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`Re-introducing Honeyin the
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`Peter C. Molan, BSc(Hons), PhD
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`Topical Hyperbaric Oxygen and Electrical
`Stimulation: Exploring Potential Synergy
`Laura E. Edsberg, PhD; Michael S. Brogan, PT, MS, CWS;C. David Jaynes,
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`Ultraviolet Light C in the Treatmentof
`Chronic Wounds with MRSA:A Case Study
`
`Thao P. Thai, BScPT, MSc; Pamela E. Houghton, BScPT, PhD; David H.
`Keast, MD, CCFP; Karen E. Campbell, RN, MScN, NP; and M.Gail
`Woodbury, BScPT, MSc, PhD
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`Mind-Body Techniques
`in WoundHealing
`Karen A. Wientjes, PT, MPH, CWS
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`—OstomyWound Management
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`2
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`Contemporary topics in skin, wound,
`ostomy, and incontinence care
`
`OstomyWoundManagement
`November 2002, Vol. 48, Issue 11
`
`Features
`
`Departments
`
`Editor’s Opinion
`OnBeing a
`Healing Coach
`
`Foresight
`The Truth about Medical Codes: It’s More Than
`a Bunch of Numbers
`
`The Ostomy Files
`A One-— or Two-Piece Pouching System
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`MyScope of Practice
`The Challenges of a Nurse/Entrepreneur
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`AAWC
`
`Information for Authors
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`Classifieds
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`Industry News/New Products
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`Advertisers Index
`
`6 1
`
`0
`
`Re-introducing Honeyin the
`Management of Wounds and
`Ulcers — Theory and Practice
`Peter C. Molan, BSc(Hons), PhD
`
`Topical Hyperbaric Oxygen and
`Electrical Stimulation: Exploring
`Potential Synergy
`Laura E. Edsberg, PhD; Michael S. Brogan,PT,
`MS, CWS; C. David Jaynes, PhD; and Kristin
`Fries, PhD
`
`Ultraviolet Light C in the
`Treatment of Chronic Wounds
`with MRSA:A Case Study
`Thao P. Thai, BScPT, MSc; Pamela E.
`Houghton, BScPT, PhD; David H. Keast, MD,
`CCFP; Karen E. Campbell, RN, MScN, NP;
`and M. Gail Woodbury, BScPT, MSc, PhD
`
`28
`
`42
`
`52
`
`62
`
`Mind-Body Techniques in
`WoundHealing
`Karen A.Wientjes, PT, MPH, CVS
`
`
`
`Right medial lower
`wound after 1 month
`of weekly UVC treat-
`ments. See related story
`on page 52.
`
`4
`
`OstomyWound Management
`
`3
`
`

`

`ULTRAVIOLET LIGHT C IN
`THE TREATMENT OF CHRONIC
`WOUNDS WITH MRSA:
`A CASE STUDY
`
`— Thao P. Thai, BScPT, MSc; Pamela E. Houghton, BScPT, PhD; David H. Keast, MD, CCFP; Karen
`E. Campbell, RN, MScN, NP; and M. Gail Woodbury, BScPT, MSc, PhD
`
`The prevalence of antibiotic-resistant bacteria suchas
`methicillin-resistant Staphylococcus aureus is rapidly
`increasing in healthcare facilities and spreading to the com-
`munity. Methicillin-resistant S. aureus colonize the skin and
`open wounds and can interfere with wound healing. Recent
`studies have shownthatultraviolet light C can kill antibiot-
`ic-resistant strains ofbacteria such as methicillin-resistantS.
