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Case study wound care
Chris 66 year old male obese patient
Weight and Height: Unknown
Social:
Unknown
Alcohol & smoking: Unknown
Family: Unknown
Allergies & sensitivities: Nil known
Facts of the Case
 Bitten on his right foot by a cat eight weeks ago.
 Wound has progressively worsened.
 Transferred from Yass hospital.
 Treated in yass hospital with augmentin duo forte (amoxycillin+ clavulanic acid) with no
improvement.
Looking at facts of this case, this patient had cat bitten eight weeks ago and wound has worsened,
could be the couple of reasons, Hygienic as he is obese therefore with weight mobility decreases.
Moreover, it’s from eight weeks that means he did not look after his health very well.
Augmentin did not work, but could be the other reason if he is not taking his medications or
preexisting cellulitis.
Past medical History
 Type 2 Diabetes
 Right renal calculi
 Mild pancytopenia
 Hypertension
 Tetanus vaccination up to date
 No other history of infection
Presented to the emergency department with:
 Worsening infection of the right foot
 Centred in distal, centre ball of the foot
 Necrotic with severe oedema and discharge
 Good peripheral pulses
 Fever for previous three days
 Modest pain
Diagnosis: Right foot abscess and cellulitis
Medications on admission:
 Simvastatin
 Micardis plus (telmisartan and hydrochorothiazide)
 Lantis (insulin glargine)
 Diamicron(gliclazide)
Treatment Plan
Pathology- FBC, LFTs, UEC, blood culture. Culture of skin swab
 X-ray
 IV timentin
 Withhold metformin, Indomethacin and perindopril, Insulin sliding scale
 Infectious diseases review
 Urgent surgical review and debridement
Ceased on admission
 Amoxicillin, indomethacin, perindopril, metformin.
They have stopped augmentin duo forte start it on Timentin (Ticarcillin and Clavulanate).
Streptococcus and Staphylococcus species are sensitive to Timentin. Cat bits and cellulitis
involve these two species. Looking at his lab results patient has mild renal impairment; therefore
they stopped indomethacin, perindopril and metformin, these srugs al are cleared through
kidneys1. Another reason could be metformin is not recommended before the surgery and using
insulin instead and metformin is contraindicated in severe infection or trauma2.
Pathology Results:
CRP measures the concentration in blood serum of a special type of protein produced in the liver
that is present during episodes of acute inflammation or infection. CRP is high, which shows that
patient got infection2.
Issues:
 CRP high which presents during episodes of acute inflammation or infection.
 Mild Renal impairment
 HbA1C from last July was 7.1 ( In diabetes patient they try to below 7)
 Blood and skin cultures still negative.
 Using indomethacin but no history of Gout.
 Do not have BP reading, body temperature and his cholesterol levels.
Endocrinology review:
 Cease gliclazide and lantus
 Commence Novamix
 Aim for BSL<9, if >18 consider extra actrapid.
 Recommence metformin.
 BSLs currently varying from 15 and 25mmol/L
He is obese gliclazide has side effect of weight gain therefore they have stoped gliclazide
and started on lantus which is long acting (1-2 Hour)but novamix has action in 25 min
and using actrapid if needs quick action less than 5min3. Recommenced on metformin,
metformin is one of the first medicines you are likely to be offered. It helps to control
blood sugar levels better than just using diet and exercise. It doesn’t make you put on
weight, unlike many other diabetes medicine2, 3.
Medication Chart:
Medications
Dose
Indications
Timentin( Ticarcillin with clavulanic
acid)
3.1gm IV Q6h infused over 30
min
Cellulites
Perindopril
10mg D
Hypertension
Simvastatin
80mg PO
Cholesterol
Fenofibrate
145mg D
Cholesterol
Paracetamol
1g PO QID
Pain
Oxycodone
5-10mg PRN PO q3h
Pain
Enoxaprin
40mg SC D
Prophylactic for
thrombosis
Telmisartan and Hydrochorothiazide
80mg/12.5 mg PO D
Hypertension
Metformin
1g BD
Diabetes
Novomix
Variable BD
Diabetes
He is using Paracetamol and oxycondene? Endone dose conventional product, initially 5–15 mg
every 4–6 hours. However, in this patient they are using every 3 hours which is high dose2.
