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Antibiotics and Antiseptics for Pressure Ulcers (Protocol) Antibiotics and antiseptics for pressure ulcers (Protocol) Norman G, Dumville JC, Moore ZEH, Tanner J, Christie J This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2015, Issue 3 http://www.thecochranelibrary.com Antibiotics and antiseptics for pressure ulcers (Protocol) Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. TABLE OF CONTENTS HEADER....................................... 1 ABSTRACT ...................................... 1 BACKGROUND .................................... 1 OBJECTIVES ..................................... 5 METHODS ...................................... 5 ACKNOWLEDGEMENTS . 11 REFERENCES ..................................... 11 APPENDICES ..................................... 15 WHAT’SNEW..................................... 19 CONTRIBUTIONSOFAUTHORS . 19 DECLARATIONSOFINTEREST . 19 SOURCESOFSUPPORT . 20 Antibiotics and antiseptics for pressure ulcers (Protocol) i Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. [Intervention Protocol] Antibiotics and antiseptics for pressure ulcers Gill Norman1, Jo C Dumville1, Zena EH Moore2, Judith Tanner3, Janice Christie1 1School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK. 2School of Nursing & Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland. 3School of Health Sciences, University of Nottingham, Nottingham, UK Contact address: Gill Norman, School of Nursing, Midwifery and Social Work, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK. [email protected]. Editorial group: Cochrane Wounds Group. Publication status and date: Edited (no change to conclusions), published in Issue 3, 2015. Citation: Norman G, Dumville JC, Moore ZEH, Tanner J, Christie J. Antibiotics and antiseptics for pressure ulcers. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD011586. DOI: 10.1002/14651858.CD011586. Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of systemic and topical antimicrobials, and topical antiseptics on the healing of infected and uninfected pressure ulcers being treated in any clinical setting. BACKGROUND in bed. This includes those with limited activity and mobility or reduced bodily sensation, such as elderly people, people with spinal cord injuries (Gefen 2014), and those with acute or chronic Description of the condition health conditions (Allman 1997; Bergstrom 1998; Berlowitz 1990; Brandeis 1994). A recent systematic review, Coleman 2013, iden- Pressure ulcers, also known as bedsores, decubitus ulcers, pressure tified the key risk factors for pressure ulcers as: limitations of mo- injuries or pressure sores are defined as “a localized injury to the bility or activity; reduced perfusion (including a diagnosis of di- skin and/or underlying tissue usually over a bony prominence, abetes); and the presence of a stage 1 pressure ulcer (see classi- as a result of pressure, or pressure in combination with shear” fication below). A recent cohort study found that predictors of (EPUAP-NPUAP-PPPIA 2014). Pressure ulcers are a type of com- poor healing included the severity of the ulcer and the presence of plex wound that heals by secondary intention (from the bottom peripheral arterial disease (poor circulation/perfusion of the limb; up). McGinnis 2014). Prolonged exposure of an area of the body to pressure or compres- Children with pressure ulcers are recognised as a discrete popula- sion can damage cells, interrupt the local blood circulation (i.e. tion that includes both neonates and older children with a range of reduce perfusion), and trigger a cascade of biochemical changes conditions and risk factors (EPUAP-NPUAP-PPPIA 2014; NICE that may lead to tissue damage and ulceration (Gebhardt 2002; 2014); they are cared for in specialist paediatric facilities, and, ac- Loerakker 2010). Immobility can also lead to increased damage cordingly, are outside the scope of this review. from shear and friction, for example, when people are pulled into position in chairs and beds. People at particular risk of pressure ulcers are those who cannot Classification of pressure ulcers reposition themselves when they are seated in a chair or lying Antibiotics and antiseptics for pressure ulcers (Protocol) 1 Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. One of the most widely recognised ways of classifying pressure removed to expose the base of the wound, the true depth cannot be ulcers according to severity is that of the National Pressure Ulcer determined; but it will be either a Category/Stage III or IV. Stable Advisory Panel (NPUAP). Their international classification recog- (dry, adherent, intact without erythema or fluctuance) eschar on nises four categories, or stages, of pressure ulcers and two cate- the heels serves as “the body’s natural biological) cover” and should gories of unclassifiable pressure injuries in which wound depth or not be removed.