Transcript

Hi, I'm Dr. Christine Miller. I'm a wound care specialist and medical director of the Ambulatory Orthopedic Care Center in the University of Florida College of Medicine, Jacksonville.

What are the ways that antimicrobials are administered?

Antimicrobials can be administered in a couple of different ways. Some of the most common forms would be in topical especially, in the presence of wound healing, using products that have an antimicrobial component. And then there's also more advanced for more aggressive infectious process, we would use antibiotics on a systemic level, whether that be oral or through intravenous venues or ways of treatment.

Under what circumstances should antimicrobials be administered in wound care?

This is actually kind of an interesting area and really a focus of patient safety, as well as the age old question of when or when not to prescribe antibiotics, particularly wound care. I think that it is a bit of a gray area. We want to make sure that we are addressing the infection if it's present, but we also want to make sure that we're not overprescribing antibiotics because I think, as we all know, antibiotic resistance is now a huge public health threat and risk.

The Centers for Disease Control estimates that about 30% of prescriptions for antibiotics in the outpatient setting are actually prescribed inappropriately. So that would then drive up the likelihood of resistance and also then increases your likelihood of infections from other kind of diseases such as Clostridioides difficile infections as well.

So judicious use is very, very important. And I think that's why you're seeing more of a push towards programs that focus on antimicrobial stewardship. And that is a concerted effort usually from a multidisciplinary team to focus on prescriber practices for antibiotic therapy and also to sort of track prescribing and then track and trend as well as offer opportunities then to educate both patients and providers about appropriate drug selection, dose selection, and duration. So we're using antibiotics appropriately with also minimizing the risk of overuse and then driving up of resistance.

What are the key challenges or considerations you face when deciding on the appropriate antimicrobial therapy for chronic wounds?

So for me, I think a particular challenge is, especially in this, in the setting of chronic wounds, you know, you can see a wound that may be stalling and healing. And, you know, you are looking at the tenants of wound healing of moisture management, looking for infection, controlling around the wound margins.

But there's always that gray area in chronic wounds of “is it infected or is it not?” And a lot of times we're left upon clinical scale on experience of the practitioner to look into the wound because we know that not all wounds that have an odor are infected or not all wounds that have exudate or drainage are infected. So it's always a challenge in terms of “how do we treat a possible infection without over treating it?” And sort of staying in that proverbial sweet spot in terms of looking at wound management.

We know that, you know, when you culture a chronic wound, you're more than likely going to grow out a culture of just colonizing bacteria and not really, or skin contaminant, and maybe not really addressing or seeing, you know, really a causative agent. So I think that the biggest factors that we face are “how do we manage the infection, if it's really there?” and then “what do we select?” and I think that that's when we tend to look towards whether we're going to do a topical antimicrobial therapy, like a antimicrobial foam for example there's several out there, that will help sort of minimize any infectious process topically or more locally at the wound surface. That's probably some of the biggest challenges.

I know that there's a lot of new technology out there, which is very exciting in terms of early infection detection, the fluorescence imaging where you can actually get images of colonization of bacterium and would kind of be a better guideline to know whether or not your debridement is effective enough or maybe more debridement or your wound hygiene techniques are effective. The caveat to that though is that those are relative expensive modalities, and like myself, I practice in an urban-saving hospital.

So I would face some pretty harsh economic challenges in trying to incorporate that kind of technology into my practice currently.

Can you describe a specific case or scenario where the use of antimicrobial agents had a significant impact on the patient’s outcome?

Well, I think this would be an interesting tale about when we actually over prescribe and not everything requires an infectious control agent.

I was treating a patient for what was a venous leg wound or what seemed to be a venous leg wound. And he had been treated in other sites and other wound centers around the city. And then he came to me through a referral through a friend at church who I treated and when we were treating him you know getting his history and, I found out or it was uncovered that his wound over the wounded area was where he had sustained a trauma several years ago. He was the victim of a gunshot wound to the lower extremity several several years before and it had a fixation to that area and whatnot. And he'd already, at this point, when I met him, had already undergone hyperbaric oxygen therapy, multiple skin grafting, and nothing was actually really working for him. And he'd been through antibiotics several rounds, in fact.

And it really wasn't until we started working together, you know, that I said to him, "Well, you know, I think that the underlying cause of why you're not able to heal, though we went through the proper steps through the standard of care, was that hardware that was in his bone currently, you know, even though he was not showing any acute clinical signs of infection, likely was harboring bacteria and he was getting into sort of a chronic osteomyelitis sort of scenario that was never allowing him to heal. So I worked in tandem with our ortho colleagues and they removed the hardware and we then continued on the localized wound care and he was able to heal up within, I would say, less than a month afterwards post-op. He was completely healed and that was 2 years ago. He stays healed now. I keep in touch with him.

So that's a good example of sometimes, you know, if wounds aren't responding, yes, we have a knee jerk reaction to want to use anti-infectious or anti-microbial agents, but again, we have to really keep the full systemic scenario in place and the reality was that you know he could have had all the oral antibiotics and IV antibiotics till the cows came home, but without removing the hardware that was really a conduit for the bacteria, he was never going to be fully healed and obtain full closure.

About the Speaker 

Christine Miller, DPM, PhD is a certified wound specialist by the American Board of Wound Management and a Fellow of the American College of Clinical Wound Specialists. She currently serves as the Co-Director of the Limb Salvage Program at the University of Florida, College of Medicine-Jacksonville.