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Question and answer
Journal
of Hospital
Infection
(1990) 16, 173-174
Question
and answer
Which microorganisms are considered signi$cant as a cause of infection in chronic leg ulcers OYpressure sores?It has been suggested that ‘Eusol’ should not be used for treatment of such infected leg ulcers or pressure sores. What advice should be given to treat these patients? A wide range of organisms can be isolated from varicose ulcers and pressure sores. These include Proteus spp., Pseudomonas aeruginosa, Klebsiella and Enterobacter spp., Staphylococcus aweus and other skin flora, various streptococci, particularly Streptococcus faecalis and anaerobes such as Bacteroides spp. and peptococci (Dagher, Alongi & Smith, 1978; Henderson Marples & Richardson, 1980, Gilchrist & Reed, 1989). In addition to Streptococcus pyogenes, anaerobes may be responsible for cellulitis. The role of bacteria in delaying healing remains uncertain. Streptococcus pyogenes and to a lesser extent P. aeruginosa are responsible for graft failure in burns patients (Lowbury, 1976). Solme studies have suggested that the presence of a large number of organisms l(i.e. over lo5 per cm* or g of tissue) will delay healing (Lookingbill, Miller & Knowles, 1978; Mummery & Richardson, 1979). Other studies have indicated that most organisms colonizing ulcers do not influence healing (Gilchrist & Reed, 1989). Mixtures of organisms are frequently present on the surface of ulcers, and laboratory time can be wasted by carrying out unnecessary antibiotic sensitivity tests. Systemic antibiotic therapy is only required in the presence of cellulitis or other clinical sepsis. The requirement for topical antimicrobial agents is therefore limited. Some antiseptics, particularly chlorine-releasing compounds, such as ‘Eusol’, are toxic to cells and will delay healing (Brennan & Leaper, 1985; Brennan, Foster & Leaper, 1986). Although ‘Eusol’ or similar compounds may be of initial value in debridement, they should not be used when the wound is clean, and it is now generally agreed that chlorine-releasing agents should not be used (Morgan, 1989). Debridement can be achieved satisfactorily by other methods (Drugs & Therapeutic Bulletin, 1986). Similarly, topical antibiotics, particularly those which are also used systemically such as gentamicin or fusidic acid, should be avoided if possible as resistance may emerge during treatment. However, short treatments, e.g. for 2 days, may be acceptable to reduce the number of organisms before grafting (Henderson et al., 1980). The optimal local treatment of ulcers is still uncertain. Healing is influenced by many factors, especially the local blood supply, but a number of new dressing materials are now available which are claimed to improve 019%6701/90/060173
+02
0
lO3.00/0
173
1990
The
Hospital
Infection
Society
174
Question
and Answer
healing. The indications for a specific type of dressing depends on the state of the wound. Various alginates, dextranomers, hydrogels, hydrocolloids and semi-permeable films are available in addition to the more conventional dressings and topical applications (Drugs & Therapeutic Bulletin, 1986). The indications for these various dressings are outside the scope of this answer (Barrett, 1989). The new dressings are often expensive, but are now routinely used for the treatment of chronic ulcers. In addition to local treatment, the underlying causes, e.g. venous incompetence, ischaemia, diabetes etc, require consideration and surgical removal of slough and grafting may sometimes be appropriate. G. A. J. Ayliffe
Hospital Infection Research Laboratory, Dudley Road Hospital, Dudley Road, Birmingham B18 7QH
References Barrett, E. (1989). The management of pressure sores. Intensive Therapy @ Clinical Monitoring 10, 255-259. Brennan, S. S., Foster, M. E. &Leaper, D. J. (1986). Antiseptic toxicity in wound healing by secondary intention. Journal of Hospital Infection 8, 263-267. Brennan, S. S. & Leaper, D. J. (1985). The effect of antiseptics on the healing wound: a study using the rabbit ear chamber. British Journal of Surgery 72, 780-782. Dagher, F. J., Alongi, S. V. & Smith, A. (1978). Bacterial studies of leg ulcers. Angiology 29, 641-653. Drugs & Therapeutic Bulletin (1986). Dressings for leg ulcers. Drugs and Therapeutic Bulletin 24, 9-l 2. Gilchrist, B. & Reed, C. (1989). The bacteriology of chronic venous ulcers treated with occlusive hydrocolloid dressings. British Journal of Dermatology 121, 337-344. Henderson, H. P., Marples, R. R. & Richardson, J. F. (1980). Comparison of antibacterial agents in the preparation of varicose ulcers for skin grafts. Journal of Hospital Infection 1, 141-147. Lookingbill, D. P., Miller, S. H. & Knowles, R. C. (1978). Bacteriology of chronic leg ulcers. Archives of Dermatology 114, 1765-1768. Lowbury, E. J. L. (1976). Prophylaxis and treatment for infection in burns. BritishJournal of Hospital Medicine 15, 566-572. Morgan, D. A. (1989). Chlorinated solutions: (E) useful or (e) useless. The Pharmaceutical Journal 243, 219-220. Mummery, R. V. & Richardson, W. W. (1979). Clinical trial of ‘Debrisan’ in superficial ulceration. Journal of International Research 7, 263-271.
