Many healthcare workers still do not understand that when you take a bacterial swab from a chronic wound, and the results show staphylococcus aureus or enterococci ( or other pathogenic bacteria), this should not automatically translate into a prescription for antibiotics. All chronic wounds are colonized with bacteria. Staphylococcus aureus, for example, is a very common guest in most chronic wounds and only rarely poses a real threat. Most bacteria in chronic wounds behave quite well as long as the numbers are kept under control. As long as the tissue is adequately perfused and there is not too much necrotic tissue, the bacterial load of chronic wounds keeps a good balance by itself. If we suspect a bacterial imbalance  - for example, if there is increased inflammation or odour, we should try topical antibacterial solutions or dressings first. Superoxodized water, polyhexanide solutions, or diluted vinegar are examples of antibacterial rinses that can keep bacterial numbers in check. All these solutions have in common that the antibacterial effect is not long-lasting - probably only a few hours. Therefore it is ideal if the dressing choice also has some antibacterial effect. You could use honey or granulated sugar to limit bacterial growth. Silver or iodine impregnated dressings can be used before even considering antibiotics. Please also refer to the chapter about "topical antimicrobials."

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Of course, there are situations where we definitely have to use antibiotics to save limbs and lives. If the patient is systemically affected with fever or general malaise, or rapid deterioration of the wound area, there will be a strong indication for using antibiotics. We also have a lower threshold for starting with antibiotics in patients with diabetic foot problems as these ulcerations quickly deteriorate when there is a bacterial infection. If the patient has a comprised immune deficiency due to, for example, HIV, then this may also warrant a more aggressive approach towards antibiotic treatment. As a rule of thumb, we also consider antibiotic treatment in most cases where we see exposed bone or hardware. However, keep in mind that there is a general trend internationally towards shorter treatment periods. Previously we were taught to treat, for example, diabetic patients with infected foot ulcers on antibiotics for at least 2-3 weeks. Today, we use much shorter treatment periods, sometimes only a week unless bone or tendon involvement warrants longer treatment periods. Many countries have devised national recommendations for antibiotics in both the primary and secondary healthcare systems. 

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Another misconception is that pus-filled boils and abscesses always need antibiotics. What these conditions need is a scalpel to drain the pus out. Once this has been done, antibiotics are rarely necessary unless the patient has a high fever or shows other signs of systemic infection. Antibacterial solutions can be used to rinse the abscess cavity afterwards. 

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When we administer antibiotics, we usually do this systemically. This means we either give the antibiotics orally, intravenously or by intramuscular injection. The antibiotic will then travel through the entire body and eventually reach the infection area. Although systemic antibiotic therapy is seen as the standard of care, we must remember that our normal bacterial flora will also be affected by this and can cause antibiotic resistance. It is, therefore, relevant to ask whether topically applied antibiotics directly into the wound can be utilized. The consensus was previously that topical antibiotics lead to antibiotic resistance problems. But is the danger of resistance not actually worse when we use systemic antibiotics- when all the bacteria of our body come into contact with the given antibiotic? This is a highly relevant discussion, and we do not have a definite answer to this. Keep in mind that some infections will not respond adequately to topical antibiotics because the bacterial infection already has spread far away from the wound bed into other tissue regions where a topically applied antibiotic will not reach. 

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At a recent congress, a microbiologist explained that topically applied antibiotics actually lead to fewer resistance issues - when used correctly. The problem is that many caregivers see topical antibiotics as something relatively harmless and have a surprisingly low threshold to applying them into wounds, whether they seem infected or not. In Norway, where we work, we see confirmation of this daily. A majority of our patients report that their GPs prescribed some form of topical antibiotic during the course of the wound treatment. Furthermore, many patients believe that every wound requires a topical antibiotic, and since some of these products can be obtained without a prescription, their use is widespread. So, in conclusion:  topically applied antibiotics theoretically will pose less of a risk for resistance- as long as they are used with restrictions. When they, however, are used without discrimination, they pose a significant threat for developing resistant bacterial strains. 

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We mentioned earlier that we rarely need antibiotic treatment at our wound clinic, and we never (very rarely) use topical antibacterials. When we see a need for controlling a bacterial imbalance in the wound, we use antibacterial products- this is not the same as antibiotics - and reserve the need for systemic antibiotics for the more severe cases.

There is also some misconception about when to give intravenous antibiotics and when we can switch to oral antibiotics.   Intravenously administered antibiotics in general work quicker as they bypass the digestive tract. They are warranted in severe infection and when the patient is in poor condition and may not be able to swallow oral antibiotics. Some health workers ( and almost all patients) think that intravenous antibiotics are at least twice as effective as oral antibiotics. That is a  misconception - the efficacy of oral antibiotics is usually around 80-90% of the intravenous form. The biggest advantage of administering an antibiotic intravenously is that it works more rapidly at the start. Once the body has been "saturated" with the intravenous antibiotic, we can switch to the oral form. Note that there is an international trend towards switching from intravenous to oral antibiotics earlier than before. Sometimes only a single intravenous dose may be required before the patient can be changed to oral antibiotics. This can save many resources and be a helpful workaround at rural dispensaries with no possibility of hospitalizing the patient. The patient can receive a single dose of antibiotics intravenously as an out-patient, then return home with a prescription for oral antibiotics. 

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On a side note: some healthcare workers still believe that crushing antibiotic tablets and sprinkling them into a wound can outperform systemic antibiotic therapy. Do not use that method - it is considered even worse in terms of developing resistant strains than using systemic or other topical antibiotics! It can even have adverse effects on the healing of the wound. Many years ago, it was not uncommon to crush metronidazole tablets and sprinkle the resulting powder onto malignant ulcerations ( for example, breast cancer ulcerations) to control odour and superficial infections. This method is seen as obsolete and should not be utilized anymore. There are excellent antibacterial solutions instead that we should use. For example, odour control can be achieved by several different products like activated charcoal. 

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Remember: Always take a bacterial swab BEFORE starting the patient on antibiotic treatment. This is important to ensure that the patient receives the correct type of antibiotics. Before taking the bacterial swab, you have to clean the wound bed properly and irrigate it thoroughly with saline to remove the irrelevant bacteria present in any chronic wound. We are interested in the bacteria that adhere to the bottom of the wound bed - they are usually the ones relevant to the patient's infection. You need not worry about washing away too many bacteria - we guarantee you that you will get growth of bacteria on your swab even though you have cleaned the wound well beforehand! Do not use antibacterial solutions ( like super oxidized water or polyhexanide)  when cleaning the wound before taking a bacterial sample, as this may interfere with the results. The standard procedure is as follows:  We take a good bacterial swab and start the patient on a course of antibiotics.

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After a few days, the results should be back from the lab, and we have to check that the strain(s) of bacteria found match the antibiotics we have prescribed. This is something that is often overlooked - very often, the antibiotic treatment is not adjusted after the microbiological test results are back. This also has to do with some challenging logistics in rural parts of Africa. The patient may have travelled half a day to get to the dispensary and may not be easy to reach after the lab report comes back. Please refer to our separate chapter on taking a good bacterial swab which you find under "Tools" in the menu.