Simvastatin dose range 10–80 mg once daily, existing or high risk of coronary heart disease.
Usual dose, 40 mg once daily2.
Metformin has right dose renal impairment 30-60 ml/min – 1gm daily.
Cat bit
It is estimated that 5 to 15 percent of all animal bites that occur each year are from cats.
Cat teeth are sharp and pointed which typically lead to lacerations and puncture wounds that
allow bacteria to make its way into deep tissues. A cat bite is more likely to lead to an infection
than a dog bite3. Those who are bitten by cats should be aware of the cat bite infection symptoms
because these infections can be very serious if left untreated.
There are certain types of bacteria associated with cat bites. These include3,4:
•Pasteurella species
•Streptococcus species
•Actinomyces species
•Staphylococcus species
•Propionibacterium species
•Peptostreptococcus species
•Bacteroides species
•Wolinella species
•Clostridium species
•Fusobacterium species
Symptoms and diagnosis3,4:
Warmth around the wound, redness around the wound, swelling, pus discharge, and pain. As the
infection progresses, patients may experience fever, low body temperature, fast heartbeat, low
blood pressure, fatigue, and headache
 Blood tests.
 Imaging studies, such as x-rays, magnetic resonance imaging, computed tomography, or
bone scans may be done.
 Wound culture and sampling.
Blood tests will allow doctors to analyze whether an infection is present or not. They will
primarily be look to see if the patient's white blood cell count is elevated and will be
looking for the presence of the types of bacteria associated with a cat bite. These are done
to see if there are any foreign objects in the wound, to look for broken bones, and to
better analyze the injury.
Wound culture and sampling involves taking a small piece of tissue or fluid from the wound and
sending it to be tested at a laboratory. This is done to help determine what type of infection the
patient has so that they can be prescribed the correct medication to treat it. However, in this
patient we do not have any wound culture results.
Treatment Plan3
In all cases a patient's tetanus immunization status must be assessed.
The recommended management for animal bites is thorough cleaning, debridement,
irrigation, elevation and immobilization.
If Infection not established (Low risk) : Antibiotics may not be necessary for mild wounds
not involving tendons or joints that can be adequately debrided and irrigated and that are seen
within 8 hours.
High risk: Wounds having a high risk of infection include:
 Wounds with delayed presentation (8 hours or more).
 Puncture wounds unable to be debrided adequately.
 Wounds on hands, feet or face
 Wounds with underlying structures involved (eg bones, joints, tendons)
 Wounds in the immuno-compromised patient.
 Presumptive therapy is necessary; use:
 amoxycillin+clavulanate 875+125 mg orally BD for 5 days
 If commencement of oral therapy will be delayed
 procaine penicillin 1.5 g IM, as a single dose, followed by amoxycillin+clavulanate.
Established infection: Infected tissue for Gram stain and aerobic and anaerobic cultures
should be obtained before antibiotic therapy. Delaying primary wound closure should also be
considered.
Use initially:
1. Piperacillin+tazobactam 4+0.5 g IV, 8-hourly or
 ticarcillin+clavulanate 3+0.1 g IV, q6h
2. Metronidazole 400 mg orally 12 hourly
Change to oral therapy once patient is stable.
Amoxycillin+clavulanate 875+125 mg orally 12hourly
Modify therapy according to Gram stain and culture.
For severe and penetrating injuries, treatment duration is usually a total of 14 days (IV + oral).
Longer directed therapy is needed for injuries involving bones, joints and/or tendons.
