The Role of Wound Care Clinicians in Combating Lethal Infections

In this issue of Wound Management & Prevention, Banerjee et al¹ illustrate some of the challenges that confront wound care clinicians. For example, if a wound exhibits signs of infection, is it actually infected and, if so, what should be used to treat it? In this study¹ of 40 patients with diabetes mellitus who presented with signs and symptoms of infection in their foot ulcer, 75% of the 28 aerobic isolates found were multidrug-resistant. In everyday practice, chances are the antibiotic medications wound patients commonly receive either are not needed or not effective; this, in turn, exacerbates the problem of multidrug resistance. 

Bacterial resistance to antibiotics is multifactorial and an established threat to public health, yet antibiotic stewardship programs for humans do not appear to have been widely adopted.^2,3 Although some industrialized countries have successfully banned the routine use of antibiotics in agriculture (which has led to dramatic reductions in rates of clinical resistance in patients to some of the targeted antibiotics) other countries, including the United States, have not; the most recent data⁴ (2014) show annual US sales of antibiotics for livestock use totaled 15.4 million kilograms (34 million pounds), 4 times the amount for human use. The epidemic continues and people die from previously treatable infections.

Until recently, the emergence of fungi resistant to the (limited number of) treatments available had not received widespread attention, but that is changing with the global spread of many multidrug-resistant fungi, including Candida auris.^5,6 Not unlike antibiotic-resistant bacteria, the reasons for the growing resistance of fungi to drugs appear to be multifactorial and may include the ubiquitous use of azoles — a lethal pathogen — in humans and agriculture, notably widespread use on crops. In one outbreak of C auris fungus in a hospital in Spain, 41% of infected patients died.⁶C auris is very tenacious against commonly used cleaning procedures and spreads rapidly. According to officials at Mount Sinai Hospital in New York, after a patient who had C auris died, everything in the room — from the ceiling to the floor and everything in between — tested positive for the fungus that was so difficult to kill parts of the floor and ceiling had to be removed to ensure fungus eradication. The head of the fungal branch at the Centers for Disease Control and Prevention (CDC) said of C auris, “It is a creature from the black lagoon.”⁶

Although the clinician’s role in combating these global threats may seem limited, awareness is a good first step. No global effort will succeed without the commitment of every health care professional. These pathogens prey upon our most vulnerable populations, which include many of our patients. Hence, efforts must be implemented to optimize the patient’s immune system, the systemic variables that affect healing, and the wound environment itself along with judicious use of antimicrobials and antifungals to reduce the risk of developing resistance. This includes utilizing antibiotic and antifungal stewardship programs and limiting the use of increasingly ineffective topicals.^7,8 The CDC, among others, encourages watchful waiting approaches to reduce the use of antibiotics.³ Or, as Dr. Bolton⁹ reminds wound care clinicians, the signs of inflammation caused by ongoing or repeated tissue injury are the same signs of inflammation caused by invasive infection and the wrong decision places patients at risk of receiving debridement and antimicrobial therapy when they may really need more rigorous management of the host and environmental factors causing the chronic wound to break down. These are words to live by to help wounds heal while protecting current and future patients from the alarming spread of lethal pathogens.