should concentrate on surgical technique, appropriate antibiotic use, and prevention of vasoconstriction (volume, warming). Postoperatively, the focus should be on prevention of vasoconstriction through pain relief, warming, and adequate volume resuscitation and on maintaining nutrition and normoglycemia. These approaches apply as well to chronic wounds. Additionally, maintenance of a moist environment, correction of local vasospasm with sympathetic blockade or warming, and stimulation of angiogenesis through aggressive debridement or hyperbaric oxygen therapy enhance healing of chronic wounds.

Principles of closed surgical wound care

A review of the factors before, during and after surgical procedures that may predispose patients to post-operative wound infection

Treatments and healing rates in a community leg ulcer clinic

Leg ulcer management is increasingly becoming a nurse-led specialty with practitioners implementing evidence-based care that is efficient, effective and resourceful. A large percentage of patients with leg ulceration are treated in the community. This article will discuss the healing rates and management of venous leg ulcers, many of which were longstanding problems, in a community leg ulcer clinic.

Research utilization: development of a central venous catheter procedure

The Nursing Research Committee in a large, tertiary care teaching hospital used Horn model for research use to develop research bases practice guidelines for the care of patients with central venous catheters. Development of these guidelines was the outcome of a process for planned change including a critique of relevant literature consultation with clinical experts, involvement and commitment of stakeholders, and the development of an educational plan. The recommendations focus on the technique for the central venous catheter procedure, cleansing of the site, use of ointments, and application of dressings. Used as clinical practice guidelines, they offer nurses a scientific basis for their practice.

Instrument sterilization, skin preparation, and wound management

Recent advances in instrument sterilization include the introduction of gas plasma sterilization and the increased use of glutaraldehyde. Gas plasma sterilization has the advantages of no toxic residue effects, reduced turnover time, and applicability for sterilization of heat- and moisture-sensitive instruments. Chlorhexidine gluconate (4%) appears to be a superior preoperative surgical scrub for both the surgeon and the patient because of its increased antimicrobial efficacy, residual activity, and minimal tissue reactions. There are many new wound dressings and topical medications for treatment of wounds, but the efficacy of most of these preparations has been evaluated only in humans, dogs, and cats. The ideal topical wound preparation and dressing for equine wounds, particularly wounds affecting the distal limb, have not yet been found.

Phenytoin in wound healing

OBJECTIVE

To describe a patient with a massive Grade IV pressure ulcer that responded rapidly to treatment with topical phenytoin and to review the literature supporting the use of this therapy.

CASE SUMMARY

A 55-year-old morbidly obese white man (266 kg), with respiratory failure secondary to obesity-hypoventilation syndrome and heart failure, developed pressure ulcers on his lower back and sacrum with the first 2 weeks of hospitalization. Traditional methods of treatment were unsuccessful, and by day 79, the wound involved the entire lumbosacral area and buttocks, and had extensive undermining and sinus tract formation. Within 2 days of applying topical phenytoin, fresh granulation was apparent. After 54 days of treatment, nearly all the sinus tracts were healed. Four months after treatment with topical phenytoin had facilitated the healing of the wounds, even though the patient's multiple underlying medical problems had not resolved.

DISCUSSION

Phenytoin has been used in the healing of pressure sores, venous stasis and diabetic ulcers, traumatic wounds, and burns. Many of the existing clinical studies have methodologic flaws, such as inappropriate statistical analysis, inadequate control groups, and the absence of randomization and double-blinding. Nevertheless, all the studies have reported enhancement of wound healing, with insignificant adverse effects. Phenytoin may promote wound healing by a number of mechanisms, including stimulation of fibroblast proliferation, facilitation of collagen deposition, glucocorticoid antagonism, and antibacterial activity.

CONCLUSIONS

Phenytoin promoted the healing of a massive necrotizing soft tissue wound that was unresponsive to conventional treatment. Clinical success in this difficult case and the other reports in the literature suggest that phenytoin is effective in would healing and deserves further investigation.

