Antibiotics and antiseptics for venous leg ulcers.

BACKGROUND: Venous leg ulcers are a type of chronic wound affecting up to 1% of adults in developed countries at some point during their life. Many of these wounds are colonised by bacteria or show signs of clinical infection. The presence of infection may delay ulcer healing. There are two main strategies used to prevent and treat clinical infection in venous leg ulcers: systemic antibiotics and topical antibiotics or antiseptics. OBJECTIVES: The objective of the review is to determine the effects of systemic antibiotics and topical antibiotics and antiseptics on the healing of venous ulcers. SEARCH STRATEGY: The following databases were searched up to October 2007: the Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials; MEDLINE; EMBASE; and CINAHL. In addition, the reference lists of included studies and relevant review articles were examined. SELECTION CRITERIA: Randomised controlled trials recruiting people with venous leg ulceration that evaluated at least one systemic antibiotic, topical antibiotic or topical antiseptic and reported an objective assessment of wound healing (e.g. time to complete healing, frequency of complete healing, change in ulcer surface area) were eligible for inclusion. Selection decisions were made by three authors working independently. DATA COLLECTION AND ANALYSIS: Information on the characteristics of participants, interventions and outcomes were recorded on a standardised data extraction form. In addition, aspects of trial methods were extracted, including methods of randomisation and allocation concealment, use of blinded outcome assessment, intention-to-treat analysis, reporting of patient follow-up and study group comparability at baseline. Data extraction and validity assessment were conducted by one author and checked by a second. MAIN RESULTS: Twenty two trials were identified of different antibiotics and antiseptics, including systemic antibiotics (5 trials). The remainder were topical preparations: cadexomer iodine (10 trials); povidone iodine (2 trials); peroxide-based preparations (3 trials); ethacridine lactate (1 trial); and mupirocin (1 trial). For the systemic antibiotics, the only comparison where a statistically significant between-group difference was detected was that in favour of the antihelminthic levamisole when compared with placebo. This trial, in common with the other evaluations of systemic antibiotics, was small and so the observed effect could have occurred by chance. In terms of topical preparations, there is some evidence to suggest that cadexomer iodine generates higher healing rates than standard care. One study showed a statistically significant result in favour of cadexomer iodine when compared with standard care (not involving compression) in terms of frequency of complete healing at six weeks (RR 2.29, 95% CI 1.10 to 4.74). The intervention regimen used was intensive, involving daily dressing changes, and so these findings may not be generalisable to most everyday clinical settings. When cadexomer iodine was compared with standard care with all patients receiving compression, the pooled estimate from two trials for frequency of complete healing at 4 to 6 weeks indicated significantly higher healing rates for cadexomer iodine (RR 6.72, 95% CI 1.56 to 28.95). Surrogate healing outcomes such as change in ulcer surface area and daily or weekly healing rate showed favourable results for cadexomer iodine, peroxide-based preparations and ethacridine lactate in some studies. These surrogate outcomes may not be valid proxies for complete healing of the wound. Most of the trials were small and many had methodological problems such as poor baseline comparability between groups, failure to use (or report) true randomisation, adequate allocation concealment, blinded outcome assessment and analysis by intention-to-treat. AUTHORS' CONCLUSIONS: At present, there is no existing evidence to support the routine use of systemic antibiotics to promote healing in venous leg ulcers. However, the lack of reliable evidence means that it is not possible to recommend the discontinuation of any of the agents reviewed. In terms of topical preparations, there is some evidence to support the use of cadexomer iodine. Further good quality research is required before definitive conclusions can be made about the effectiveness of systemic antibiotics and topical preparations such as povidone iodine, peroxide-based preparations, ethacridine lactate and mupirocin in healing venous leg ulceration. In light of the increasing problem of bacterial resistance to antibiotics, current prescribing guidelines recommend that antibacterial preparations should only be used in cases of defined infection and not for bacterial colonisation.

Hanging wet-to-dry dressings out to dry.

Wet-to-dry dressings have been standard procedure for home care wound care patients although research indicates gauze dressings are not an optimal wound care modality for the patient, the clinician, or the healthcare system. Gauze dressings do not effectively support optimal healing and are more labor intensive to use than advanced dressings such as films, foams, hydrocolloids, and hydrogels. This article provides clinicians with the rationale and evidence needed to collaborate with physicians in choosing the most cost-effective wound care products to achieve positive patient outcomes.

Battling bacteria in wound care.

A critical aspect of effective and cost-efficient wound management is infection prevention and actions taken to minimize bacterial levels in the wound. This article describes effective wound cleansing and debridement, appropriate use of advanced dressings, procedures for dressing changes, and the appropriate use and understanding of topical antimicrobial agents.

Wound care products: how to choose.