of Hospital
Infection
(1990) 16, 173-174
Question
and answer
Which microorganisms are considered signi$cant as a cause of infection in chronic leg ulcers OYpressure sores?It has been suggested that ‘Eusol’ should not be used for treatment of such infected leg ulcers or pressure sores. What advice should be given to treat these patients? A wide range of organisms can be isolated from varicose ulcers and pressure sores. These include Proteus spp., Pseudomonas aeruginosa, Klebsiella and Enterobacter spp., Staphylococcus aweus and other skin flora, various streptococci, particularly Streptococcus faecalis and anaerobes such as Bacteroides spp. and peptococci (Dagher, Alongi & Smith, 1978; Henderson Marples & Richardson, 1980, Gilchrist & Reed, 1989). In addition to Streptococcus pyogenes, anaerobes may be responsible for cellulitis. The role of bacteria in delaying healing remains uncertain. Streptococcus pyogenes and to a lesser extent P. aeruginosa are responsible for graft failure in burns patients (Lowbury, 1976). Solme studies have suggested that the presence of a large number of organisms l(i.e. over lo5 per cm* or g of tissue) will delay healing (Lookingbill, Miller & Knowles, 1978; Mummery & Richardson, 1979). Other studies have indicated that most organisms colonizing ulcers do not influence healing (Gilchrist & Reed, 1989). Mixtures of organisms are frequently present on the surface of ulcers, and laboratory time can be wasted by carrying out unnecessary antibiotic sensitivity tests. Systemic antibiotic therapy is only required in the presence of cellulitis or other clinical sepsis. The requirement for topical antimicrobial agents is therefore limited. Some antiseptics, particularly chlorine-releasing compounds, such as ‘Eusol’, are toxic to cells and will delay healing (Brennan & Leaper, 1985; Brennan, Foster & Leaper, 1986). Although ‘Eusol’ or similar compounds may be of initial value in debridement, they should not be used when the wound is clean, and it is now generally agreed that chlorine-releasing agents should not be used (Morgan, 1989). Debridement can be achieved satisfactorily by other methods (Drugs & Therapeutic Bulletin, 1986). Similarly, topical antibiotics, particularly those which are also used systemically such as gentamicin or fusidic acid, should be avoided if possible as resistance may emerge during treatment. However, short treatments, e.g. for 2 days, may be acceptable to reduce the number of organisms before grafting (Henderson et al., 1980). The optimal local treatment of ulcers is still uncertain. Healing is influenced by many factors, especially the local blood supply, but a number of new dressing materials are now available which are claimed to improve 019%6701/90/060173
+02
0
lO3.00/0
173
1990
The
Hospital
Infection
Society
174
Question
and Answer
healing. The indications for a specific type of dressing depends on the state of the wound. Various alginates, dextranomers, hydrogels, hydrocolloids and semi-permeable films are available in addition to the more conventional dressings and topical applications (Drugs & Therapeutic Bulletin, 1986). The indications for these various dressings are outside the scope of this answer (Barrett, 1989). The new dressings are often expensive, but are now routinely used for the treatment of chronic ulcers. In addition to local treatment, the underlying causes, e.g. venous incompetence, ischaemia, diabetes etc, require consideration and surgical removal of slough and grafting may sometimes be appropriate. G. A. J. Ayliffe
Hospital Infection Research Laboratory, Dudley Road Hospital, Dudley Road, Birmingham B18 7QH
References Barrett, E. (1989). The management of pressure sores. Intensive Therapy @ Clinical Monitoring 10, 255-259. Brennan, S. S., Foster, M. E. &Leaper, D. J. (1986). Antiseptic toxicity in wound healing by secondary intention. Journal of Hospital Infection 8, 263-267. Brennan, S. S. & Leaper, D. J. (1985). The effect of antiseptics on the healing wound: a study using the rabbit ear chamber. British Journal of Surgery 72, 780-782. Dagher, F. J., Alongi, S. V. & Smith, A. (1978). Bacterial studies of leg ulcers. Angiology 29, 641-653. Drugs & Therapeutic Bulletin (1986). Dressings for leg ulcers. Drugs and Therapeutic Bulletin 24, 9-l 2. Gilchrist, B. & Reed, C. (1989). The bacteriology of chronic venous ulcers treated with occlusive hydrocolloid dressings. British Journal of Dermatology 121, 337-344. Henderson, H. P., Marples, R. R. & Richardson, J. F. (1980). Comparison of antibacterial agents in the preparation of varicose ulcers for skin grafts. Journal of Hospital Infection 1, 141-147. Lookingbill, D. P., Miller, S. H. & Knowles, R. C. (1978). Bacteriology of chronic leg ulcers. Archives of Dermatology 114, 1765-1768. Lowbury, E. J. L. (1976). Prophylaxis and treatment for infection in burns. BritishJournal of Hospital Medicine 15, 566-572. Morgan, D. A. (1989). Chlorinated solutions: (E) useful or (e) useless. The Pharmaceutical Journal 243, 219-220. Mummery, R. V. & Richardson, W. W. (1979). Clinical trial of ‘Debrisan’ in superficial ulceration. Journal of International Research 7, 263-271.