Sunday, January 29, 2012

Proper Wound Care & Topical Antimicrobials

A common questions posed by students is "Are we supposed to treat every wound with anti-bacterial product(s)?"   My response (opinion) is most of the time, no.  In a normal, healthy athlete, an abrasion or small laceration not requiring stitches (usually defined as anything under one inch in length, although depth can skew this a bit) doesn't necessarily need an antibiotic or anti bacterial treatment.  Please keep in mind I'm talking about small cuts and scrapes here. Treatments should be utilized only when certain signs or symptoms call for them; I like to use the example of headaches.  Is is safe to take an analgesic or anti-inflammatory (for example Tylenol or Motrin) just because you may get a headache at some point during the day?  Of course not;.  My guess is the problem lies here.  Perception. 

I think the first place to start is to understand who the intended audience is for recommendations.  Hospital workers?  General population?  Then we can really dive into the material.

Now, in the case of an athlete who has a weakened immune system or other dermatological/medical condition, that may be required treatment, but for most of our day to day, it seems like overkill.  Not everyone agrees though.  For instance, the Mayo Clinic states here that a thin layer of antibiotic cream should be applied to minor cuts and scrapes.  This fascinates and confuses me, as I've read articles/protocols which state that cleaning small wounds with clean drinking water and soap (or simple saline solution) often will be the correct management plan. However, this literature review also points to confusing evidence.  At least I'm not alone.

Take Home Point:  Just because it's an OTC (over the counter) medication, doesn't mean it's safe and can be used at will; it needs to be used correctly at the appropriate time.  For instance, it has been suggested that use of Povidine/Iodine and Hydrogen Peroxide actually delay the healing process.  When we were younger, my mother used to practically bathe me in hydrogen peroxide and slather on Neosporin on everything.  We know a little better now though that it may not be the best choice.  So what to do?  Let me further muddy the waters.  The FDA published "The Benefits of Topical OTC Antimicrobial Products" which states they provide a great advantage to the general public.  Really?  What about the healthy population? I should also note here that these products do a great job of killing bacteria; there is no questioning that.  However, all bacteria may be killed (good or bad) which can have unintended consequences. Now let's flip it around.  This blog in Scientific American alludes to the fact that we may be going way overboard in our usage here, even suggesting (citing research) that it makes sick people worse. For those who want the cliff notes version, studies by both Aiello and Larsen showed no advantage in using anti bacterial soap over regular hand washing. 

Now I know what your thinking.  What about MRSA?  Great question.  The NATA offers our protocol right here and a position statement here.  Now of course, this is not your normal, run of the mill cut or scrape.  This would and should require more.  Furthermore, it recommends following standard infection control precautions.  My question is...which ones?  And also, should we enact "standard infection control precautions" before or after we know what we are dealing with?  I think it is easy for someone to read this statement and immediately believe it applies to everyone, everywhere.   Is it possible that we are all interpreting that we should use these products on everything, all of the time?  Diving deeper in, the NATA document references the CDC's Hand Hygiene Task Force (for real) which created the Guideline for Hand Hygiene in the Health Care Setting. Again, count me as confused and fascinated; so in order to combat pesky dermatological conditions, we should bathe in anti-microbials; but wait, didn't MRSA originate in health care facilities where these exact precautions were taken?  On top of that, community acquired MRSA is now on a furious rise.  So I ask; Are we doing the right thing? 

This of course bleeds into (sorry) how  we define prevention. Some would argue that prevention begins when you treat the wound, so throw everything you have against it.  My definition starts prior to that; make sure you know your athlete, their specific medical history and let them know the signs of infection prior to utilizing a shotgun approach.  Watch closely and educate your athlete.  And before I forget, most importantly, wash your hands. Practice good hygiene and basic wound care.  Wash your hands in soap in water, sing the ABC's and be happy.  One more thing; wash your hands even after you've used gloves treating someone.   Your opinion?

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