Working in PPS means that agencies and clinicians must determine which wound care regimen will reach the intended patient goal in the most cost-effective way in terms of supply and visit cost. This article outlines the specific rationale clinicians can use when assessing wounds and choosing the dressing(s) that are appropriate to meet patient and agency goals. Using the performance-based model approach, clinicians learn how to choose dressings based on product price versus treatment costs.

Dressings and ajunctive therapies: AHCPR guidelines revisited.

The Agency for Health Care Policy and Research Pressure Ulcer Treatment Guidelines released in 1994 offered 11 recommendations relating to the use of dressings and adjunctive therapies. These recommendations were based on evidence gleaned from the medical literature from 1966 to mid-1993 as well as the accumulated expertise of a multidisciplinary advisory panel. As the recommendations are now 5 years old, a review of the literature published since 1993 was undertaken in order to determine additional evidence for their continued validity or disapproval. The review focused on evidence at the level of controlled clinical trials of dressings and adjunctive therapies in the treatment of pressure ulcers.

Beyond risk assessment: elements for pressure ulcer prevention.

Considerable emphasis has been placed on identifying individuals who are at risk for developing pressure ulcers. However, the generality of diagnostic discriminations and consequent intervention strategies may have resulted in less effective outcomes than otherwise would be possible. When such processes are carried out in a system devoid of the fundamental elements required for increased diagnostic/prescriptive precision and systematic improvement, practitioners are, at best, relegated to relying on external trial-based research to yield new "best practices." At worst, ineffective and costly practices continue without systematic evaluation and alteration. Several necessary elements of any empirically-based prevention system are addressed, and an attempt to integrate the elements into a system for field utilization is illustrated. If successful, the system will result in incremental improvements in the outcomes of prevention efforts over time.

What is needed to monitor healing in the outpatient clinic setting?

To monitor healing in the outpatient setting, clinicians need: easily usable tools to collect data, whether a checklist or software program real-time analysis (or at least timely analysis) of the data relative to a treatment protocol a method of analysis that allows manipulation of the data for multiple purposes communication of the analysis; future actions should be based on this analysis. The result will be a dynamic, cyclical monitoring system, most meaningful when it is not retrospective and static, but fluid so that adjustments can be made as needed.

Wound healing microbiology.

The relationship between wound healing and cutaneous microbiology is a complex one mediated by the type of wound, its treatment, and the defense mounted by the injured individual. Acute wounds harbor microflora similar to that of noninjured skin. "Dirty" traumatic wounds or chronic wounds with devitalized tissue offer more opportunity for microflora colonization, with the potential for bacterial adherence to the host cells and ultimate invasion into viable tissue or infection. The alterations of these wound environments can be brought on by topical treatments. Occlusive dressings with various moisture vapor transmission rates can provide a wound environment suitable for microflora proliferation. In spite of this increase in numbers of organisms, most wounds do not become infected, as shown by a survey of published trials. Infection requires the proper pathogenic microorganism, its attachment, and subsequent multiplication. To cause an infection, an organism must invade viable tissue and evade the host defense response. The many occlusive dressing types available offer an opportunity to select a wound therapy tailored for the microenvironment most suitable for healing. Wounds can be protected from exogenous microfloral contamination with dressings. Some dressing types, such as hydrocolloid dressings with no moisture vapor transmission, should not be used on chronic wounds suspected of harboring anaerobic organisms. Other typical treatments, such as antiseptics, can injure tissue and make infection more probable, providing devitalized tissue for bacterial adhesion. Povidone-iodine solution has been shown not be efficacious, whereas povidone-iodine cream effectively limits bacteria and infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Electrical stimulation and ultrasound in wound healing.

The events that lead to tissue repair are very complex. Because our understanding of these processes is increasing in scope, the use of nontraditional treatment therapies should be considered. Evidence is reported in the literature that both electrical stimulation and ultrasound therapies may be beneficial in certain circumstances to heal various wound types. Owing to clinicians' unfamiliarity with the current research and general understanding of such therapies, many patients receive only traditional treatment and remain unexposed to the potential benefits of the nontraditional. With continued research to better define optimal treatment parameters, improved wound healing will result.

New taxanes from Taxus brevifolia.

The isolation of two taxanes from Taxus brevifolia Nutt. is described, together with the isolation of two acetylated taxol derivatives from an acetylated fraction from the same plant. The compounds were identified on the basis of their spectroscopic properties as taxa-4(20),11-diene-2 alpha, 5 alpha, 7 beta, 9 alpha, 10 beta, 13 alpha-hexaol 2,7,9,10,13-pentaacetate (1) (decinnamoyltaxinine J), 10-deacetylbaccatin III (2), taxol 2',7-diacetate (3), and 10-deacetyltaxol 2',7-diacetate (4).