10/10/2013. Diane Langemo, PhD, RN, FAAN. 2.5 million infections worldwide/year. 10,000 deaths/year worldwide

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1 Diane Langemo, PhD, RN, FAAN 2.5 million infections worldwide/year 10,000 deaths/year worldwide Superbugs can survive many days to a week on surfaces Each new antibiotic eventually alters the DNA of the bacteria, enhancing resistance Overuse of common topicals resistance Screen on admission Avoid direct contact Rigorous hygiene Soap/H20 or sanitizer (at least 62% alcohol base) Friction, scrubbing briskly at least 15 sec Dry well Mask, gown, gloves Be alert & discerning Sterile drapes & dressings Discretion in ABT scripts Cover cuts/abrasions Person Don t share lockers, shoes, socks, towels, gym clothes, razors Don t let beds butt up against one another HOT H20 for laundry Regular cleaning/ disinfecting of high risk surfaces Private rooms Removal of invasive devices ASAP Environment 1

2 Antimicrobials Bleach on inanimate objects Products should have disinfectant label with EPA Reg# Gown, gloves, mask, eye protection for body fluid contact Control Your Own Environment!! Contamination - Infection Continuum Definition of Infection: The presence of replicating microorganisms within a wound with subsequent host injury. Wound infection is far less common than wound colonization & contamination. Chronic Wound Care, Gordon Dow The presence of non-replicating organisms in the wound. All chronic wounds are contaminated. All diabetic foot wounds are contaminated Many of those wounds become critically colonized with a high bio burden with >10 5 microorganisms per gram of tissue These contaminants come from the indigenous microflora and/or the environment. 2

3 The presence of replicating microorganisms adherent to the wound with the absence of injury to the host or host response. Most of these organisms are normal skin flora: Staphylococcus epidermidis Other coagulase negative Staph. Corynebacterium sp. Brevibacterium sp. Propionibacterium acnes Pityrosporum sp. The presence of replicating microorganisms within a wound that cause host injury manifested by local or systemic response. Primary pathogens of concern: Staphylococcus aureus, Beta-hemolytic Streptococcus (S. pyogenes,s. agalactiae), E. coli Proteus Klebsiella Pseudomonas Acinetobacter Stenotrophomonas (Xanthomonas) Anaerobes Classic Signs: erythema (rubor), warmth (calor), tenderness, purulent drainage, pain (dolor), and swelling (tumor) Secondary signs: delayed wound healing over time, friability and discoloration of granulation tissue, pocketing at the base of the wound, foul odor, wound breakdown, increase drainage, and increased pain Other signs: Induration, bullae, crepitus, abscess, fasciitis, osteomyelitis 3

4 Delayed healing Increased drainage (serous or purulent) Foul odor (anaerobes or G-) Yellow/brown slough Hypertrophic granulation tissue Local Wound Care Remove nonviable tissue Reduce bacterial load Reduce moisture 1. Tissue Management 2. Inflammation & Infection Control 3. Moisture Balance 4. Epithelial (edge) Advancement 4

5 Tissue Management: remove nonviable tissue; goal to metalloproteinases Inflammation/infection Control: bacteria in all wounds; restore bacterial balance; debride; topicals, systemic meds, BS control Moisture Balance: balanced moist wound healing w/warm bed; absorptive or retentive dressing; neg pressure; systemic edema control; limb elevation or compression Epithelial Advancement: promote epithelial migration from edges, wound contraction, skin function restoration; Removal of nonviable tissue from wound bed bioburden & biofilms odor Promote epithelialization Promote absorption of topical agents Allow for thorough wound bed assessment Limit time of inflammatory phase of healing process Autolytic: provides moist environment for non-viable tissue Mechanical: Wet-to-dry technique; quicker, >painful Conservative sharp/sharp: uses scalpel or scissors to remove only non-viable tissue Surgical: done with anesthesia, may remove some viable tissue Chemical: uses enzymatic agents, topical antimicrobials, honey, sterile maggots, etc 5

6 Antiseptic: agent that inhibits bacterial growth, includes disinfectants Antibacterial: agent that suppresses or destroys bacteria Disinfectant: agent that destroys microorganisms (use on inanimate objects) Endogenously produced PMNs during peroxidation for destruction of bacteria. Bacteriocidal at 2.6ppm with 5 min exposure Noncytotoxic at therapeutic concentrations Broad spectrum effectivity Lowers ph Effective against Pseudomonas Causes local stinging &/or burning May select out Staph aureus Antiseptic 6

7 10% aqueous solution delivers 0.9% iodine in wound bed Broad spectrum (anaerobes, fungi & viruses) Toxic w/long use over large area Possibly thyrotoxic Decreased activity in presence of exudate or pus Can be used with enzymatic debrider Can be used in heavily infected conditions (Saad et al., 2013, Endocrinology) Cadexomer is slow releasing iodine agent Antiseptic, antimicrobial Disinfectant and antiseptic Used: inter-operative irrigation, pre- post-op skin & mucus membrane disinfection, wound dressings, DFU, routine antisepsis, surface disinfection 2% alcohol or 0.5% aqueous solutions Low tissue toxicity Range of log reduction seen for Pseudomonas aeruginosa, E Coli, MRSA, Acinetobacter baumannii, VRE (Minnich, Stolarick et al., 2012;58(10):32-36) Broad spectrum antimicrobial Lower tissue toxicity with slow release form Can be used with enzymatic debriding agents to prevent secondary bacterial infections 7