`aureus in both laboratory cultures and animaltissue. This
`clinical report describes the effects of ultraviolet light C on
`wound bioburden andclosure in three people with chronic
`ulcers infected with methicillin-resistant S. aureus. Inall
`three patients, ultravioletlight C treatment reduced wound
`bioburden and facilitated wound healing. Two patients had
`complete wound closure following 1 week of ultraviolet light
`C treatment. This case study suggests that ultraviolet light C
`is a promising adjunctive therapy for chronic wounds con-
`taining antibiotic-resistant bacteria such as methicillin-
`resistant S, aureus,
`
`Ostomy/Wound Management 2002;48(11);52—60
`
`worldwide developmentofvirulentbacteria
`
`A«areresistanttomultipleantimicrobial
`
`treatments is occurring.' Onestrain of antibiot-
`ic-resistant bacteria currently receiving attentionis
`methicillin-resistant Staphylococcus aureus (MRSA). In
`many hospitals in the United States and Europe,the
`prevalence of MRSAhasincreased from less than 3%
`in the early 1980sto rates as high as 40% in the 1990s,.~
`* Sincethefirst report of MRSA in Canadain 1981, the
`number of MRSAcases has increased dramatically, and
`cases of community-acquired MRSAalso have been
`documented.** Methicillin-resistant S. aureus bacteria
`colonize the skin and open wounds and mayinterfere
`with woundhealing.”
`Artificially produced ultraviolet light (UVL) was
`introduced as a therapeutic treatment for skin disor-
`ders at the beginning of the 20" century.” Cell culture
`and animal studies that have examined mechanisms by
`which UVL augments woundrepair propose that UVL
`can stimulate cell proliferation,epidermal thickness,”
`blood flow in the cutaneouscapillaries,” and wound
`debridement.” A particular wavelength of UVL of
`between 200 nm and 290 nm called ultravioletlight C
`(UVC) has been shownto have bactericidal effects.”**
`Recent studies indicate that UVC can kill antibiotic-
`resistant strains of bacteria such as MRSAin laboratory
`cells and in animaltissue.” However, whether UVC
`can kill these bacteria when applied to human chronic
`wounds, using suggested clinical protocols, is not
`
`The authorsareaffiliated with the SchoolofPhysical Therapy, Faculty ofHealth Sciences, University of Western Ontario,
`London, Ontario, Canada; and Parkwood Hospital, St. Joseph’s Health Care, London, Ontario, Canada, Please address corre-
`spondence to: Dr. Pamela E. Houghton, Associate Professor, School ofPhysical Therapy, University of Western Ontario, London,
`Ontario, Canada, N6G 1H1; email: phoughto@julian.uwo.ca.
`
`52 OstomyWound Management
`
`4
`
`

`

`known.The purposeofthis case study wasto evaluate
`the potential role of UVC in reducing woundbiobur-
`den and improving woundstatus in chronic ulcers
`infected with MRSA.
`
`Case 1
`A 77-year-old man had multiple leg ulcers due to a
`combination of venous andarterial insufficiency related
`to his previous occupation that involved prolonged stand-
`ing. His long history of venous insufficiency included
`numerouscorrective surgical procedures, including vein
`stripping. He presented with hypertension,bilateral leg
`edema,andsignificantly impaired bilateral lower extremi-
`ty bloodflow with ankle brachial indices (ABI) of 0.53
`and 0.61 of the left and rightleg, respectively. He ambulat-
`ed with a cane and hadlimited mobility and impaired
`muscle pump function in both lower extremities. The
`extreme pain reported bythis patient not only limited his
`mobility, but also caused significant sleep disturbances,
`leading to mild depression. Current medicationsincluded:
`pentoxifylline (400 mgtid), enalapril maleate (2.5 mg
`bid), and acetaminophen (500 mgqid).
