Wound management is associated with a number of different factors, the wound observations play a fundamental role in understanding the exact nature of the wound and how it will proceed to heal. As discussed by Harper, Young & McNaught, (2014), the wound observation provides key information regarding the clinical status of the wound. This allows the health care professionals be able to understand the exact care need of the patient and then provide intervention to accelerate healing process. This case study involved a young woman named Mary who sustained a laceration wound over the lateral aspect of the left foot. The case scenario also elaborates that Mary had sustained this particular wound while being in the beach and she had also not washed the wound just used her handkerchief to bandage the wound, which is undoubtedly not the aseptic wound cleaning technique which should have employed in this case. The lack of following the aseptic wound cleaning can be considered the most important contributing factor that led to the infection that the patient acquired days later (Lee & Bishop, 2012).
Lacerations is an uneven or irregular wound judging by the texture, it is generally the result of tearing of the skin with a sharp or blunt object with enough force to cause an impact injury. In this case, the injury that the patient sustained had been from a broken glass bottle which resulted in a 2 cm deep wound. The inflammatory response is the second line of defences is the body and is a very common observation associated with wounds. A wound being red and swollen generally indicates the onset of infection, the inflammation and discolouration of the skin is the result of the rapid proliferation of the pathogen underneath (Frykberg & Banks, 2015). The wound was also warm to touch, it has to be mentioned that the skin near the wound might appear hot normally however of the skin is extremely hot and is not slowing any signs of cooling down it might indicate the response of the innate immunity of the body to the invading infection. Lastly, the wound observations also indicates that the wound also has steady purulent discharge. Purulent discharge often accompanies a wound and is the typical white yellow exudate that is secreted from the site of inflammation and the wound opening. It is also known as the liquor puris, a protein rich fluid containing mainly the dead leukocytes, mainly neutrophils (Bykov et al., 2017). The presence of purulent discharge generally indicates deteriorating infections, possibly of bacterial origin (Craft & Gordon, 2015).
Endogenous infection is caused generally by the pathogenic microbiota that inhabits the body itself. These pathogenic organisms stay within the body system in a dormant form until there is any imbalance in the haemodynamic stability of the body which provides an opportunity. These opportunistic pathogen enter the body and reach the vulnerable tissue due to the breakdown of the sterile barrier of the tissues. In this case, the patient had a laceration on her leg which was not aseptically cleaned or protected. This provided ample chance for the opportunistic microflora on the surface of the skin to invade the internal tissue from the wound opening and colonize the surrounding tissue. The most common skin opportunistic pathogens are the different species of Staphylococcus. However, judging the symptoms and wound observation physiology the causal pathogen can be considered the MRSA or methicillin resistant Staphylococcus aureus (Serra et al., 2015).
MRSA is a very common and lethal skin infection causing bacteria and the mode of transmission for this bacteria is generally via direct skin to skin contact. Hence, the contamination to a new host can be mediated via the hands of anyone that comes into the contact with the wound of the patient (Kansal, Rahimy, Garg & Dollin, 2017).
Exogenous contamination on the other hand is caused by the microbiota that is present in the environment. In case of wound infections, the causal organisms generally contaminates the wound of the patient by faulty wound cleaning or covering the wound. As Mary had used a handkerchief to bandage her wound, the chances of airborne and respiratory tract microbes contaminating the wound is most likely. Streptococcus pyogenes is a common bacteria that is found in the respiratory tract of the human and can cause wound infections via air droplets. Hence, it can be a possible source of contamination for Mary as she had used the handkerchief to bandage her wound (Desroche et al., 2018).
The mode of transmission for this particular bacteria is air-droplet mediated. Hence, the health care staff addressing to her wounds and coming in contact with the oozes coming out of the wound. The hands of the staff can be the best contamination source for the new host. Using equipment and supplies that have not been properly sterilized after use can also cause contamination to new host.
The first line of treatment for an infection is antibiotics to stop the spread and proliferation of the pathogenic bacteria. In this case, the patient was provided the ceftriaxone injection via intravenous route. It has to be mentioned that ceftriaxone belongs to the group of cephalosporin antibiotics which have bactericidal activities. This particular antibiotic is most effective in intravenous format and hence it has been given to the patient in the preliminary stage of the infection to stop the infection. This particular antibiotic also has a considerably high plasma half-life and is considered to be work efficiently against a broad range of microbes (Anand, Batra, Arora, Atwal & Dahiya, 2016). Hence, a stat dose of this medication was administered.
As the treatment proceeds for a wound infection patient, the intravenous antibiotic is discontinued after the initial 24 hours and a course of oral antibiotics is administrated. In this case, Mary was provided with oral cephalosporin. This is also a broad spectrum antibiotic prescribed for skin and wound infections. The mechanism of action for this antibiotic is alike penicillin group of antibiotics, stopping the cell wall formation of the bacteria, which is a very effective bacteriostatic infection controlling technique (Dalen, Fry, Campbell, Eppler & Zed, 2018). Hence, this was administered to Mary.
The further investigative tests of the patient revealed the fact that she acquired Staphylococcus aureus infection. However, staph infections are generally not treated with the cephalosporin group of antibiotics as Staphylococci are penicillinase resistant. Hence, the staph infections are generally treated with Penicillinase-resistant penicillins such as dicloxacillin (Nissen et al., 2013). Hence, when it was discovered that Mary had S. aureus infection, the prescription was changed and she was administered dicloxacillin.
