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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

Person Environment

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

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/ dis-

infecting of high risk surfaces

Private rooms Removal of invasive devices

ASAP

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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 >105

microorganisms per gram of tissue

These contaminants come from the indigenous microflora and/or the environment.

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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

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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

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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

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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

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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 5.3-5.8-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

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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.”

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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

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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

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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.

www.nature.com/nrc/journal/v5/n4/fig_tab/nrc1591_2html. Kennedy, JE: High intensity focused ultrasound

in the treatment of solid tumors.

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Conner-Kerr T. The effects of low-frequency ultrasound (35KHz) on methicillin resistant staphylococcus aureus

(MRSA) in vitro. Wound Ostomy Management. 2010; 56(5): 32-42.

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, 2002.

Tissue Cavitation

Bioburden Reduction

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

0

20

40

60

80

100

0 20 40 60 80 100 120

Perc

en

t V

iab

le B

ate

ria

Time Sonocated in Seconds

Percent of Bacteria Killed by Sonocation Over Time for Several Species of Bacteria

A. baumannii

E. coli

S. aureus

S. pyogenes

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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)

Contact

Thermal

Contact

Non-thermal

Low

Frequency

(kHz)

Contact

Thermal

Non-Contact

Non-thermal

Clinical Choices Ultrasound Guided Debridement

Wound Debridement

Bioburden Elimination

Biofilm Destruction

Pain Reduction

Stimulate Stagnant Wound

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Thank You…