This patient has established infection (eight weeks ago), therefore patient is right treatment of
ticarcillin+clavulanate 3+0.1 g IV, q6h.
Cellulitis:
Infected lesions in the subcutaneous tissue of the skin and occur as a result of breaches to the
skin's cutaneous barrier5,6.
The most common causative bacterial infectious agents for cellulitis are Staphylococcus aureus
and Streptococcus pyogenes. Other less common microorganisms can also cause cellulitis.
Immunosuppressed patients can be susceptible to a wide variety of microorganisms.
Cases of cellulitis are generally either uncomplicated (local infection of subcutaneous tissue) or
can progress into more severe cellulitis where symptoms of systemic infection (Fever). If
insufficiently treated with empirical antibiotics, cellulitis can progress to systemic infection
and/or a necrotising skin infection with dire consequences such as death or limb amputation.
Risk factors developing poor cellulitis8:
 Poor blood circulation (eg. Peripheral vascular disease, venous insufficiency)
 Obesity
 Immuno-compromised (eg. Diabetes mellitus)
 Poor hygiene
 Various types of leg wounds (eg. Leg ulcers, animal bites, cuts)
 Foot infections (eg. Toe web interigo, tinea)
 Lymphoedema
Uncontrolled Diabetes9:
•
Peripheral neuropathy – consistent high blood glucose damages peripheral nerves
leading to decreased sensation of heat, cold, pain etc.
•
Peripheral vascular disease - Persistently high blood glucose directly damages
vascular endothelium which can lead to increased atherosclerosis formation and
decreased blood flow.
•
Immuno-compromised – diabetic patients can have decreased cell mediated
immunity leading an increased susceptibility to infection.
Patient is obese not enough exercise, patient has some of these risk factors (including poor blood
circulation, obesity, diabetes and could be poor hygiene), it is evident that the patient is at a high
risk of developing cellulitis
Recommended treatment3:
•
First line treatment
•
•
Non-immediate hypersensitivity to penicillin
•
•
Di/flucloxacillin 2g IV 6 hourly
Cephazolin 2g IV 8 hourly
Immediate hypersensitivity to penicillin
•
Clindamycin 450mg IV/oral 8 hourly
•
Lincomycin 600mg IV 8 hourly
•
Vancomycin 1.5g IV 12 hourly
This patient is using Timentin bacteria are sensitive for cellulitis organisms such a
Staphylococcus aureus and Streptococcus pyogenes.
Necrotising fascitis3:
Necrotising fasciitis (NF) more commonly known as “flesh-eating disease” is a rare
infection of the subcutaneous tissues, and it is more common seen in immune
compromised patients. There are many types of bacteria that might be the cause for
NF these include;
 Group A streptococcus (Streptococcus pyogenes),
 Staphylococcus aureus (MRSA),
 Vibrio vulnificus,
 Clostridium perfringens,
 Bacteroides fragilis.
But the organism that is most commonly found to cause NF is group a betahemolytic streptococci, and normally develops from a previous complicated wound.
NF may also occur in the setting of diabetes mellitus, surgery, trauma, or
infectious processes.
Drug Interactions:
Potential drug interactions
Adverse effects
Fenofibrate and simvastatin
Development of rhabdomyolysis.
Enoxaparin and simvastatin
Increased risk of hyperkalaemia.
Enoxaparin and Perindopril
Hydrochorothiazide and
perindopril
Increased the risk of renal impairment
Fenofibrate and simvastatin may increase the risk of developing toxicities.
Concurrent use in patients described the development of rhabdomyolysis2, 10. Observe
patients for toxic effects of these agents especially myopathy. Use this combination
with caution and monitor for signs of drug toxicity.
Enoxaparin and Perindopril, low molecular weight heparins can decrease the
excretion of potassium by suppressing aldosterone, resulting in an increased risk of
hyperkalaemia during concomitant use with ACE inhibitors. Monitor serum
potassium levels closely if low molecular weight heparins and ACE inhibitors are
used together, especially in patients at a relatively high risk for hyperkalaemia10. Use
combination with caution and monitor serum potassium levels.
