STARMedic
10-25-2007, 09:31 AM
These are excerpts from another thread on another forum from a friend....
This is one topic I am an expert in, treating Staph. & eczema every day. Lot of misconceptions + myths floating about here.
1. I was trained that actually 40% of people carry staph. in their nasal passages and less commonly genital areas; its called "colonization" when you have the bacteria on the skin but rarely get infected. Most people with this get occasional folliculitis - what appears as pimple on their scalp (acne rarely occurs in scalp), or acne on their trunk. Unless a cellulitis or infections occurs, these patients are not treated with systemic (oral) antibiotics because we are leading to even more aggressive bacteria such as Vancomycin-resistant Staph., worse than MRSA
2. The biggest thing I see is people not covering open wounds, even those small cuts, scapes & burns. Keep wounds covered until they are completely healed!!! Repeat: Keep wounds covered with topical antibiotic ointment and bandaid! Wash with soap & water (peroxide is only used to remove dried blood as a debriding agent, it actually inhibits wound healing if use for more 3 day); its not wise to use hibiclens, phisohex etc. (very old school). Wounds heal quicker when you keep them covered - a hole in skin has to heal from outside edges inward, cells don't migrate well across a dried crust (and this is even more of a nidus for bacterial growth). I recommend Polysporin since only 2% of the population are allergic to that, toss out your Neosporin or triple antibiotic that causes allergic reactions that people misinterpret as infections in 15% of population. If allergic to polysporin, get Rx for mupirocin (aka Bactroban, Centany), or at least keep moist with Aquaphor. For those that whine "I'm allergic to bandaids", try Nexcare waterproof with clear edges, or make up your own bandage with Telfa pad & paper tape. I have used products like "NuSkin", "crack-healing ointment, spray bandage" on small paper & field cuts, but you need to apply several times a day, its really suboptimal, and if you see open skin antibiotic ointment & bandage!
3. There is a big difference between impetiginization (= impetigo) which is a very early infection of a superficial wound and should not be treated with oral antibiotics unless there is another co-morbid issues such as recent surgery/joint replacement, other skin condition, such as eczema, or immunocompromised; and a cellulitis. I am big believer in doing bacterial cultures of all wounds that are clearly infected to establish MRSA vs other infections; if it comes back MRSA I bring the patient back in to culture their nose to see if they are a colonizer. I treat impetiginized wounds with topical mupirocin both at the wound and inside the nose. Still, with recent events I warn patient at first sign of fever > 101, chills, unexplained malaise, altered mental status to high-tail it to an ER. There is a new topical antibiotic cream that is supposed to be successful in treating some MRSA called Altabax, but we fear this too will be carelessly over-prescribed and lead to more resistant Staph.
3. When is a wound infected? It is normal for an open wound to produce what is called exudate, a clear-to white-to slightly yellow drainage that represent the body's way to keep the area moist & provide proteins & good healing chemicals called cytokines to allow those skin cells to migrate and for the edges to be pink (= white blood cells guarding the area which is good)!
If that drainage gets yellow-green, the border becomes an angry red instead of pink, surrounding skin becomes pink over 3mm past the wound, area is warm, and increasing in pain, the area has an infection that probably needs to be treated with an Rx. A key to being infected is the area gets bright red & starts to hurt more, typically no sooner than 3-4 days after the trauma. I can't stress enough how important keeping the original cut clean, moist & covered is to prevent this from happening.
4. If you think its infected, don't blow it off! Guys are terrible at this, and the health insurance crisis doesn't help.
5. The above on eczema made me cringe! 1:10 Bleach bath is no longer recommended in the treatment of eczema - unless your doc is 50+; it is just an irritant that dries the skin out more, which makes eczema worse. The key is to treat the eczema aggressively, with emphasis on good moisturizing and bathing habits (short, tepid not hot showers with mild soaps like Dove or Cetaphil, smothering of a good moisturizer cream like Cetaphil, Cerave, Aquaphor, Aveeno or Eucerin twice a day), I believe a full 70% of mild to moderate eczema can be successfully treated with complications like infection avoided if the moisturizers are used like an Rx twice a day on all areas that patient has ever had eczema (buy the pound jars), every day even when the eczema isn't there. Oral antihistamines like Atarax in young kids, Claritin, Zyrtec, etc. not just reduce itch but actually downgrade the whole immune response causing eczema. If you treat the eczema effectively, the kids don't scratch, kids don't scratch and they don't have open wounds that get colonized with staph. that causes an even worsening of the eczema called super-antigen response and does require oral antibiotics.
