Trip Answers

Question answered:09/06/08

CKS have a guideline on venous leg ulcers [1] and this discusses swabbing and antibiotics.  In the section on infected leg ulcers (as opposed to uncomplicated leg ulcers), they report:

 

“How do I manage an infected venous leg ulcer?

 

Managing infected venous leg ulcers involves:
 - Cleaning the ulcer,
 - Dressing the ulcer,
 - Taking a wound swab and prescribing an antibiotic,
 - Following up and,
 - Giving life-style advice.

 

What features suggest an infected venous leg ulcer?

Signs of an infected venous leg ulcer include:
 - Enlarging ulcer.
 - Increased exudate.
 - Increased pain.
 - Pyrexia.
 - Foul odour.
 - Cellulitis: surrounding skin is red, hot and non-scaling

 

How should I clean a venous ulcer?
 - Irrigate the ulcer at each dressing change with warm tap water or saline, then dry (strict aseptic technique is not required).
 - Remove slough, necrotic, fibrous, or excess granulation tissue by gentle washing.
 - Debridement is not usually necessary. If debridement is being considered, the procedure should be carried out by a trained healthcare professional.

 

When should I take a wound swab for an infected venous leg ulcer?
 - Take a swab for all suspected infected venous leg ulcers before prescribing an antibiotic.
 - Clean the infected ulcer with tap water or saline prior to taking the swab”

 

Later the guideline reports:

 

“If the infection is not responding, check swab results and consider changing the antibiotic based on sensitivity information. Consider possible complications or allergic contact dermatitis as a cause for the ongoing symptoms.

 

If the infection is sensitive to the empirical antibiotic but only slowly responding and not deteriorating, review after 7 days and consider continuing the antibiotic for a further 7 days.”

 

You may also be interested in the recent Cochrane systematic review ‘Antibiotics and antiseptics for venous leg ulcers’ [2] which concludes:

 

“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.”

 

References

1) http://cks.library.nhs.uk/leg_ulcer_venous
2) http://www.cochrane.org/reviews/en/ab003557.html
 

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