Foot lesions in patients with diabetes mellitus

Diabetic foot ulcers are common. If treatment is delayed or is inappropriate, the lesions can become infected, resulting in gangrene and amputation. Physicians and clinics that perform aggressive therapy for these ulcers, provide revascularization when indicated, practice a team approach, suggest the use of therapeutic shoes, and repeatedly educate patients in foot care have reduced their amputation rates by 50% or greater. Goals of the United States Department of Health for the year 2000 include a 40% reduction in the amputation rate in patients with diabetes. This should be the goal of everyone providing care for patients with diabetes.

Hydrogen peroxide inhibits human keratinocyte migration

BACKGROUND

Reepithelialization is an important component of wound healing. In the first 48 hours keratinocyte migration and proliferation are important events in this process. Although the literature agrees that the risk/benefit of antiseptics has not been established, hydrogen peroxide is still commonly used in the management of acute and chronic wounds.

OBJECTIVE

The purpose of this study was to evaluate the effect of hydrogen peroxide on human keratinocyte migration and proliferative potential.

METHODS

The viability and proliferative potential of human keratinocytes in the presence of hydrogen peroxide was assessed by trypan blue exclusion, cell morphology, substratum attachment, and thymidine incorporation. Using concentrations of hydrogen peroxide that do not affect keratinocyte viability, keratinocyte migration was evaluated by a standard motility assay.

RESULTS

Hydrogen peroxide in concentrations < or = 700 microM was found to have no effect on keratinocyte viability. At these low concentrations, however, hydrogen peroxide had a profound inhibitory effect upon keratinocyte migration on extracellular matrix and decreased the proliferative potential of the cells in a concentration-dependent fashion.

CONCLUSION

Hydrogen peroxide, in very low concentrations (1000-fold less than the "everyday use" dilution) inhibits keratinocyte migration and proliferation.

Postoperative mediastinitis: classification and management

Although the incidence of mediastinal wound infection in patients undergoing median sternotomy for cardiopulmonary bypass is less than 1%, its associated morbidity, mortality, and "cost" remain unacceptably high. There is considerable lack of consensus regarding the ideal operative treatment of complicated median sternotomy wounds. The aim of this article is to review the current preventive, diagnostic, and therapeutic techniques offered to patients with mediastinitis. We also propose a new classification for postoperative mediastinitis. Data from the English-language literature suggest that the type of mediastinitis and direct assessment of the mediastinum under general anesthesia are the main determinants of the nature of subsequent operative treatment. Wound debridement and removal of foreign materials are essential steps of whatever procedures are applied. Closed mediastinal irrigation can be successful in type I mediastinitis, whereas major reconstructive operation is probably the treatment of choice for patients with mediastinitis types II to V. Refinement of the current diagnostic tools and further evaluation of the benefits of primary sternal fixation in combination with a reconstructive procedure in mediastinitis types I to III could improve the outcome of this dreaded complication.

Differences in early versus late extracavitary arterial graft infections

PURPOSE

The purpose of this report was to determine differences in presentation, bacteriology, management, and outcome of early (EGIs) versus late extracavitary arterial graft infections (LGIs).

METHODS

Between July 1, 1979, and June 30, 1994, we treated 141 patients with infected extracavitary arterial grafts (112 prosthetic, 29 vein) with selective partial or complete graft preservation.

RESULTS

A total of 99 (70%) EGIs (< 2 months) and 42 (30%) LGIs (4 to 96 months) were involved. The hospital mortality rate was 14% (20 of 141), and the amputation rate in survivors was 13% (16 of 121). No significant difference in mortality (16% [16 of 99] vs 10% (4 of 42]) or limb loss (16% [13 of 83] vs 8% [3 of 38]) was seen between EGIs and LGIs, respectively (p > 0.05). Patients with EGIs were as likely to have a disrupted anastomosis (17% [17 of 99] vs 21% [9 of 42]) or systemic sepsis (4% [4 of 99] vs 4% [2 of 42]) as patients with LGIs, respectively (p > 0.05). Patients with EGIs were more likely to have patent, intact grafts and to be treated by complete graft preservation (61% [61 of 99] vs 26% [11 of 42]) (p = 0.0001). In comparison, patients with LGIs were more likely to have occluded grafts and to require subtotal graft excision (48% [20 of 42] vs 18% [18 of 99]) (p = 0.0001). Surviving patients with EGIs treated by complete graft preservation were more likely to have successful healing of their wounds after long-term follow-up (average 3 years) than patients with LGIs (79% [41 of 52] vs 40% [4 of 10], respectively) (p = 0.03). The pathogens cultured from wounds of EGIs versus LGIs were pure gram-positive bacteria in 49 (49%) versus 19 (46%), pure gram-negatives in 18 (18%) versus 11 (26%), and both types in 33 (33%) versus 12 (28%) (p > 0.05).

