Clinically isolated bacteria resistance to silver-based wound dressings.

OBJECTIVE: Silver has become a global treatment option with the US Food and Drug Administration providing marketing clearance for many silver-impregnated wound dressings and topical agents. However, the increased use of silver-based products across medical disciplines has raised questions concerning the development of acute silver resistance. In this study, the efficacy of previously identified silver-resistant clinical bacteria (Klebsiella pneumoniae and Enterobacter cloacae) against a variety of commercially available silver-based wound dressings was further investigated. METHOD: To further explore the clinical significance of these isolates, multiple time-course and repeat-challenge assays were conducted with nine dressings using a panel of silver-resistant and silver-sensitive microorganisms. Silver-impregnated dressings were ranked by silver species, quantity of silver and overall efficacy. RESULTS: Both silver-resistant strains were largely unaffected and exhibited phenotypic resistance even when exposed to the high silver concentrations found in commercially available wound dressings. In stark contrast, the majority of the dressings were able to maintain a high degree of efficacy over the course of 72 hours and during repeated bacterial challenges against silver-sensitive microorganisms. CONCLUSION: Our findings provide additional evidence that clinically significant silver-resistance has emerged in the clinical setting. Such resistant microbes are capable of sustained silver resistance against a wide variety of silver adjuvants. These findings suggest that the further development and dissemination of these resistance mechanisms could significantly impact current practices in wound healing.

Moral distress in physicians and nurses: Impact on professional quality of life and turnover.

OBJECTIVE: The purpose of this study was to investigate moral distress (MD) and turnover intent as related to professional quality of life in physicians and nurses at a tertiary care hospital. METHOD: Health care providers from a variety of hospital departments anonymously completed 2 validated questionnaires (Moral Distress Scale-Revised and Professional Quality of Life Scale). Compassion fatigue (as measured by secondary traumatic stress [STS] and burnout [BRN]) and compassion satisfaction are subscales which make up one's professional quality of life. Relationships between these constructs and clinicians' years in health care, critical care patient load, and professional discipline were explored. RESULTS: The findings (n = 329) demonstrated significant correlations between STS, BRN, and MD. Scores associated with intentions to leave or stay in a position were indicative of high verses low MD. We report highest scoring situations of MD as well as when physicians and nurses demonstrate to be most at risk for STS, BRN and MD. Both physicians and nurses identified the events contributing to the highest level of MD as being compelled to provide care that seems ineffective and working with a critical care patient load >50%. CONCLUSION: The results from this study of physicians and nurses suggest that the presence of MD significantly impacts turnover intent and professional quality of life. Therefore implementation of emotional wellness activities (e.g., empowerment, opportunity for open dialog regarding ethical dilemmas, policy making involvement) coupled with ongoing monitoring and routine assessment of these maladaptive characteristics is warranted. (PsycINFO Database Record

Diabetic Wounds Exhibit Decreased Ym1 and Arginase Expression with Increased Expression of IL-17 and IL-20.

Objective: Impaired wound healing in diabetic (DB) patients is a significant health problem; however, the roles that cytokines and innate immune cells contribute to this impaired healing are not completely understood. Approach: A mouse model was used to compare the innate immune response during DB and normal wound healing. Two 5-mm full-thickness wounds were created on the dorsal skin of BKS.Cg-m+/+Leprdb/J (DB) and C57BL/6 (wild-type) mice. Innate immune cell markers and cytokine mRNA levels were measured in wound biopsies during the first week of healing. Results: Innate immune cell influx (typified by the Gr-1 neutrophil marker and the Ym1 macrophage marker) was delayed in the DB wounds. Expression of the M2 macrophage-related genes, Ym1 and arginase 1, was significantly reduced in the DB wounds. PCR array analysis demonstrated altered cytokine expression in DB wounds. Most prominently, both interleukin (IL)-17 and IL-20 mRNA levels were significantly increased in the DB wounds. Innovation: This is the first study to identify increased levels of IL-17 and IL-20 in DB wounds. These cytokines are also elevated in the inflammatory skin disorder, psoriasis; thus, they may be potential therapeutic targets to aid in DB wound healing. Conclusion: The entire cytokine profile of DB wounds over the course of healing is not completely understood. This study suggests that the IL-17 and IL-20 families of cytokines should be further analyzed in the context of DB wound healing.

Management of Tissue Loss After Agkistrodon Snakebite: Appropriate Use of Crotalidae-Fab Antivenin.