`
`Ostomy/Wound Management 2002;48(1 1):52-60
`
`ed as type andrelative amountof bacteria present —
`eg, no growth (0), occasional growth (scant), light
`growth (1+), moderate growth (2+), or heavy growth
`(3+). Other outcome measures included taking pho-
`tographsandassessing changes in wound appearance
`Method
`using the Pressure Sore Status Tool (PSST).” The PSST
`is a pen-and-papertool consisting of 13 domains that
`UVC treatmentprotocol, Using an application tech-
`nique that has been previously described by Nussbaum
`assess the composition of wound bed; woundsize,
`et al," UVC was applied at a distance of 1 inch and per-
`depth, and exudate; and the condition of the periulcer
`pendicular to the wound using premeasured disposable
`skin and wound edge. Scores assigned onascale of 1 to
`spacers. Before treatment, a 254-nm, cold quartz UVC
`5 to each of the individual domains of the PSST are
`generator, approvedfor clinical use in Canada (sup-
`totaled to derive a total score ranging between 13 and
`plied by Medfaxx Inc., Raleigh, NC) was warmed for 5
`65, with 13 representing a completely healed wound.
`minutes before being placed over the wound. The ulcer
`The PSST haspreviously been shownto produce valid
`was cleansed withsterile saline, a thick layer of petrole-
`andreliable assessments of wound appearance.”
`um jelly was applied to the surrounding periulcer skin
`and any healthy granulation tissue, and the wound
`edges were covered with a drape.
`The UVC generator was applied to the woundfor 180
`seconds per woundsite. This length of time is recom-
`mended for the treatmentof infected ulcers*' and was
`selected based on the MRSAkilling rates reported in a
`previousin vitro study.” To shield the eyes from UVC,
`the therapist and patient wore protective goggles. All
`products applied to the patient were sterilized or dis-
`cardedafter a single use. Equipmentthat had to be
`reused was decontaminated using appropriate protocols.
`Subject recruitment. Approvalfor research involving
`human subjects was obtained from appropriate institu-
`tional review boards. The purpose, method,risks, and
`benefits of UVC treatmentwere explained to the
`patients and/ortheir substitute-decision makers and
`informed consent was obtained. Patients included in
`this case series had a chronic ulcer present for at
`least 3 months that was infected with MRSA.By
`definition, an infected woundhasa positive swab
`culture and clinicalsignsofinfection, including:
`marked redness extending beyond the wound
`margins; increased pain; and increased amounts of
`foul smelling, purulent wound exudates. Oral
`antibiotic or topical antimicrobial therapy may or
`maynotbe required.”
`Outcome measures. To determine the magni-
`tude of bacterial burden in woundsforthis case
`study, clinicians used a standardized protocolfor
`administering a semiquantitative swab.”**! The lab
`
`results from the semiquantitative swabare report- earlier pre-clinical study observations: Ultraviolet light C
`
`KEY POINTS
`* Chronic wounds are an importantrisk factor for acquiring
`antibiotic-resistant bacteria that may, in turn, delay healing.
`* The case studies presented here build on and confirm
`
`can kill methicillin-resistant Staphylococcus aureus, as well
`as other non-antibiotic resistant bacteria.
`Given existing treatment limitations, current trends in the
`emergence of antibiotic-resistant bacteria, and the encour-
`aging results reported here, research to ascertain the
`effectiveness of treatments that may help break the cycle
`of antibiotic resistance is long overdue.
`
`November 2002 Vol48 Isuell 53
`
`5
`
`

`

`At his initial wound
`evaluation in July 1998,
`the patient presented
`
`
`SemiquantitativeSwabResults
`
`with a total of six large N+
`
`—*—MRSA —®— Pseudomonas
`
`- © ~ Staph Aureus
`
`_— +
`
`"Scan
`
`superficial ulcers located
`in the medial andlateral
`lowerleg region bilater-
`ally. These ulcers ranged
`in size from approxi-
`mately 1.54 cm’ to 30
`cm’. He reported that the
`ulcers developed follow-
`ing surgery to repair an
`abdominal aneurysm.
