Too Much of a Good Thing

Dear Readers, Too much of a good thing is wonderful. —Mae West   Mae West’s quote may reflect some people’s view of life, but when it comes to using systemic antibiotics in patients with chronic wounds, it should not. In all the years at our wound center I can’t remember a single patient referred to us for treatment of a wound that was not being treated with or had not been on antibiotics. Many had been in the hospital for intravenous antibiotics. Upon examining the patient, there was no sign of infection (now don’t jump to say it was because they were on the antibiotics!), and the patients said the antibiotics did not change anything about their wounds. Many times the reason given for the referral was that “the patient had had multiple courses of several different antibiotics and the wound had not healed.” All of us should know that there is more to wound healing than antibiotics, but the overuse of systemic antibiotics in patients with chronic wounds is amazing.   In a 1-year study, 66% of patients with chronic wounds received antibiotics for their wounds while only 12% had any identifiable sign of infection.¹ This usage was independent of the presence of diabetes mellitus or other risk factors. In another study of patients with chronic wounds 60% had received systemic antibiotics in the 6 months preceding the study with not a single patient having any documented evidence of infection.² Why would this be the case? One telling fact emerged from the Howell-Jones study.¹ The usage of antibiotics was directly related to the number of visits to the physician. In other words, when the patients continued to return with the wound, the physician did not seem to know what else to do except prescribe antibiotics. Unfortunately, it seems that the learning curve is quite long. The patient is subjected to many courses of antibiotics before someone realizes that they are not the cure for the chronic wound.   Obviously, antibiotics have their place in the treatment of patients with chronic wounds, but only with the correct indications. Studies have shown that there is little evidence to support the use of systemic antibiotics in patients with chronic wounds in the absence of infection.³ Treatment of chronic wounds with antibiotics must be restricted “to infected wounds, and infection must be determined on clinical grounds and not microbiology results (swab cultures) due to the universal colonization of such wounds.”⁴ That brings up an entirely different question beyond the scope of this editorial, but it is important to limit the use of systemic antibiotics to patients with clinical infection and not just a positive swab culture. Another group showed that only 49% of all prescriptions for antibiotics met diagnostic criteria for infection.⁵   Smith and colleagues⁶ have stated, “the primary goal of antibiotic stewardship is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms, and the emergence of resistance.” He fails to mention the tremendous cost associated with this practice. All of these problems of indiscriminate antibiotic use are worsening each year. We must be careful to avoid the inappropriate use of systemic antibiotics in our own practices and work to educate those who are most prone to over use them. It is hard to change old habits but hopefully we can convince our colleagues that, in these cases, less of a good thing may be wonderful. 1. Howell-Jones RS, Price PE, Howard AJ, Thomas DW. Antibiotic prescribing for chronic skin wounds in primary care. Wound Repair Regen. 2006;14(4):387–393. 2. Tammelin A, Lindholm C, Hambraeus A. Chronic ulcers and antibiotic treatment. J Wound Care. 1998;7(9):435–437. 3. O’Meara S, Cullum N, Majid M, Sheldon T. Systemic reviews of wound care management: (3) antimicrobial agents for chronic wounds; (4) diabetic foot ulceration.Health Technol Assess. 2000;4(21):1–237. 4. National Institute for Clinical Excellence. Type 2 Diabetes. Prevention and Management of Foot Problems: Clinical Guideline 10. London: National Institute for Clinical Excellence; 2004. 5. Loeb M, Simor AE, Landry L, et al. Antibiotic use in Ontario facilities that provide chronic care. J Gen Intern Med. 2001;16(6):376–383. 6. Smith PW, Watkins K, Miller H, VanSchooneveld T. Antibiotic stewardship programs in long-term care facilities. Ann Long Term Care. 2011;19(4):20–25.