Although initially created for the treatment of rattlesnake (genus: Crotalus) bites, Crotalidae-Fab antivenin is used to treat many different pit viper envenomations. However, the efficacy of Crotalidae-Fab in preventing tissue loss from copperhead (Agkistrodon contortrix) or cottonmouth (Agkistrodon piscivorus) snakebites remains unclear. Recent reports show that Agkistrodon-related bites rarely require treatment beyond simple observation and pain control. The purpose of this study was to examine the amount of tissue loss in patients who received Crotalidae-Fab compared with those who did not after an Agkistrodon bite. After institutional review board approval, a retrospective study was completed at a Level 1 trauma center. Between 2009 and 2013, a total of 57 snakebites were identified. Of the 57 bites, the snake species was documented in 36 cases including 31 copperheads, 1 cottonmouth, and 4 rattlesnakes. The other 21 bites were from unknown or nonvenomous species. Of the 32 Agkistrodon-related bites, 15 patients received Crotalidae-Fab (average of 3 vials administered) and 17 did not receive Crotalidae-Fab. None of the 32 patients, regardless of treatment option, had tissue loss or required surgical interventions. Only 1 patient received Crotalidae-Fab and debridement of a vesicle associated with the bite. No clinically significant differences were observed between the groups. These findings support previous literature that failed to show added benefit of Crotalidae-Fab treatment for Agkistrodon bites beyond patient comfort and pain control. Evaluation of current protocols for Agkistrodon envenomations is warranted. Snakebite wound education in trauma physicians and nurses may decrease unnecessary use of antivenom medication.

Unprecedented Silver Resistance in Clinically Isolated Enterobacteriaceae: Major Implications for Burn and Wound Management.

Increased utilization of inorganic silver as an adjunctive to many medical devices has raised concerns of emergent silver resistance in clinical bacteria. Although the molecular basis for silver resistance has been previously characterized, to date, significant phenotypic expression of these genes in clinical settings is yet to be observed. Here, we identified the first strains of clinical bacteria expressing silver resistance at a level that could significantly impact wound care and the use of silver-based dressings. Screening of 859 clinical isolates confirmed 31 harbored at least 1 silver resistance gene. Despite the presence of these genes, MIC testing revealed most of the bacteria displayed little or no increase in resistance to ionic silver (200 to 300 µM Ag(+)). However, 2 isolates (Klebsiella pneumonia and Enterobacter cloacae) were capable of robust growth at exceedingly high silver concentrations, with MIC values reaching 5,500 µM Ag(+). DNA sequencing of these two strains revealed the presence of genes homologous to known genetic determinants of heavy metal resistance. Darkening of the bacteria's pigment was observed after exposure to high silver concentrations. Scanning electron microscopy images showed the presence of silver nanoparticles embedded in the extracellular polymeric substance of both isolates. This finding suggested that the isolates may neutralize ionic silver via reduction to elemental silver. Antimicrobial testing revealed both organisms to be completely resistant to many commercially available silver-impregnated burn and wound dressings. Taken together, these findings provide the first evidence of clinical bacteria capable of expressing silver resistance at levels that could significantly impact wound management.

Hospital hand hygiene compliance improves with increased monitoring and immediate feedback.

BACKGROUND: Health care-associated infections are serious complications impacting 2 million patients and accounting for approximately 100,000 deaths per year. In the present study, we evaluated the effectiveness of a new hand hygiene monitoring program (HHMP) and measured the sustainability of this effectiveness over a 1-year period. METHODS: The HHMP consisted of 4 key components: extensive education, conspicuous and visible monitors, immediate feedback concerning compliance to health care workers, and real-time data dissemination to leadership. The HHMP was implemented in 2 hospital care units. Two different, but similar, departments served as controls, and hand hygiene compliance was monitored via the "secret shopper" technique. All 4 departments were followed for 12 months. RESULTS: Both experimental departments showed statistically significant increases in hand hygiene compliance. Experimental department 1 increased compliance from 49% to an average of 90%, and experimental department 2 increased compliance from 60% to an average of 96%. Both experimental departments were able to sustain these results for at least 6 months. Compliance rates were significantly higher in the experimental departments compared with the control departments. No significant changes were seen in the control departments. CONCLUSIONS: These finding suggest that continuous monitoring by salient observers and immediate feedback are critical to the success of hand hygiene programs.

Mucormycosis: a rare fungal infection in tornado victims.

This article reviews four immunocompetent patients who developed a rare fungal infection, mucormycosis, secondary to multiple traumatic injuries sustained during an EF-5 tornado in Joplin, MO. Commonly found in soil and decaying organic matter, mucorales are fungi associated with soft tissue and cutaneous infections. Onset of this fungal infection can occur without clinical signs, presenting several days to several weeks after injury, delaying diagnosis. A multidisciplinary treatment approach including aggressive antifungal therapy and aggressive surgical debridement is critical. This diagnosis should be considered in all patients presenting with injuries sustained from high-velocity embedment of debris such as natural disasters or explosions. We present four cases of mucormycosis, species Apophysomyces trapeziformis. Data reported includes predisposing factors, number of days between injury and diagnosis of mucormycosis, surgical treatment, antifungal therapy, outcomes, and potential risk factors that may have contributed to the development of mucormycosis.

Effectiveness and cost of failure mode and effects analysis methodology to reduce neurosurgical site infections.

