Magical thinking- do antibiotics improve chronic wound healing?

We’ve previously addressed this topic here.   It’s certainly the case that chronic skin ulcers (leg or elsewhere) drive an enormous amount of antibiotic prescribing, perhaps because these ulcers are so hard to heal and a degree of therapeutic impatience occurs. The annual survey of chronic wounds last year in our health district indicated that 28% of inpatients with wounds had received antibiotic treatment in the preceding 2 weeks, unnecessary exposure that leads to increased individual and community risk from antibiotic resistance, C. difficile infection and other unintended consequences, including mortality.

Criteria for systemic antibiotics include:

  • presence of cellulitis (don’t overcall it – more than just redness) – minimise duration of treatment (7-10 days maximum) and target Gram positives – beta-haemolytic Streptococci and Staphylococcus aureus.
  • presence of underlying osteomyelitis (treatment may well require scalpelmycin – consult your surgeon- and also consult infectious diseases as prolonged treatment usually required)

Wound swabs are almost never appropriate as a positive result is not indicative of clinical infection per se and even in the presence of clinical infection, a positive result is often not indicative of the offending pathogen(s).

In patients with diabetic foot ulcers and underlying osteomyelitis, best practice is to culture a bone biopsy collected via intact skin – surface wound cultures are a poor substitute.  This schema for diagnosis of diabetic foot osteomyelitis may serve as a useful guide (from reference 2, International Working Group on the Diabetes Foot guidelines) .

Our laboratory comment attached to reports from chronic ulcer swabs advises:

ulcer1

References

  1. Diabetes Metab Res Rev. 2016 Jan;32 Suppl 1:254-60. doi: 10.1002/dmrr.2736. Pitfalls in diagnosing diabetic foot infections. Peters EJ
  2. Open Forum Infect Dis. 2014 Aug 7;1(2). Diagnosing diabetic foot osteomyelitis: narrative review and a suggested 2-step score-based diagnostic pathway for clinicians. Markanday A.

2 comments

  1. neil2513 · · Reply

    Thank you
    I have extensively emailed this

    Liked by 1 person

  2. Thought might interest

    From: neil wearne [mailto:neilwearne@doctor.com]
    Sent: Friday, 28 October 2016 9:21 PM
    To: Neil Wearne
    Subject: Fw: Re: Daniel – someone has repeated your work?

    Sent: Friday, October 28, 2016 at 5:42 PM
    From: “Daniel Isacson” <ddisacson@gmail.com>
    To: “neil wearne” <neilwearne@doctor.com>
    Subject: Re: Daniel – someone has repeated your work?
    Hi Neil

    Hope all is well with you? Yes they repeated the study. They’ve been working on it since ours was published, given they were so late they had to do an excellent job on it which they did, but now there’s 2 randomized multicenter trials out there so arguing that the evidence is not out just won’t work anymore.

    I presented my last paper at the international colosurgeons meeting in Milan. This was again Another outpatient no antibiotic treatment study, which has now been replicated in 3 more countries with same gret results. Still when the moderator asked how many people here treat uncomplicated diverticulitis without antibiotics no one except some Nordic coutnry memebers raised their hands.

    ALso as you know the Australian journal refused to publish my article. Too scared they were.

    Like

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