“ extent, or both, cannot be accurately determined: such ulcers are Suspected deep tissue injury - depth unknown: ”Purple or ma- generally severe and would be grouped clinically with category 3 roon localized area of discoloured intact skin or blood-filled blis- or 4 ulcers (EPUAP-NPUAP-PPPIA 2014). The definitions for ter due to damage of underlying soft tissue from pressure and/ the categories of severity for ulcers are as follows: or shear. Further description: The area may be preceded by tissue Category/Stage 1: non-blanchable erythema: “Intact skin with that is painful, firm, mushy, boggy, warmer or cooler as compared non-blanchable redness of a localised area usually over a bony to adjacent tissue. Deep tissue injury may be difficult to detect prominence. Darkly pigmented skin may not have visible blanch- in individuals with dark skin tones. Evolution may include a thin ing; its colour may differ from the surrounding area. The area may blister over a dark wound bed. The wound may further evolve and be painful, firm, soft, warmer or cooler as compared to adjacent become covered by thin eschar. Evolution may be rapid exposing tissue. Category/Stage I may be difficult to detect in individuals additional layers of tissue even with treatment.“ with dark skin tones. May indicate ’at risk’ individuals (a heralding sign of risk).” Category 2: partial thickness tissue loss: “Partial thickness loss of Prevalence dermis presenting as a shallow open ulcer with a red pink wound Pressure ulcers are one of the most common types of complex bed, without slough. May also present as an intact or open/rup- wound. Prevalence refers to the number of people with a pressure tured serum-filled or sero-sanguinous filled blister. Presents as a ulcer at a point in time, or during a specific time period (Bonita shiny or dry shallow ulcer without slough or bruising (bruising 2006). Prevalence estimates differ according to the population indicates suspected deep tissue injury). This category/stage should assessed, the assessment methods used and whether or not category not be used to describe skin tears, tape burns, perineal dermatitis, 1 ulcers are included in the estimates. maceration or excoriation.“ In the UK, national pressure ulcer data are collected across com- Category 3: full thickness tissue loss: ”Full thickness tissue loss. munity and acute settings - although data collection is not yet Subcutaneous fat may be visible but bone, tendon or muscle are universal - as part of the National Health Service (NHS) Safety not exposed. Slough may be present but does not obscure the Thermometer initiative (Power 2012). In April 2014, prevalence depth of tissue loss. May include undermining and tunnelling.The in NHS patients was 4.6% (National Safety Thermometer Data depth of a Category/Stage III pressure ulcer varies by anatomical 2014). These data represent patients cared for across a range of location. The bridge of the nose, ear, occiput and malleolus do settings including acute hospital wards, community and residen- not have subcutaneous tissue and Category/Stage III ulcers can tial care and at home. Most patients had category 2 ulcers (3.0%), be shallow. In contrast, areas of significant adiposity can develop with 1.1% having category 3 and 0.6% having category 4 ul- extremely deep Category/Stage III pressure ulcers. Bone/tendon cers (category 1 ulcers were not included in the reporting). The is not visible or directly palpable.“ point prevalence of pressure ulceration in the total adult popu- Category 4: full thickness tissue loss with exposed muscle, ten- lation (rather than those currently receiving medical treatment) don or bone: ”Full thickness tissue loss with exposed bone, ten- was recently estimated using a cross-sectional survey undertaken don or muscle. Slough or eschar may be present in some parts of in Leeds, in the UK. The total adult population was 751,485, and the wound bed. Often includes undermining and tunnelling. The the point prevalence (including grade 1 ulcers) was 0.31 per 1000 depth of a Category/Stage IV pressure ulcer varies by anatomical (Hall 2014). Pressure ulcer prevalence estimates specifically for location. The bridge of the nose, ear, occiput and malleolus do community settings have reported rates of 0.77 per 1000 adults not have subcutaneous tissue and these ulcers can be shallow. Cat-
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