`After 2 years of standard wound care and manytopi-
`cal antimicrobial and oral antibiotic treatments,five
`lower extremity wounds remainedin thelateral and
`medial aspect ofthe right lower leg as well as the medi-
`al aspect ofthe left lower leg. Before enrolling in this
`case study, the patient tried oral antibiotics on a recur-
`ring basis (ciprofloxacin in July 1998, November 1998,
`May 1999, June 1999, and August 1999; clarithromycin
`in June 1999 and August 1999). In addition, several dif
`ferent topical antimicrobials were tried, including
`mupirocin (Bactroban’, SmithKline Beecham
`Pharmaceuticals, Mississauga, Ontario, Canada), cadex-
`omeriodine (lodosorb’, Perstorp Pharma, Lund,
`Sweden), and nanocrystalline silver dressings
`(Acticoat”, Westaim Biomedical Corp, Exeter, NH, Fort
`Saskatchewan, Alberta, Canada) in combination with
`mechanical debridement.In general, the patient found
`it difficult to tolerate the application of topical antimi-
`crobials because they exacerbated his pain.
`Atthe time of this study, the patient’s wounds were
`superficial with no undermining and had attached
`edges andloosely adherent slough. Only minimal gran-
`ulation tissue was present. Examination of the dressings
`showed that his wounds were producing copious
`amounts of purulent yellow exudate. Furthermore, sig-
`nificant erythema surrounded the wounds.
`Semiquantitative bacterial cultures obtained before
`treatmentrevealed the presence of three types of bacte-
`ria: methicillin-resistant S. aureus (MRSA)inhis right
`medial lower ulcer and a combination of Pseudomonas
`aeruginosa and S. aureus in his left medial ulcer.
`The wounds were treated with standard wound care
`consisting of saline cleansing, several layers of absorp-
`
`oO
`
`——_— == == oe
`After Single
`UVC Treatment
`
`After 2 weeksof
`seven UVC Treatments
`
`After One Month ofweekly
`UVC Treatments
`
`Figure 1
`Changesin bacterial colonization of lower leg wounds: CaseI.
`
`tive hydrofiber dressing (Acquacel’; Convatec, Skillman,
`NJ), mild compression therapy (Surepress’;Convatec,
`Skillman, NJ), and self-adherent tape (Coban”, 3M,St.
`Paul, Minn.).
`Using the UVC treatmentprotocol described previ-
`ously, the patient received seven UVC treatments over a
`14-day period. Treatment was scheduled to coincide
`with dressing changesonalternate days. This intensive
`2-week treatmentperiod was followed by 1 month of
`weekly UVC treatments. Each woundreceived 180 sec-
`onds of UVCirradiation per treatmentsession. During
`the initial seven UVC treatments, the patient received
`no other antibiotic treatment. However, during the |
`month of weekly UVC treatments, the patient’s stan-
`dard woundcare regimen included a 15-day course of
`ciprofloxacin (500 mgbid) anda trial of sodium chlo-
`ride-impregnated absorbent dressing (Mesalt"; SCA
`Molnlycke, Regensdorf, Switzerland). Use of the sodi-
`um chloride-impregnated absorbent dressing waslater
`discontinued because the subject reported he could not
`tolerate the increased pain that occurred when the
`dressing was applied.
`The two woundsthat were closely monitored were
`the left medial and right medial lower ulcer, which were
`approximately 18.3 cm* and 15.3 cm’in size, respective-
`ly. Results obtained from semiquantitative swabs taken
`from the two lowerleg woundsites showed that heavy
`growth of P. aeruginosa (3+) was completely eradicated
`after the first UVC treatment and no growthofS.
`aureus wasevidentafter 2 weeks ofalternate day UVC
`treatments (see Figure 1). A continuing treatment pro-
`gram of one UVCtreatment per week for 1 month,in
`addition to conventional wound care and antibiotics,
`
`54 OstomyWound Management
`
`6
`
`

`

`
`
`Figure 2a
`Case I: Right medial lower woundafter seven daily UVC
`treatments.
`
`was required to remove MRSA from the woundbed. Of
`note: Both wounds contained a moderate growth (2+)
`of S. aureus.