CONCLUSION

Complete graft preservation can be attempted more frequently and is more likely to be successful in EGIs than in LGIs. No difference in bacteriology was seen between the two groups. Graft-preserving treatment can be successful but should only be cautiously attempted in patients with late extracavitary arterial graft infections.

Cytotoxic effects of four antibiotics on endothelial cells

Intravenous administration of antibiotics often causes local pain and thrombophlebitis at the site of injection. An in vitro model that could predict these effects would be of great value. In this study the effects of four antibiotics, benzylpenicillin, cefuroxime, dicloxacillin and erythromycin, have been evaluated on three types of endothelial cells in culture. The cell types employed were primary culture from human umbilical vein, primary culture from bovine aorta, and the cell line EA-hy 926, a hybride endothelial cell. These cells were exposed to antibiotics for 24 hr and subsequently toxic effects on cells were evaluated by three different assays. Benzylpenicillin was atoxic in all types of cells and in all assays, in contrast to the other antibiotics. The other three antibiotics exerted dose dependent toxic effects in all investigated cells when DNA-synthesis and total cell protein were used as toxicity assays but the results varied between the cell types. There were no significant differences between the effects of cefuroxime, dicloxacillin and erythromycin on bovine endothelial cells. In the other cell types, however, there were significant differences between some drugs but the outcome depended on the cell type. It is concluded that it is possible to show differences between the effect of antibiotics on endothelial cells, but the result depends on the cell type employed.

Pressure ulcers: prevention and management

OBJECTIVE

To describe important aspects of pressure ulcer prevention and management, especially in elderly patients.

DESIGN

We reviewed pertinent published material in the medical literature and summarized effective strategies in the overall management of the elderly population with pressure ulcers.

RESULTS

Pressure ulcers are commonly encountered in geriatric patients. The development of a pressure ulcer is associated with an increased risk of death. Certain well-recognized risk factors, such as immobility and incontinence, may predispose to the development of pressure ulcers; consequently, risk factor modification is an important aspect of prevention and treatment. For existing lesions, various innovative patient support surfaces and wound care products have been developed to alleviate pressure and to facilitate wound healing. The use of a particular product should be based on the clinical setting and the limited scientific evidence available. With treatment, most pressure ulcers eventually heal.

CONCLUSION

Pressure ulcers are often, but not always, preventable. The occurrence of such an ulcer signals the possible presence of chronic comorbid disease and should prompt a search for underlying risk factors in patients for whom ulcer treatment is considered appropriate.

Recommendations for initial antibiotic treatment of extracavitary arterial graft infections

BACKGROUND

Initial antibiotic treatment of extracavitary arterial graft infections is usually empiric or based on Gram's stain findings. Increasing virulence of bacteria causing extracavitary arterial graft infections may render previous choices of antibiotics obsolete. The purposes of this study were to correlate Gram's stain findings of gram-positive bacteria and gram-negative bacteria with wound cultures and provide a microbiologic basis for appropriate initial antibiotic therapy.

METHODS

Between July 1, 1979 and June 30, 1994, specimens obtained on the day of admission from purulent wounds involving 113 extracavitary arterial graft infections were retrospectively reviewed for Gram's stain and culture and sensitivity results.

RESULTS

Gram's stain findings correlated with final cultures on only 28 of 113 cases (25%), including 20 of 48 pure gram-positive, 2 of 24 pure gram-negative, and 6 of 41 mixed bacterial cultures. Staphylococcus aureus was the most common gram-positive bacteria cultured (43 isolates) and Pseudomonas species was the most common gram-negative bacteria (25 isolates). Bacteria were sensitive to a first-generation cephalosporin in only 32% (36 of 113) of infections. A combination of vancomycin and either ticarcillin-clavulanic acid or ceftazidime, which have minimal toxicity and provide excellent coverage against staphylococci, Pseudomonas, and other gram-negative bacteria, would have covered 96% (109) and 95% (107) of cultured organisms, respectively.

