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.
When would you consider obtaining a wound culture and prescribing antibiotics? What is your empiric oral antibiotic of choice?
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.
“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.
Dr. Suzuki notes that technically, one should not be prescribing antibiotics for wounds that appear uninfected. However, he notes an incidence in which that was not true. He recalls a young, healthy male in his 20s who presented with a leg wound that was chronic and non-progressing for a few months. Dr. Suzuki tried different dressings on him for several weeks and then says he prescribed cephalexin “in desperation.
“In two weeks, the wound cleared up beautifully,” he remembers. “I am not advocating giving out antibiotics randomly but I guess you have to consider the option once in a while based on the risk versus benefit.”
When would you consider switching the wound care goals from curative to palliative?
Dr. Rogers primarily defines palliative care in wound healing as the prevention of infection or prevention of wound deterioration. He emphasizes that the patient’s goals, situation and prognosis are paramount. For the patient with an ischemic ulcer without viable vascular interventional possibilities, he says palliative care may also be an option.
“I think palliative wound care may be perceived by some people as ‘giving up,’ but I do believe it is an important concept in this day and age,” says Dr. Suzuki. He cites statistics from a hospice that one-third of hospice patients die with wounds rather than from wounds. He agrees, saying that some of his wound patients do die before complete wound closure occurs.
Dr. Suzuki advocates keeping an open communication with the patients and their families. He emphasizes reviewing their expectations, treatment goals (curative versus palliative) and treatment options (aggressive/surgical versus conservative) from time to time.
“Since major leg amputation is very traumatic to our patients, I often recommend palliative wound care instead for the end-of-life patients, unless they have intractable pain or sepsis,” adds Dr. Suzuki.
If Dr. Pupp’s patients do not respond to curative wound care and they are in the end stages of a terminal disease, he will provide palliative care so as not to impair the quality of the end of life. Dr. Pupp cites the importance of keeping the patient comfortable and preventing further tissue breakdown, which is usually a result of pressure.
In the face of a recalcitrant wound, from whom would you obtain a second opinion?
Citing the importance of a team approach, Dr. Pupp seeks the second opinion of vascular/endovascular specialists if patients need increased blood flow and tissue perfusion for healing. Vascular specialists (vascular surgeons, interventional radiologists and interventional cardiologists) who can help DPMs manage arterial and venous problems are “indispensable,” according to Dr. Suzuki. Dr. Rogers also regularly consults vascular surgeons.
For patients with diabetes, Dr. Pupp will always obtain cardiology clearance/ consults. If patients do not respond to antibiotic treatment or have limb-threatening infections, he consults infectious disease specialists. He refers patients with poorly controlled diabetes to an endocrinologist.
Dr. Suzuki works closely with plastic surgeons and can consult them for input. He notes the importance of other physicians (infectious disease, nephrology, rheumatology, cardiology, etc.) in managing the wound patients, who are often older and have more comorbidities than the average population. He also notes another “second opinion” of asking patients what they think and what has worked for them.
“I think consults from multiple practitioners of varying specialties are helpful in achieving a successful outcome,” says Dr. Rogers.
Dr. Pupp is a Fellow of the American College of Foot and Ankle Surgeons. He is the Director of the Foot and Ankle Clinic at Oakland Regional Hospital in Southfield, Mich. He is also a member of the Residency Training Committee at Providence Hospital in Southfield, Mich.
Dr. Rogers is the Director of the Amputation Prevention Center at Broadlawns Medical Center in Des Moines, Iowa. He directs research at the center and has been an investigator on over 20 clinical trials.
Dr. Suzuki is the Medical Director of Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo, Japan.