6. On "carelessness is key" 1+. I wash hands and wear gloves between every patient I touch. Use of Purell, Germ-X, or WetOnes 100+. How many of you guys wash your hands after you urinate? I was at a match Saturday that didn't have bathroom facilities; saw plenty of guys going behind trucks to take a leak, not one use Purell or hand wipes, yet there was a lot of hand-shaking after the match. Do you really want to be touching so-and-so's wanker? I like you guys, but not that much.
And my final recap: Keep open wounds moist & covered with antibiotic ointment and bandage until it heals!
Public service announcement done.
Two shoes: I hear what you saying, alot, but people interpret crust as healing. Next time you have two similar cuts, treat one with covering and one without. You know the ad "Neosporin helps wounds heal quicker"? Its not the Neosporin per se, its just the moist covering that does it. Regarding Staph. being in your system: staph. routinely gets into our bloodstream, through cuts etc. But, with a healthy immune system, a couple bacteria get taken care of by your immune system rather readily, even without antibiotics. Problem is, when it doesn't, staph. can release endotoxins, stimulate cell changes including TREM-1 (triggered receptor expressed on myeloid cells) and interleukins (IL-1 and IL-10) production, which are sometimes countered by our own heat shock protein (HSP90); that causes the entire body shut down quickly, kidneys, vascular collapse, and respiratory failure. So, in answer to your question, if you survive sepsis (= substantial infection in the blood stream), you usually don't "keep" it internally (there are rare exceptions such as artificial joints/stents/parts, damaged heart valves etc.). However, if you are a "colonizer", which again 40% of people are, it recurs inside the nose and genitals. Yes, it can be treated super-aggressively with a course of two antibiotics, but if you are a colonizer chances are at some point you will recolonize and its back, with even more attitude. There is a good argument for not treating colonizers with oral antibiotics, since we are just creating greater resistance issues.
As long as we keep making stronger antibiotics, the staph. develop resistance. The answer to this problem will be discovering what is it about some individuals' immune system that makes them vulnerable to a having a small skin infection go internal, and why most can tolerate a fair amount of staph. even without treatment without lethal consequences.
Excellent point made on cutting nails. In ICU & hem-onc units there are often "no artificial nails, no long nails" rules for a reason.
Edited by UKDslayer (October 20, 2007 15:33)
Edit Reason: incomplete phrase completed
Top
Hope this is beneficial....
Bruce
This is one topic I am an expert in, treating Staph. & eczema every day. Lot of misconceptions + myths floating about here.
1. I was trained that actually 40% of people carry staph. in their nasal passages and less commonly genital areas; its called "colonization" when you have the bacteria on the skin but rarely get infected. Most people with this get occasional folliculitis - what appears as pimple on their scalp (acne rarely occurs in scalp), or acne on their trunk. Unless a cellulitis or infections occurs, these patients are not treated with systemic (oral) antibiotics because we are leading to even more aggressive bacteria such as Vancomycin-resistant Staph., worse than MRSA
2. The biggest thing I see is people not covering open wounds, even those small cuts, scapes & burns. Keep wounds covered until they are completely healed!!! Repeat: Keep wounds covered with topical antibiotic ointment and bandaid! Wash with soap & water (peroxide is only used to remove dried blood as a debriding agent, it actually inhibits wound healing if use for more 3 day); its not wise to use hibiclens, phisohex etc. (very old school). Wounds heal quicker when you keep them covered - a hole in skin has to heal from outside edges inward, cells don't migrate well across a dried crust (and this is even more of a nidus for bacterial growth). I recommend Polysporin since only 2% of the population are allergic to that, toss out your Neosporin or triple antibiotic that causes allergic reactions that people misinterpret as infections in 15% of population. If allergic to polysporin, get Rx for mupirocin (aka Bactroban, Centany), or at least keep moist with Aquaphor. For those that whine "I'm allergic to bandaids", try Nexcare waterproof with clear edges, or make up your own bandage with Telfa pad & paper tape. I have used products like "NuSkin", "crack-healing ointment, spray bandage" on small paper & field cuts, but you need to apply several times a day, its really suboptimal, and if you see open skin antibiotic ointment & bandage!
3. There is a big difference between impetiginization (= impetigo) which is a very early infection of a superficial wound and should not be treated with oral antibiotics unless there is another co-morbid issues such as recent surgery/joint replacement, other skin condition, such as eczema, or immunocompromised; and a cellulitis. I am big believer in doing bacterial cultures of all wounds that are clearly infected to establish MRSA vs other infections; if it comes back MRSA I bring the patient back in to culture their nose to see if they are a colonizer. I treat impetiginized wounds with topical mupirocin both at the wound and inside the nose. Still, with recent events I warn patient at first sign of fever > 101, chills, unexplained malaise, altered mental status to high-tail it to an ER. There is a new topical antibiotic cream that is supposed to be successful in treating some MRSA called Altabax, but we fear this too will be carelessly over-prescribed and lead to more resistant Staph.