CONCLUSIONS

Regardless of Gram's stain findings, current recommendations for initial treatment of extracavitary arterial graft infections should include vancomycin and ceftazidime or ticarcillin-clavulanic acid until final culture and sensitivity results dictate the use of more selective antibiotics.

Parameters of wound assessment

Close examination of all aspects of a patient's condition as well as the wound itself will minimise the risk of failure in wound management. Involving the patient and the patient's carer can secure cooperation and compliance with treatment and can positively influence the outcome of care.

Selective preservation of infected prosthetic arterial grafts. Analysis of a 20-year experience with 120 extracavitary-infected grafts

OBJECTIVE

The authors report on their 20-year experience with 120 patients with infected extracavitary prosthetic arterial grafts (95 polytetraflouroethylene, 25 Dacron). Throughout this experience, an effort was made, when appropriate, to salvage all or a portion of these infected grafts.

METHODS

When patients had arterial bleeding (20 cases) or systemic sepsis (6 cases), immediate graft excision was performed. When the infected graft was occluded (43 cases), subtotal graft excision was performed, leaving an oversewn 2- to 3-mm graft remnant to maintain patency of the artery. Complete graft preservation was attempted in 51 cases in which the graft was patent, the patient was not septic, and the anastomoses were intact. Aggressive operative wound debridement was repeated, as necessary, to achieve wound healing. The preferred method of revascularization, when necessary, included secondary bypasses tunneled through uninfected (often lateral) routes. Follow-up averaged 3 years (range, 1 month-20 years).

RESULTS

This strategy resulted in a hospital mortality of 12% (14/120) and a hospital amputation rate in survivors of 13% (14/106 threatened limbs). Of the surviving patients treated by complete graft preservation, the hospital amputation rate was only 4% (2/45) and long-term complete graft preservation was successful in 71% (32/45) of cases. Partial graft preservation also proved successful in 85% (35/41) of surviving patients who had occluded grafts. Successful complete graft preservation was as likely when gram-negative or gram-positive bacteria were cultured from the wound, with the exception of Pseudomonas (successful graft preservation in only 40% [4/10] of cases).

CONCLUSION

Based on this 20-year experience, the authors conclude that selective partial or complete graft preservation represents a simpler and better method of managing infected extracavitary prosthetic grafts than routine total graft excision.

Assessment and management of foot disease in patients with diabetes

Limb- or life-threatening complications in patients with diabetes can be prevented with an integrated, multidisciplinary approach. Most patients seen in clinical practice are in the early stages of the disease process. Glycemic control retards the progression of neuropathy, which is the most important risk factor for ulceration. Early detection of the loss of protective sensation and implementation of strategies to prevent ulceration will reduce the rates of limb-threatening complications. Clinicians should routinely examine the feet of diabetic patients. Education in foot care, proper footwear, and close follow-up are required to prevent or promptly detect neuropathic injury. If ulceration occurs, removal of pressure from the site of the ulcer and careful management of the wound will allow healing in most cases. The failure to heal despite these measures should prompt a search for associated arterial insufficiency. If infection is present, appropriate antimicrobial therapy combined with immediate surgical intervention, including revascularization when necessary, will increase the chances of saving the limb. With this comprehensive approach, it is possible to achieve the goal of a 40 percent decrease in amputation rates among diabetic patients by the year 2000.

Elderly skin care: principles of chronic wound care

1. Chronic wounds are a frequently encountered problem in elders. Chronic wounds are characterized by loss of skin or underlying soft tissue and do not progress toward healing with conventional wound care treatment. 2. There are four basic principles of chronic wound care: remove debris and cleanse the wound; provide a moist wound healing environment through the use of proper dressings; protect the wound from further injury; and provide substrates essential to the wound healing process. 3. Underlying the care of chronic wounds is the necessity to assess the wound on an ongoing basis. Changes in wound care must be based on changing wound parameters, and timely, complete, and accurate wound assessments must be documented.