Hydrochlorothiazide and perindopril, the use of ACE inhibitors and thiazide
diuretics may cause first-dose hypotension. Co-administration may also increase the
risk of renal impairment. The addition of an NSAID to this combination (ACE
inhibitor + diuretic) will further increase the risk of renal impairment, especially in
the elderly. Monitor serum potassium as both hyperkalaemia and hypokalaemia have
been reported with concurrent therapy12.
Status Day 4
Amputation of right 2nd – 4th toes
There is not enough blood getting into your toe to keep it alive.
The lack of blood causes severe pain and allows serious
infection to take hold. If left untreated, the toe will eventually
get necrotic (go dead) and become life threatening. The only
choice is to take off the toe.
Vacuum press dressing- Plans to fill
the wound and conduct skin graft
depending on healing
Skin grafting is a type of medical grafting involving the
transplantation of skin. Skin grafting is often used to treat: Extensive
wounding or trauma Burns and Areas of extensive skin loss due to
infection such as necrotizing fasciitis. The grafting serves two
purposes: it can reduce the course of treatment needed (and time in
the hospital), and it can improve the function and appearance of the
area of the body which receives the skin graft.
Observations stable
Continues IV timentin
For severe and penetrating injuries, treatment duration is usually a
total of 14 days (IV + oral). Longer directed therapy is needed for
injuries involving bones, joints and/or tendons.
This case seems incomplete, did not say anything about what about when patient will be
discharged from the hospital what antibiotics they will recommend to him. Timentin does not
come in oral form.
Change to oral therapy once patient is stable. If the infecting pathogen is uncertain, use3:
amoxycillin+clavulanate 875+125 mg orally, 12-hourly.
While patient is in the hospital or discharged from the hospital, need local treatment on the
wound to prevent further infections
Wound care3:
 Prepare the wound bed to maximise the rate of wound healing.
 Debride the wound of slough or necrotic tissue, reduce the bacterial burden, and to
promote granulation tissue and epithelialisation. Ensure the patient receives adequate
pain relief.
 There are 5 main types of modern wound dressings: films, hydrogels, hydrocolloids,
alginates and foams. Films, hydrogels and hydrocolloids increase the wound moisture
whereas alginates and foams absorb exudate. These modern dressings are expensive.
More traditional wound dressings (eg nonadherent pad dressings, tulle gras, combine, saline
soaks) can also be useful. These dressings are cheaper and may be adequate in some situations
when cost is a consideration. They generally provide a drier absorbent system of dressing, but
moisture levels may be adequate.
Choice of dressings3:
Types (available forms)
Activated charcoal, Activated
charcoal with silver
Alginate (sheet, rope),
Hydrofibre alginate
Cadexomer iodine
Film
Foam polyurethane (sheet,
pack)
Hydroactive (sheet, cavity)
Hydrocolloid Hydrocolloid
( Thin, Sheet, Paste, Powder,
Extra-absorbent)
Hydrocolloid/alginate
( Sheet)
Hydrogel (amorphous)
Non-adherent (padding
dressing, nonparaffin tulle,
Extra absorbing dressing,
paraffin tulle)
Silver containing dressing
Soft absorbent padding
Zinc paste (bandage,
stocking)
Table from eTG
Function
Used on malodorous wounds to adsorb odour and bacteria.
Absorbs exudate and maintains moist environment without
maceration. Some products have haemostatic properties. Not
used on dry wounds.
Antibacterial, absorbing, slough-reducing dressing.
Semi-permeable, transparent and flexible. Provides moist wound
environment and encourages autolysis but does not absorb
exudate.
Semi-permeable, transparent and flexible. Provides moist wound
environment and encourages autolysis but does not absorb
exudate.
