The best treatment for infection is prevention. A clean environment, especially where dressing changes take place, is essential. This includes keeping the dressing-change location free from pets and cleanng it regularly with a disinfectant. Good hand hygiene is the single most important aspect of preventing infection. Alcohol-based hand sanitizers such as Purel are very effective. They provide fast, antimicrobial efficacy against many bacteria, including the antibiotic-resistant organisms MRSA (methicillin-resistant staphylococcus aureus) and VRE (vancomycin-resistant enterococci).
If large jars of ointments are used, be certain to avoid “double-dipping” during dressing changes. Use a plastic sppo or knife or a wooden tongue-depressor to transfer a small amount or ointment into a plastic container or plastic bag. If you happen to contaminate the ointment, dispose of that portion.
Everyone carries bacteria on their skin. The bacteria can live and multiply (colonize) without causing injury or infection. Under the right circumstances, these bacteria invade the skin, multiply, and cause infection. Circumstances that can increase the risk of infection include the following:
- Wound area: Larger wounds are more susceptible.
- Necrotic (dead or dying )tissue: Crusts, scabs and non-viable tissue should be softened and removed. This ay be accomplished by irrigating the wound with water or saline or using s dressing such as a hydrogel.
- Malnutrition: Protein and numerous vitamins and minerals are required for wound healing.
- Poor blood flow to wound: Blood carries oxygen and nutrients.
- Every effort must be made to maintain good overall health to decrease susceptibility to infections.
Typical features of infection include:
- Delayed healing
- Increased exudate (drainage)
- Increased redness
- Increased pain
- Increased swelling
- Increased warmth of skin compared with surrounding area
- Malodorous (unpleasant odor)
- Easy bleeding
Wound infections are common. Use of oral antibiotics is best avoided, if possible, because EB is a lifelong disorder, and wound infections are a lifelong occurrence. If oral antibiotics are used indiscriminately, resistant bacteria may develop, and the individual ultimately may require IV antibiotics when treatment is required. Therefore, topical treatments are utilized as a first step. In any infected wound that is not improving with the use of topical therapy in 2-3 days should be evaluated by a physician. A wound culture may need to be performed in order to determine the cause of the infection and the antibiotics to which the microorganism is susceptible, and oral antibiotics may be required.
Commonly prescribed topical antibiotics include:
Mupirocin (Bactroban) cream or ointment: Mupirocin is effective against MRSA and other Staphylococcus aureus strains, Group A Streptococcus, and Candida. In general, this medication should be applied three times daily. However, most people with EB will not apply an ointment three times a day because doing so would involve dressing changes. Even if applying this medication only once per day, patients should seek medical consultation and treatment if there is no improvement in the infected area within three days. Please note that although Mupirocin is a topical medication, it still should be considered a potent antibiotic and should not be used casually or indiscriminately. It only should be used when an infected lesion is present. Resistant bacteria may develop from regular use of this medication.
Silver sulfadiazine (Silvadene®): Silver sulfadiazine is an antibacterial and antifungal cream. Application occurs daily with dressing changes. The appeal of this medication and other silver products is that bacteria do not become resistant to silver. There are many questions about the safety of long-term use of silver products, in particular topical antibiotic creams. Until clinical trials prove they are safe on a regular long-term basis, individuals should use the products cautiously and for limited periods of time.
Other topical treatments for infection include:
Topical antifungal creams such as ketoconazole, econazole, and naftifine may be used if there is growth of yeast, most commonly Candida albicans. Y Mupiroieast are commonly found on the skin and do not usually cause infection. In the setting of recent or frequent exposure to antibiotics, however, which may reduce the population of normal, “good” skin bacteria, Candida species may overgrow and cause skin infection.
Bleach is a sanitizer and disinfectant for a wide range of bacteria, fungi and viruses. A dilute bleach solution (two teaspoons of bleach per gallon of water) can be mixed and used as a compress or as a soak for heavily draining wounds or infected wounds. Bleach baths (1/8 to ¼ cup of bleach in the bathtub) may be helpful when there are multiple infected wounds or frequent recurrences if the child can tolerate sitting in the bathtub.
Acetic acid compresses or soaks are useful in treating Pseudomonas aeruginosa infections, which are resistant to many antibiotics. These bacteria are common inhabitants of soil and water, so they literally are everywhere. This is a bacterium that thrives in warm, moist environments but is unable to survive in an acetic environment. It has a characteristic fruity odor and blue-green color.
Acetic acid can be bought or mixed at home from vinegar and water:
If using 3 percent vinegar mix, create a 1:12 solution (1 part vinegar, 11 parts water)
If using 5 percent vinegar mix, create a 1:20 solution (1 part vinegar, 19 parts water)
When infection extends beyond the margins of the wound, or when a fever is present, the primary care practitioner should evaluate the individual and possibly prescribe an oral antibiotic. If oral antibiotics are beng prescribed, a wound culture should be obtained from the skin in order to determine the cause of the infection and the antibiotics to which it is susceptible. All of the antibiotic should be taken as prescribed. If doses are skipped, or the medication is discontinued because the area looks and feels better, some bacteria may survive and resist future antibiotic treatment.
- Silver dressings and wound gels containing silver are popular because of their antibacterial and antifungal properties. Silver products are appealing because bacteria do not become resistant to silver. There are, however, questions about the safety of long-term use of silver products. Until clinical trials prove these products are safe on a regular long-term basis, individuals should use the products cautiously and for limited periods of time. Use for up to 7 days on a wound is generally considered safe; after this time, a non-silver dressing may be used. Examples of silver dressings include Restore Contact-Silver (Hollister) and Restore Foam-Silver (Hollister).
- Honey is an ancient remedy for infected wounds. It has been rediscovered in an age where conventional medicine is being challenged by the development of resistant bacteria. The medical literature validates the antimicrobial action of honey against bacteria and fungi, as well its wound-healing properties.
Jennie Hon, an EB nurse specialist in the United Kingdom, published an article in the British Journal of Nursing that detailed one patient’s experience healing a 20-year wound in 15 weeks using a honey-impregnated gauze dressing.
There are other anecdotal reports from EB patients about wound healing with honey. Some people, however, report that it stings when applied, and that it seems to make their dressings heavier and uncomfortable.
Active Manuka Honey (www.manukahoneyusa.com) is raw honey that has not been over-heated or over-strained.
The available honey-containg products are Medihoney®. Regular, store-bought honey should NEVER be applied to the skin, in particular in infants, as it may contain the spores of Clostridium botulinum, which may cause infantile botulism, a disorder of muscle paralysis.