Pressure ulcers: a review

This article reviews the etiology, pathology, description, risk factors, prevention, medical and surgical management, and complications of pressure ulcers. Pressure ulcers, which develop primarily from pressure and shear, are also known as decubitus ulcers, bed sores, and pressure sores. They continue to occur in hospitals, nursing homes, and among disabled persons in the community. Estimates of the prevalence of pressure ulcers in hospitalized patients range from 3% to 14% and up to 25% in nursing homes. Persons with spinal cord injury and the elderly are two groups at high risk. The most common sites of development are the sacrum, ischium, trochanters, and about the ankles and heels. Areas of ongoing research such as electrical stimulation and growth factors are discussed.

Nursing treatment of patients with chronic leg ulcers in the community

A descriptive survey of current reported practice by 146 community nurses for their nursing treatment of leg ulcers was undertaken. Sixty-four per cent of nurses reported they would apply compression bandages to only venous ulcers; in only 23% of cases could the products described achieve an adequate level of compression. A variety of modern wound dressings were used by the nurses; 89% of nurses reported using a combination of different products layered over the ulcer. There is no evidence that this has any beneficial effect and could therefore be a potential waste of money, as well as contributing to allergic skin reactions. It would be useful if primary-health-care teams and Family Health Service Authority information pharmacists formulated protocols based upon effective treatments for patients with chronic leg ulcers.

Venous ulcers

Successful therapy of venous ulcers combines local wound treatment modalities and ambulatory hemodynamic support to control the underlying disease. Compression bandaging reduces or eliminates edema, and a moist wound environment not only debrides necrotic tissue but also aids development of granulation tissue, a prerequisite for epidermal repair. We have occluded chronic wounds, known to be heavily colonized, with a hydrocolloid dressing for up to 7 days and found that soft-tissue infections occurred in only 1% of all dressing changes in our clinic, compared with 6.5% generally reported in the literature. In venous ulcers, resident bacteria may be beneficial in that their proteolytic activity assists with autolysis of fibrinopurulent wound exudate. The importance of lysing fibrin and reducing the number of existing fibrin "cuffs," thereby improving local tissue oxygenation and nutrient/waste exchange, is not completely understood; however, this phenomenon, in part, may explain the excellent clinical results obtained with one type of hydrocolloid dressing (DuoDERM), which has been shown to lyse fibrin more effectively than other types of moisture-retentive and hydrocolloid dressings.

Essentials of pressure ulcer treatment. The diabetic experience

BACKGROUND

Diabetes accounts for over half of the lower extremity amputations in the United States. However, ulcers of the diabetic foot can often be treated successfully and amputations avoided.

OBJECTIVE

To review treatment of diabetic foot ulcers.

RESULTS

Physicians must recognize the critical clinical and diagnostic features of ischemic and neuropathic ulcers. Therapy is directed towards vascular repair in the ischemic ulcer and relief of weight bearing through casting and shoes with molded insoles in the neuropathic ulcer. Sound principles of wound care apply to all ulcers.

CONCLUSION

For successful preventive foot care patients and physicians need to understand how and why ulcers form and the rationale for the types of footwear and care necessary to prevent ulcers.

A modified technique of delayed primary closure using a povidone iodine wick: influence on wound healing in an experimental model

We report a modified technique of delayed primary wound closure using a wound wick. A rodent model was used to determine its influence on healing. After loose primary closure of two paravertebral incisions on the dorsum of male rats, a 10 cm length of ribbon gauze, soaked in either saline or 1% povidone-iodine, was inserted into the right sided wound. Wicks were soaked daily with the same solution until removal on the third post-operative day. The inclusion of a wick soaked in saline had an early transient effect on healing. A more prolonged impairment of healing was demonstrated in povidone-iodine wicked wounds and their respective controls. These data suggest that povidone-iodine impaired healing not only in the wicked wound, but also inhibited healing in the adjacent unwicked wound which was not directly exposed to the antiseptic. The observed delay in healing in povidone-iodine wicked wounds must however be balanced against its beneficial effect on wound infection rates. We suggest that further evaluation of this method of closure in contaminated wounds is warranted.