`In addition to marked changesin the type andrela-
`tive amountof bacteria present within the wound bed,
`improvements in wound appearance were observed
`(see Figures 2a and 2b). After 1 month of UVCtreat-
`ment, the authors observed the presence ofepithelial
`buds, normal skin color surrounding the wound, and
`the emergenceof healthy “beefy” red granulation tissue
`in the right medial lower wound. This improvementin
`woundappearancewasreflected in a reduction of PSST
`scores (see Tables 1 and 2).
`
`Case 2
`A 78-year-old womanhadpoorly controlled type
`2 diabetes for 12 years and lower extremity neuropa-
`thy for 5 years. She also had a decreased lower
`extremity blood flow (ABI < 0.8) and absent pedal
`pulses. Her medical history included: obesity,
`ischemic heart disease,atrial fibrillation, myocardial
`infarct, congestive heart failure, hypertension for 12
`to 15 years, and poor pulmonary function, requiring
`intermittent use of oxygen administered via nasal
`prongs. She was admitted from a nursing home to
`the hospital for chronic pain and immobility, exacer-
`bated by a history of spinal stenosis at L2, L3, and
`L5, with surgery in 1998, and osteoarthritis (OA)
`requiring left knee and bilateral hip replacements.
`She took numerous medications, including aceta-
`minophen 500 mg,twotablets qid, for pain.
`Immobile for 3 months before admission, she had
`developed severe depression and anxiety that were
`
`
`
`Figure 2b
`Case 1: Right medial lower wound after 1 month of weekly
`UVC treatments.
`
`poorly controlled. She presented at the hospital with
`an ulcer located on thefifth toe of her right foot that
`had been present for approximately 3 months before
`admission. A previoustrial of oral antibiotics (lev-
`ofloxacin, 500 mg OD for 7 days), was unsuccessful.
`Standard woundcare consisting of saline cleansing
`and a transparent dressing (Tegaderm”, 3M,St. Paul,
`Minn.), in conjunction with wearing a protective
`boot, had not resulted in wound closure.
`At the time of this study, the right fifth toe ulcer
`was approximately 0.4 cm*. Semiquantitative swab
`cultures indicated that the toe ulcer was colonized
`with MRSA(see Figure 3). Before UVC treatment,
`the wound wassuperficial with no undermining, had
`attached edges, and contained loosely adherent
`slough, with ‘minimal granulation tissue present.
`Examination of the wound dressings revealed that
`the wound was producing a moderate amount of
`serosanguineous exudate.
`Using the UVC treatmentregimen previously
`described, the patient was treated with seven consec-
`utive, daily UVC treatments of 180 secondseach to
`the right fifth toe ulcer. During the UVC treatment
`period, she continued to receive the standard wound
`care described.
`
`The reduction in bacterial bioburden of the ulcer
`(see Table 1) was associated with concurrent wound
`reepithelialization, and the ulcer was healed follow-
`ing 1 week of UVC treatments. This marked
`improvement in woundstatus wasreflected in a
`change of PSST scores from a PSST score of 30 pre-
`UVCtreatmentto a score of 14 post-UVC treatment
`(see Table 2).
`
`November'2002 ‘Vol. 48 Isue11 55
`
`7
`
`

`

`TABLE|
`EFFECTS OF UVC ON WOUNDS WITH MRSA:
`
`SEMIQUANTITATIVE SWAB RESULTS
`
`
`
`
`
`* Wound without MRSA was notincluded:left medial
`
`tained nonadherentyellow slough. The
`wound was approximately 0.6 cm’in size
`(see Figure 4). Semiquantitative swab cul-
`tures indicated that the ulcer contained
`MRSA.Theskin surroundingthe ulcer was
`Following Seven
`Subject Ulcer Location Before UVC
`
`
`
`on Tiesonefita.|UVTreatments. brightred, andhis third toe was swollen. He
`Case I*
`Right medial lower Heavy growth
`Light growth of
`had nonpitting edemaextending > 4 cm
`
`CERO ier)*ABARAT) around the wound, with peripheral tissue
`Case2
`Right 5* toe
`Heavy growth
`_Light growth of
`:
`9
`WEEN
`of MRSA (3+)
`MRSA (1+)
`induration between 2 cm and 4 cm extend-
`Case 3 Light growth of Occasional growth__ing less than 50% around the wound. TheLeft 3% toe
`MRSA (I+)
`of MRSA (scant)
`patient had undergoneantibiotic therapy
`before treatment with UVC consisting of
`tetracycline (250 mg qid) for 10 days.