8 Antibacterial From bees feeding on Leptospermum scoparium tree; contains H202 & methylglyoxal (MG) High viscosity; acid ph Antiinflammatory action Effective against MRSA Antimicrobial 1% cream or aqueous suspension Limited penetration with low solubility Aseptic exudate may form on wound surface; temporary burning or painful sensations; can cause skin discoloration; can inhibit trypsin Cochrane Review (2010): Insufficient evidence to establish whether silver-containing dressings or topical agents promote wound healing or prevent wound infection. 8

9 Bacitracin: its peptides disrupt both G+ and G- bacteria; disrupts cell wall; effective against Strep pyogenes Neosporin:?clinical efficacy; may enhance ABT resistant bacteria; part of TAO (polymixin B, neomycin & bacitracin) Polymyxin B: for resistant G- bacteria (except Proteus); surfactant action Scarlet Red: Selects out Gram neg bacteria Na hypochlorite: toxic = bleach Hydrogen peroxide: fizzing action (antiseptic) Quanternary ammonia: very highly toxic (antiseptic) Slow release silver: VRE: Hospital grade disinfectants; wash hands MRSA: Mupirocin; topical vancomycin (Albaugh et al., OWM 2013;59(5):34-43); Slow release AG; Manuka honey Group A Strep: C Diff: Soap/H20 better than alcohol hand sanitizer or alcohol-based cleaners; bleach or high-level disinfectants E Coli, Klebsiella, Acinetobacter baumannii: Topical treatment not recommended/available Pseudomonas aeruginosa: acetic acid, Slow release Ag 9

10 With local or systemic infection in a complex patient With local or systemic infection involving complex bacteria When C & S shows MDR microorganisms Wound with the superbugs we are discussing Ultrasound Guided Debridement Ultrasound Guided Debridement Definition Low frequency ultrasonic energy (khz) that is delivered to the wound surface and subdermal tissues resulting in selective debridement, bacterial killing microcavitational effects and cellular stimulation via acoustic streaming. Biophysical Ultrasound Energy Effect on Tissues Acoustic Streaming Cavitation 10

11 Ultrasound Energy Transfer Acoustic Streaming Initiates a unidirectional movement in fluid in an ultrasound field. This activity stimulates cell activity and enhances clinical outcomes. Ultrasound Energy Transfer Cavitation Occurs in a high-intensity field where micron-size gas bubbles significantly increase in size and violently implode during the low-pressure part of the US wave cycle. Bacteriocidal Energy Cavitation is the formation of small bubbles by the ultrasound in gas containing fluids. The vibration of the bubbles causes changes in the permeability of bacterial cell membranes and interrupts the metabolism of the bacteria. Tiny shock waves produced by bubble implosions cause preferential and rapid emulsification of necrotic fibrin and slough and fragmentation of bacteria and biofilms on wound surfaces. No damage to healthy tissue or host cells. Kennedy, JE: High intensity focused ultrasound in the treatment of solid tumors. 11

12 Percent Viable Bateria 10/10/2013 Conner-Kerr T. The effects of low-frequency ultrasound (35KHz) on methicillin resistant staphylococcus aureus (MRSA) in vitro. Wound Ostomy Management. 2010; 56(5): Kavros SJ, Wagner SA, Wennberg PW, Cockerill FR. The Effect of Ultrasound Mist Transfer Technology (MUST) on Virulent Bacterial Wound Pathogens. Abstract. Presented at Symposium on Advanced Wound Care, Tissue Cavitation Bioburden Reduction Percent of Bacteria Killed by Sonocation Over Time for Several Species of Bacteria A. baumannii E. coli S. aureus S. pyogenes Time Sonocated in Seconds Antimicrobial Effect of Low-Frequency Ultrasound in an In Vitro Wound Model. Tony Pierson, Capt, USA, Jeffrey A. Niezgoda, MD // Brooks Army Institute of Research 12

13 Chapter 28 / Kloth L, Niezgoda JA. Ultrasound For Wound Bed Preparation and Healing. In McCulloch JM, Kloth L, eds. Wound Healing: Alternatives In Management. 4th Edition, Philadelphia, PA, F. A. Davis (2011) Ultrasound Basics Ultrasound High Intensity Low Intensity High Frequency (MHz) Low Frequency (khz) Contact Thermal Contact Thermal Contact Non-thermal Non-Contact Non-thermal Clinical Choices Ultrasound Guided Debridement Wound Debridement Bioburden Elimination Biofilm Destruction Pain Reduction Stimulate Stagnant Wound 13

14 Thank You 14