A study of hydrogen peroxide generation by, and antioxidant activity of, Granuflex (DuoDERM) Hydrocolloid Granules and some other hydrogel/hydrocolloid wound management materials

The effect of Granuflex Hydrocolloid Granules (0.01-0.50% w/v) on the rate of proliferation of murine (L929) fibroblasts was examined. The dose-response curve showed a significant (P < 0.02) pro-proliferant effect at 0.05%, and a significant (P < 0.02) antiproliferant effect at 0.50%, mirroring the dose-response curve produced by hydrogen peroxide in the concentration range 10(-9) - 10(-4) mol/l. The antiproliferant effect at 0.20% w/v was abolished by catalase, suggesting that the biological activity of Granuflex was mediated by the in situ generation of hydrogen peroxide. Formation of hydrogen peroxide by Granuflex was confirmed by performing the scopoletin-horseradish peroxidase assay in the presence and absence of catalase. The total concentration of hydrogen peroxide detected was about 8 x 10(-6) mol/l (using 0.5% w/v Granuflex) after 48 h at 37 degrees C. In contrast, when hydrogen peroxide itself was added to L929 cultures, a similar antiproliferant activity was observed at concentrations between 10(-4) and 10(-5) mol/l. These results suggested that Granuflex was undergoing autoxidation in the culture medium, and hence that it might possess antioxidant activity. In assays for antioxidant activity using 1,1-diphenyl-2-picrylhydrazyl (DPPH), Granuflex, and two other hydrocolloid dressings (Comfeel Powder and Bard Absorption Dressing) showed significant ability to reduce DPPH to DPPH2. These three dressings also displayed superoxide scavenging activity in a nitroblue tetrazolium reduction assay. We conclude that, in addition to providing a moist wound-healing environment, Granuflex and certain other hydrocolloids might contribute to the establishment and maintenance of the reducing environment necessary for energy production and hence cell division.(ABSTRACT TRUNCATED AT 250 WORDS)

A review of topical agents for wounds and methods of wounding. Guidelines for wound management

This article reviews the effects of antiseptics, antimicrobials, hemostatic agents and surgical methods on the incidence of wound infection and the process of wound healing. A set of guidelines is provided to help decide what to apply topically to wounds and which method of wounding to select in order to achieve the best possible outcome in wound healing.

The diabetic foot. General considerations and proposal of a new therapeutic and preventive approach

The treatment of the diabetic foot is a common and sometimes difficult problem. The treatment of the characteristic lesions of the diabetic foot involves many forms of therapy: these include contact dressings and topical treatments. The different therapies that have been applied do not often give satisfactory results. Therefore, for this purpose, we have studied the effect of biostimulation of wound-healing by utilising the CO2 laser together with the action of the KTP laser on 25 patients (11 females and 14 males), all suffering from diabetes mellitus with polyneuropathic ulcers of the foot. Low out-put laser irradiation may stimulate granulation tissue and collagen production in fibroblasts. Many studies observed a regeneration of microcirculation in the ulcer and a regeneration of lymphatic circulation. The laser irradiation method produces a sterilizing effect from bacteria that over-infect the diabetic ulcer too. Each patient underwent a surgical treatment of the edges of the ulcers with CO2 and KTP laser (wavelength 532 nm) focused, and a combined phototherapy (CO2 laser and afterwards KTP laser, defocused). The irradiation was carried out through laser beam (by optic fiber for KTP) manually directed, until all of the ulcer surface became irradiated. On the skin around the ulcer, an omental derived cream (fractionated porcine omental lipid extracts) was daily applied, independently from the laser treatment, to evaluate the angiogenic effect of this substance.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary closure for infected dehiscence of the sternum

I propose a new irrigation-suction system to achieve primary closure of the sternum in cases of postoperative infected dehisced sternotomy. Of 16 cases, I had no treatment failures, no recurring infections, and no patient deaths after 1 to 8 years of follow-up. The new system entails retrosternal and superficial sets of tubes, both in double-staggered position, with primary closure of the sternum and of the skin. Skin or muscle flaps are avoided, and the stability of the chest cage is maintained. Hospitalization time is 14 to 18 days.