`However, antibiotic treatment in conjunc-
`tion with standard woundcare consisting of
`saline cleansing and dry gauze dressings was
`
`unsuccessful at achieving woundclosure.
`
`TABLE 2
`WOUND APPEARANCE BEFORE AND
`AFTER UVC TREATMENT
`Using the UVC treatmentprotocol
`Subject Ulcer Location Before UVC
`Following Seven
`
`
`______Treatments UVCTreatments=described, the patient wasgiven daily, 180-
`Right medial lower
`*PSST = 38
`Case |
`*PSST = 29
`second UVCtreatments over a 7-day period.
`Left medial
`*PSST = 39
`*PSST = 31
`During the UVC treatmentperiod, the
`Right 5* toe
`*PSST = 30
`*PSST = 14
`patient continued to receive standard wound
`Left 3% toe
`*PSST = 34
`*PSST = 17
`care and antibiotic therapy (tetracycline, 500
`mg qid) for 10 days. The patient also was
`given vitamin E and acetaminophen.
`Methicillin-resistant S. aureus in this
`wound as determined using semiquantita-
`tive swabs was reduced followinga single
`treatment of UVC and remainedlow after 1 week of
`daily UVC treatments(see Table 1). Following comple-
`tion of the 7-day daily UVC treatment, the ulcer was
`closed with complete woundreepithelialization. This
`improvement in woundstatus wasreflected in a
`marked improvementin PSSTscores(see Table2).
`
`Case 2
`Case 3
`
`*The pressure sore status tool (PSST)is a pencil-and-paper tool for which
`scores are assigned on a scale of 1 to 5for 13 separate domains based on
`the appearance of the wound. Summationofscoresfrom the individual
`domains of the PSSTgives a total PSSTscore between 13 and 65, with 13
`representing a completely healed wound.
`
`Case 3
`Case 3 involves an 81-year-old man, with a medical
`history of Alzheimer’s Disease (5 years), dementia,falls,
`depression, and type 2 diabetes that was well controlled
`with diet. He had a history of developing recurring
`ulcers with infection on the plantar aspect ofhis toes,
`typically lasting months before healing. Contributing
`factors to the developmentofhis toe pressureulcers
`included: repeated pressure from walking more than 6
`hours per day, biomechanical imbalancesin the foot,
`loss of ankle muscle pump due to OAin the knees and
`previousright ankletriple arthrodesis, and bilateral
`lower extremity edema. The subject wasreceiving regu-
`lar chiropody visits for wound debridement on the
`plantar surface ofhisfeet.
`At the timeofthis study, a painful blister on hisleft
`third toe had developed into an open,infected wound
`with purulent yellow drainage. The ulcer was superfi-
`cial with no undermining, had attached edges, and con-
`
`56 OstomyWound Management
`
`Discussion
`Research into alternative nonantibiotic modalitiesis
`necessary to combat the widespread emergence of
`antibiotic-resistant bacteria such as MRSA.Ultraviolet
`light C band with a wavelength of between 200 nm and
`290 nm has been found to have bactericidal effects,
`particularly against antibiotic-resistant bacteria, as
`demonstrated in recent in vitro and in vivo experi-
`ments.”*** This present case study examinedtherole of
`UVC in reducing wound bioburden and improving
`wound status in chronic, MRSA-infected ulcers. Results
`from this case study suggest that UVC treatment can
`
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`
`
`Figure 3
`Case 2: Rightfifth toe before UVCtreatments.