The wound healing is a complex procedure which progresses through 4 distinctive phases, namely homeostasis, inflammation, proliferation, and remodelling (Theoret, 2016). The first stage is the coagulation which begins with the platelets and the corpuscles rushing to the area of wound and proceeding with the formation of the blood clot formation in order to cease bleeding. The next phase is the inflammation where the debris and damaged cells from wound opening site is cleared and the nutrients are pooled in the wound area. The next stage is contraction which leads to repair and restructuring of the wound tissues where the collagen granules are deposited. The last stage is repair stage where the collagen granules are realigned and remodelled closing up the broken tissues and completing the process (Theoret, 2016). The process of wound healing is further complicated when the wound becomes infected by a pathogenic organism. Hence, the wound healing process is also complicated and prolonged further by the infection, which is the case for Mary as well. In this case, the wound had been in the inflammation phase, where vasodilation takes place to provide more blood flow to the traumatized area (Marieb & Hoehn, 2016). In this case the intervention by the antibiotic will kill the existing microbes and will eliminate the nutrient competition and let the neutrophils, microphages and monocytes clean up the debris. On a more elaborative note, dicloxacillin will inhibit the production of peptidoglycan chain and therefore stopping cell wall synthesis completely, which in turn will act on stopping the proliferation of the bacteria as well (Nissen et al, 2013). This will be followed by proliferation stage where the collagen granules are deposited in the area and contraction of the wound. The last phase is the remodelling of collagen deposited by the firbocytes and fibroblasts to close the wound completely by which the healing will complete for Mary (Han & Ceilley, 2017).
References:
Anand, S., Batra, R., Arora, B., Atwal, S., & Dahiya, R. S. (2016). A comparative study of preoperative intra-incisional infiltration of ceftriaxone vs. intravenous ceftriaxone for prevention of surgical site infections in emergency cases. Journal of evolution of medical and dental sciences-jemds, 5(64), 4537-4541. Doi: 10.14260/jemds/2016/1036
Bullock, S., & Manias, E. (2013). Fundamentals of pharmacology. Pearson Higher Education AU. Retrieved from https://books.google.co.in/books?hl=en&lr=&id=ODjiBAAAQBAJ&oi=fnd&pg=PP1&dq=fundamentals+of+pharmacology&ots=WJceQdAf4V&sig=QecvtlsCVwG_hZwQQE-2mYrYXWQ#v=onepage&q=fundamentals%20of%20pharmacology&f=false
Bykov, I. M., Basov, A. A., Malyshko, V. V., Dzhimak, S. S., Fedosov, S. R., & Moiseev, A. V. (2017). Dynamics of the pro-oxidant/antioxidant system parameters in wound discharge and plasma in experimental purulent wound during its technological liquid phase treatment. Bulletin of experimental biology and medicine, 163(2), 268-271. Doi: 10.1007/s10517-017-3781-3
Craft, J. A., & Gordon, C. J. (2015). understanding pathophysiology. Retrieved from https://www.researchgate.net/profile/Christopher_Gordon11/publication/306017164_Understanding_Pathophysiology_2Ed/links/57aad86708ae3765c3b6c045/Understanding-Pathophysiology-2Ed.pdf
Dalen, D., Fry, A., Campbell, S. G., Eppler, J., & Zed, P. J. (2018). Intravenous cefazolin plus oral probenecid versus oral cephalexin for the treatment of skin and soft tissue infections: a double-blind, non-inferiority, randomised controlled trial. Emerg Med J, emermed-2017. Doi: 10.1136/emermed-2017-207420
Frykberg, R. G., & Banks, J. (2015). Challenges in the treatment of chronic wounds. Advances in wound care, 4(9), 560-582. Doi: 10.1089/wound.2015.0635
Han, G., & Ceilley, R. (2017). Chronic wound healing: a review of current management and treatments. Advances in therapy, 34(3), 599-610. Doi: 10.1007/s12325-017-0478-y
Harper, D., Young, A., & McNaught, C. E. (2014). The physiology of wound healing. Surgery (Oxford), 32(9), 445-450. Doi: 10.1016/j.mpsur.2014.06.010
Kansal, V., Rahimy, E., Garg, S., & Dollin, M. (2017). Endogenous methicillin-resistant Staphylococcus aureus endophthalmitis secondary to axillary phlegmon: a case report. Canadian Journal of Ophthalmology, 52(3), e97-e99. Doi: 10.1016/j.jcjo.2016.11.016
Lee, G., & Bishop, P. (2012). Microbiology and infection control for health professionals. Pearson Higher Education AU. Retrieved from: https://books.google.co.in/books?hl=en&lr=&id=qhTiBAAAQBAJ&oi=fnd&pg=PP1&dq=microbiology+and+infection+control+for+health+professionals+Lee&ots=hxQ7f6LZ-a&sig=RawVyNsKPSO_Q5MGLvvqtHYtSvc#v=onepage&q=microbiology%20and%20infection%20control%20for%20health%20professionals%20Lee&f=false
Marieb, E. N., & Hoehn, K. (2016). Human anatomy & physiology: Harlow: Pearson Education Limited, 2016.
Nissen, J. L., Skov, R., Knudsen, J. D., Østergaard, C., Schønheyder, H. C., Frimodt-Møller, N., & Benfield, T. (2013). Effectiveness of penicillin, dicloxacillin and cefuroxime for penicillin-susceptible Staphylococcus aureus bacteraemia: a retrospective, propensity-score-adjusted case–control and cohort analysis. Journal of Antimicrobial Chemotherapy, 68(8), 1894-1900. Doi: 10.1093/jac/dkt108
Serra, R., Grande, R., Butrico, L., Rossi, A., Settimio, U. F., Caroleo, B., … & de Franciscis, S. (2015). Chronic wound infections: the role of Pseudomonas aeruginosa and Staphylococcus aureus. Expert review of anti-infective therapy, 13(5), 605-613. Doi: 10.1586/14787210.2015.1023291
Theoret, C. (2016). Physiology of wound healing. Equine wound management, 1-13. Doi: 10.1002/9781118999219.ch1
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