3. When is a wound infected? It is normal for an open wound to produce what is called exudate, a clear-to white-to slightly yellow drainage that represent the body's way to keep the area moist & provide proteins & good healing chemicals called cytokines to allow those skin cells to migrate and for the edges to be pink (= white blood cells guarding the area which is good)!
If that drainage gets yellow-green, the border becomes an angry red instead of pink, surrounding skin becomes pink over 3mm past the wound, area is warm, and increasing in pain, the area has an infection that probably needs to be treated with an Rx. A key to being infected is the area gets bright red & starts to hurt more, typically no sooner than 3-4 days after the trauma. I can't stress enough how important keeping the original cut clean, moist & covered is to prevent this from happening.
4. If you think its infected, don't blow it off! Guys are terrible at this, and the health insurance crisis doesn't help.
5. The above on eczema made me cringe! 1:10 Bleach bath is no longer recommended in the treatment of eczema - unless your doc is 50+; it is just an irritant that dries the skin out more, which makes eczema worse. The key is to treat the eczema aggressively, with emphasis on good moisturizing and bathing habits (short, tepid not hot showers with mild soaps like Dove or Cetaphil, smothering of a good moisturizer cream like Cetaphil, Cerave, Aquaphor, Aveeno or Eucerin twice a day), I believe a full 70% of mild to moderate eczema can be successfully treated with complications like infection avoided if the moisturizers are used like an Rx twice a day on all areas that patient has ever had eczema (buy the pound jars), every day even when the eczema isn't there. Oral antihistamines like Atarax in young kids, Claritin, Zyrtec, etc. not just reduce itch but actually downgrade the whole immune response causing eczema. If you treat the eczema effectively, the kids don't scratch, kids don't scratch and they don't have open wounds that get colonized with staph. that causes an even worsening of the eczema called super-antigen response and does require oral antibiotics.
6. On "carelessness is key" 1+. I wash hands and wear gloves between every patient I touch. Use of Purell, Germ-X, or WetOnes 100+. How many of you guys wash your hands after you urinate? I was at a match Saturday that didn't have bathroom facilities; saw plenty of guys going behind trucks to take a leak, not one use Purell or hand wipes, yet there was a lot of hand-shaking after the match. Do you really want to be touching so-and-so's wanker? I like you guys, but not that much.
And my final recap: Keep open wounds moist & covered with antibiotic ointment and bandage until it heals!
Public service announcement done.
Two shoes: I hear what you saying, alot, but people interpret crust as healing. Next time you have two similar cuts, treat one with covering and one without. You know the ad "Neosporin helps wounds heal quicker"? Its not the Neosporin per se, its just the moist covering that does it. Regarding Staph. being in your system: staph. routinely gets into our bloodstream, through cuts etc. But, with a healthy immune system, a couple bacteria get taken care of by your immune system rather readily, even without antibiotics. Problem is, when it doesn't, staph. can release endotoxins, stimulate cell changes including TREM-1 (triggered receptor expressed on myeloid cells) and interleukins (IL-1 and IL-10) production, which are sometimes countered by our own heat shock protein (HSP90); that causes the entire body shut down quickly, kidneys, vascular collapse, and respiratory failure. So, in answer to your question, if you survive sepsis (= substantial infection in the blood stream), you usually don't "keep" it internally (there are rare exceptions such as artificial joints/stents/parts, damaged heart valves etc.). However, if you are a "colonizer", which again 40% of people are, it recurs inside the nose and genitals. Yes, it can be treated super-aggressively with a course of two antibiotics, but if you are a colonizer chances are at some point you will recolonize and its back, with even more attitude. There is a good argument for not treating colonizers with oral antibiotics, since we are just creating greater resistance issues.
As long as we keep making stronger antibiotics, the staph. develop resistance. The answer to this problem will be discovering what is it about some individuals' immune system that makes them vulnerable to a having a small skin infection go internal, and why most can tolerate a fair amount of staph. even without treatment without lethal consequences.
Excellent point made on cutting nails. In ICU & hem-onc units there are often "no artificial nails, no long nails" rules for a reason.
Edited by UKDslayer (October 20, 2007 15:33)
Edit Reason: incomplete phrase completed
Top
Hope this is beneficial....
Bruce