`
`
`
`Figure 4
`Case 3: Left third toe before UVC treatments.
`
`decrease the relative amount of MRSA.In all three
`cases, wound bioburden decreased,clinical signs of
`infection diminished, and the wound appearance
`improved as indicated by PSSTscores. In Case 1, UVC
`treatmentresulted in the progression towards wound
`closure as marked by improved epithelialization and
`the presence ofdistinct epithelial buds. In Cases 2 and
`3, full woundclosure was achieved, characterized by
`complete reepithelialization.
`Two clinical studies examinedtheefficacy ofultravi-
`olet light (UVL), which contains type A, B, and C wave-
`lengths, in the treatment of chronic wounds. Wills et
`al* demonstrated in a randomized, controlled study
`that patients with superficial pressure ulcers, some of
`which wereinfected, healed faster when treated with
`UVLthan control subjects receiving standardized
`woundcare only. Nussbaum et al” found that a com-
`bined therapy of ultrasound and UVCwith standard-
`ized woundcare for individuals with pressure ulcers
`resulted in faster healing times than standardized
`wound care combined with laser. The present case
`studyis the first clinical report to documenttheeffects
`of a specific wavelength of UVC treatment on chronic
`ulcers infected with MRSA.
`This case study suggests that previous findings by
`Conner-Kerret al,” indicating that UVC hasbacterici-
`dal effects on MRSA when administered in vitro, can be
`applied to the clinical situation. The killing rates for
`MRSAfor in vitro cultures were reported to be 99.9%
`at 5 seconds and 100%at 90 seconds.” The authors
`
`found that a UVC treatmenttime of 180 seconds was
`required to producesimilar bactericidaleffects in
`chronic wounds. The optimalclinical treatment time
`and length of UVC required for a 100% killing rate of
`
`MRSA in human chronic infected woundsis still
`uncertain. Results presented in this case report suggest
`that although a single 180-second treatment of UVC
`can eliminate MRSA from chronic woundsinitially col-
`onized with light growth (1+) of MRSA, more UVC
`exposure given in subsequent UVC treatments was
`required for ulcers infected with heavy growth (3+) of
`MRSA. Furthermore, several UVC treatments given
`over a 1-month period were required to eliminate
`MRSAfrom woundscolonized with high levels of mul-
`tiple types of bacteria.
`Despite the presence of a low level of MRSA remain-
`ing in the woundsafter the completion of UVCtreat-
`ment, wound appearance markedly improved inall
`three cases and two subjects had complete woundclo-
`sure. According to Dowetal,” the presence of bacteria
`does not always indicate woundinfection. In fact, bac-
`terial infection in woundsis not only determined by
`the number of organisms present in a wound,butis
`also dependenton otherfactors, such as bacteria viru-
`lence and host resistance.”
`In Case 1, before and during UVC treatment, the
`wounds contained an antibiotic-resistant strain of S.
`aureus, MRSA;following UVC treatment protocol,
`these wounds had a moderate level (2+) of S. aureus.
`This apparent change in type of bacteria presentin
`chronic wounds following UVC treatment has been
`observed previously by this research team andalso has
`been reported by others (J. McCulloch, personal com-
`munication). The mechanism for this change in swab
`results from primarily MRSA to S. aureus is uncertain;
`however, it can be postulated that UVC hastheability
`to render MRSA moresusceptible to oral antibiotics.
`The semiquantitative swabis the preferred method
`
`November 2002 Vol. 48 Issue 11 57
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`9
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`ent UVCtreatment schedule on theresults obtained in
`the present study.