Combines with exudate to form soft gel trapped within dressing.
Used to absorb exudate and rehydrate dry slough. Maintains
moist environment and aids in autolysis without maceration.
Combines with exudate to form soft, moist gel. Encourages
autolysis to aid in removal of slough.
Absorbs heavy exudate and maintains moist environment
without maceration.
Able to rehydrate dry tissue as well as absorb some fluid.
Protective dressing for minor lacerations or healed wounds.
Antibacterial dressings that either contain or release silver into
the wound.
Used under compression bandages to protect pressure points.
Used to treat skin (dermatitis) around ulcer. Acts as a protective
buffer under compression bandage.
Vacuum dressing could be useful in this patient. The application of vacuum dressings to control
negative pressure, accelerate debridement and promote healing in many different types of
wounds. The optimum level of negative pressure appears to be around 125 mmHg below
ambient five minutes on and two minutes off. The negative pressure assists with removal of
interstitial fluid, decreasing localized edema and increasing blood flow14. Therefore, this would
be useful in this patient. This in turn decreases tissue bacterial levels.
Frequency of dressing changing:
 Frequency of dressing changes will depend on the type of wound, the type of dressing
and the patient.
 Many dressings can be left on for several days; some can be left on for up to a week.
Increasing the frequency of dressing changes reduces wound moisture and can be used to control
the moisture level. Heavily exudating or excessively moist wounds may require frequent changes
(eg daily).
Continuity of care
Continuity of care after presentation
Recommendations for patient after discharge from the hospital
 Even though the patient's cellulitis was successfully treated, he is prone to reinfection as
discussed earlier in reference to his co-morbidities decrease the patient's future risk of
cellulitis, his co-morbidities such be re-evaluated. Some recommendations to decrease the
patient's risk include:
 Educate and encourage the patient to regularly (eg. weekly) check his feet and legs for
cuts/abrasions and early signs of infection/inflammation.
 The patient's feet and legs should be monitored by his GP and a podiatrist at least every 3
months.
 Encourage the patient to start with basic and light exercises (eg. light walking) in
collaboration with his GP and an exercise physiologist. His initial goals would be to
increase his lung capacity and improve his blood circulation, particularly to the limbs.
Further along, his future goals would be to lose weight.
 Educate and encourage the patient on how to better maintain his diabetes with dietary
advice from a dietician and review of his diabetic drug therapy with his GP
Role of key health professionals
 Diabetes educator: educate patient on how to recognise signs of hypoglycaemia.
 Community nurse: aid with administration of medicines (eg insulin) and check up on
patient, monitoring blood glucose levels
 General practitioner: regular follow up with patient to ensure diabetes is being controlled,
and no new signs of infection, monitoring clinical signs and organ function
 Hospital pharmacist: ensuring medication reconciliation has been filled out correctly and
that medicines are being administered properly.
 Community pharmacist: communicating with carer regarding medication issues, dose
administration aids.
Wound care nurse: wound care management and monitoring of healing
Take home massages:
 A cat bite is more likely to lead to an infection than a dog bite.
 S. Aureus and S. Pyogenes are the most common pathogens associated with cellulitis of
the legs.
 Suspected cellulitis should be treated with empirical antibiotics stat. (ie. di/flucloxacillin
500 mg orally, 6-hourly for 7 to 10 days).
 Common risk factors for cellulitis include: poor circulation, immunosupression,
lymphoedema, obesity, cuts, animal bits, and foot infections.
 By controlling patient lifestyle factors, the risk of infection is greatly reduced.
 Pharmacists have an integral role in referring patients who present with slow growing
unusual looking lesions
 Good diabetic control is important in aiding recovery from any infection
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14. An introduction to the use of vacuum assisted closure Accessed on 05th May 2011.
http://www.worldwidewounds.com/2001/may/Thomas/Vacuum-Assisted-Closure.html