Essential Insights On Addressing Common Wound Dilemmas

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Author(s): 
Kazu Suzuki, DPM, CWS

   Whether it is dealing with recalcitrant wounds, choosing appropriate empiric antibiotics for infected wounds or weighing the benefits of palliative care, our expert panelists offer their perspectives on a wide range of wound care issues.

   

Q:

When would you consider obtaining a wound culture and prescribing antibiotics? What is your empiric oral antibiotic of choice?

   

A:

If there is any sign of wound infection, such as constant pain, erythema, edema and/or odor, Kazu Suzuki, DPM, CWS, will not hesitate to obtain a wound culture. Guy Pupp, DPM, concurs. He notes that other classic signs of infection include fever and purulence. After obtaining a culture, Dr. Suzuki will prescribe a short course of empiric oral antibiotics for seven to 10 days, and subsequently adjust as the culture and sensitivity results come back.

   Lee C. Rogers, DPM, only performs cultures in the presence of an infection.

    “Culturing an uninfected wound will cause confusion among clinicians in what to do with the ‘positive’ culture when it is reported, not to mention the medical/ legal aspects of not treating a ‘positive’ culture,” notes Dr. Rogers.

   Dr. Suzuki notes his area’s high prevalence of community-acquired methicillin resistant Staphylococcus aureus (CA-MRSA). He acknowledges that his antibiotic recommendations may not be appropriate for other parts of the country as they are based on the antibiogram in his institution.

   Therefore, his first choice of oral antibiotics for wound infection (cellulitis) to cover possible MRSA would be trimethoprim/sulfamethoxazole (Bactrim, Roche), doxycycline or levoflaxacin (Levaquin, Ortho-McNeil). Dr. Suzuki may also add cephalexin (Keflex, Middlebrook Pharmaceuticals) if he wants coverage for Staph or Strep. Bactrim DS is “definitely the workhorse” in his institution. He adds that he is seeing more MRSA that is resistant to clindamycin. However, Dr. Suzuki cautions that one should not give Bactrim to patients on warfarin (Coumadin, Bristol Myers-Squibb) and physicians should adjust the dosage carefully based on the creatinine clearance.

   For chronic wounds that do not respond to appropriate therapy, Dr. Pupp will consider the wound’s bacterial burden, which increases the metabolic load and produces endotoxins and proteases. He notes that bacterial burden also stimulates a prolonged inflammatory wound environment, which does not allow wounds to heal. If the patient’s bacterial burden is problematic and the patient is not responding to newer antibacterial dressings, Dr. Pupp uses oral antibiotics. His empiric oral antibiotic of choice is Bactrim due to its coverage of MRSA, which he frequently encounters in patients with diabetes. He also uses ciprofloxacin (Cipro, Bayer) with clindamycin depending on the patient’s allergies.

   Dr. Rogers will use a polymerase chain reaction (PCR)-based DNA test for MRSA. He says this test can produce results in two hours and allows clinicians to exclude MRSA coverage in the empiric treatment if results are negative. When it comes to empiric therapy, he first determines the class of infection based on the Infectious Diseases Society of America (IDSA) classification. When it comes to IDSA mild infections (less than 2 cm surrounding cellulitis), he uses a penicillin derivative, cephalosporin or clindamycin. If the patient is at risk for MRSA (or if the DNA screen is positive), Dr. Rogers uses linezolid (Zyvox, Pfizer), trimethoprim/sulfamethoxazole or minocycline.

   Dr. Rogers will admit patients with moderate or severe infections (greater than 2 cm surrounding cellulitis with/ without systemic signs of infection) as classified by the IDSA. He uses de-escalation therapy with tigecycline (Tygacil, Wyeth) monotherapy or linezolid plus a gram-negative agent.

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