`
`Limitations
`Concurrent woundcare therapies, including the uti-
`lization of oral antibiotic therapy and wounddressing
`protocols, were not standardized in this study.
`Furthermore, the woundhistory, primary etiology of
`the wound, and medical history varied greatly between
`subjects and practical issues required the frequency of
`UVCtreatmentsto be tailored to accommodate the
`patient and wounddressing protocol. The influence of
`these factors on the ability of UVC treatment to reduce
`MRSAcolonization of chronic wounds cannot be
`assessed in this case series. An additional limitation of
`the present study is the extremely small sample size.
`Results obtained from these fewindividuals do notsuf-
`ficiently represent the larger population of individuals
`with chronic woundsthat are colonized with MRSA.
`Future work involving a larger sample size is warranted.
`
`for bacterial determination in this case study becauseit
`The individual had a greater pretreatmentbacterial
`bioburden with multiple types ofbacteria, his ulcers
`is economically feasible and easily administered by
`staff. When the swabbing technique is compared with
`were present for an extended duration of time, and he
`
`tissue biopsy, Levine et al* foundalinear relationship had multiple ulcers — all of which were muchlarger
`between the swab andbiopsy counts ofviable bacteria
`than thosein either of the two other cases. Therefore,
`in the same wound:10° organisms by biopsy were
`the authors are unableto assess the influence of differ-
`equal to 10° organisms by swab culture. Herruzo-
`Cabreraet al* concludedin their study that when the
`semiquantitative swab approach wasevaluated,thefol-
`lowing were demonstrated: sensitivity of 97.8%, speci-
`ficity of 86.9%, positive predictive value of 90.7%, and
`a negative predictive value of 96.8%. The researchers
`concluded that semiquantitative cultures are useful for
`surveillance of infection and equivalent to quantitative
`biopsy cultures.
`The three patients described in this case report were
`on-and-off antibiotics numerous times. Two of these
`patients received oral antibiotics during the UVCtreat-
`ments. The prescription oforal antibiotic therapy was
`left to the discretion of the individual’s attending physi-
`cian (not the sameindividualin all three cases). As out-
`lined in a recentarticle by Sibbald etal,” oral antibi-
`otics are not always indicated for chronic wounds with
`localized infection.
`The frequency of UVC treatments administered var-
`ied for the individual cases presented in this report.
`The UVC protocol was changed based on a numberof
`practical issues, including the frequency of dressing
`changes and proximity of the patient to the wound
`treatment center, The patients described in Case 2 and
`Case 3 were both residentsof a local facility and
`received daily dressing changes. Therefore,it was feasi-
`ble to administer daily UVC treatments. The patient
`presented in Case 1 wasliving at home somedistance
`from the woundcenter, and wounddressings, including
`compression wraps, were changedless frequently. For
`this individual, the most feasible treatment protocol
`was UVCtreatments given on alternate daysovera 2-
`week period, followed by weekly UVC treatmentsfor 1
`month. The results showed that individuals who
`received more frequent UVC treatments required only
`1 week of UVC treatments to achieve complete wound
`closure; whereas, the individual who had UVCtreat-
`mentsless often required more than 6 weeks of UVC
`treatment to eradicate MRSA from the wound bed.
`However, manyotherfactors likely contributed to the
`extended UVCtreatment protocol required for Case 1.
`
`Conclusion
`In this case study involving three patients with
`chronic woundslocally infected with MRSA in whom
`previous standard woundcare and topical and oral
`antimicrobial therapy had failed, UVC treatment was
`found to reduce bacterial load andfacilitate healing.
`This case study suggests that UVC is a promising
`adjunctive therapy for chronic woundsinfected with
`antibiotic-resistant bacteria such as MRSA. However,
`only future randomized controlled trials can ascertain
`the efficacy of UVC and determine the optimal treat-
`ment dosage time and length of UVC treatment.
`Additionally, prolonged and repeated exposures to
`ultraviolet light have been associated with an increased
`risk of developing ce