Mercy Hospital Springfield is a tertiary care facility with 32 000 discharges and 15 000 inpatient surgeries in 2011. From June 2009 through January 2011, a stable inpatient elective neurosurgery infection rate of 2.15% was observed. The failure mode and effects analysis (FMEA) methodology to reduce inpatient neurosurgery infections was utilized. Following FMEA implementation, overall elective neurosurgery infection rates were reduced to 1.51% and sustained through May 2012. Compared with baseline, the post-FMEA deep-space and organ infection rate was reduced by 41% (P = .052). Overall hospital inpatient clean surgery infection rates for the same time frame did not decrease to the same extent, suggesting a specific effect of the FMEA. The study team believes that the FMEA interventions resulted in 14 fewer expected infections, $270 270 in savings, a 168-day reduction in expected length of stay, and 22 fewer readmissions. Given the serious morbidity and cost of health care-associated infections, the study team concludes that FMEA implementation was clinically cost-effective.

Ten "tips and tricks" to provide trauma care without residents.

The utilization of medical students, residents, and fellows within the orthopaedic trauma team helps alleviate workload demands. However, many nonacademic hospitals lack these clinical resources. Therefore, orthopaedic trauma surgeons often must be creative in developing alternative methods to better manage time, staff, and patients. Incorporating midlevel providers and maximizing surgical technician assistance are favorable for both the hospital and the patient. In addition, using currently available medical devices in unique and innovative ways can help simplify patient procedures and optimize care. The purpose of this article is to detail precise tips and tricks for overcoming challenges observed during orthopaedic trauma cases when residents are unavailable.

Silver dressings improve diabetic wound healing without reducing bioburden.

UNLABELLED: Introduction. Silver dressings are widely used in the treatment of chronic wounds to reduce bacterial bioburden. However, little is known about the mechanism of silver ions on the healing process. In this study, a mouse model of wound healing was used to examine the effect of silver dressings in normal and diabetic wounds. METHODS: Two 5-mm full-thickness wounds were created on the dorsal skin of diabetic BKS.Cg- m+/+Leprdb/J mice (experimental group) and wild type C57BL/6 mice (control group), and treated with either a silver or gauze dressing. Measurement of wound areas by digital planimetry demonstrated faster healing in the silver-treated wounds of both diabetic and control mice. RESULTS: Quantitative bacterial cultures showed a reduction of bioburden in silver-treated wounds in wild type mice. Unexpectedly, there was no decrease in bioburden in the silver-treated diabetic wounds compared to the control diabetic wounds, despite improved healing in the silver-treated diabetic wounds. Staphylococcus xylosus, a known biofilm producer, was the only bacteria identified in all the wounds. In vitro studies showed S. xylosus produced biofilms faster in higher glucose environments; this may explain the increased bioburden in the wounds in diabetic mice compared to wild type mice. CONCLUSION: The results demonstrate improved healing and reduced bioburden in normal wounds with silver dressings. In contrast, silver dressings improved healing in diabetic wounds despite no effect on bioburden, suggesting silver may have beneficial effects in addition to its antimicrobial properties.

The prevalence of phenotypic silver resistance in clinical isolates.

UNLABELLED: Research has shown silver to be an effective antimicrobial agent against bacteria, virus, yeast, and fungi. Due to the increased use of silver-based wound products during the past decade, concerns of widespread silver resistance have been raised.1 The purpose of this study was to assess the prevalence of phenotypic silver resistance in clinical isolates. METHODS: A total of 130 different microorganism strains were collected from patients admitted to a tertiary care hospital. To determine phenotypic silver resistance, a corrected zone of inhibition (CZOI) test was used. The isolate (0.1 mL) was streaked on nutrient agar in 3 directions to form a confluent lawn. A silver dressing and a control gauze dressing were placed on the lawn and incubated for 24 hours. The CZOI was determined by averaging the zone of clearance in both directions across the dressing and then subtracting the dressing size. Corrected zone of inhibition tests were conducted in duplicate. To confirm the silver dressing killed the microorganism and did not simply hinder bacterial growth, a culture was taken from underneath each silver dressing and plated separately. RESULTS: All of the isolates showed no growth when tested against the silver-based dressing. The CZOI values ranged between 0.0 mm and 7.25 mm. No growth was observed in the secondary culture from underneath the dressing, indicating the silver dressing was bactericidal for all 130 isolates tested and not simply bacteriostatic. The control gauze dressing did not show any antimicrobial properties. CONCLUSION: The threat of widespread silver resistance in clinical isolates remains low. However, continued monitoring for silver resistance should be maintained.

A clinical trial to investigate the effect of silver nylon dressings on mediastinitis rates in postoperative cardiac sternotomy incisions.

Mediastinitis is a rare but serious postoperative complication of cardiac surgery that increases mortality rates, hospital length of stay, and medical costs. A clinical trial was conducted to investigate whether the type of postoperative surgical dressing (silver nylon or standard gauze) affects the rate of mediastinal infections. The sample consisted of 1,600 surgical cardiac patients. Infection rates in the standard gauze group (control, n = 1,235) were collected retrospectively from 24 months of infection control records. In the prospective treatment arm of the study, the wounds of all consecutive surgical patients (n = 365) were covered with a silver nylon dressing and patients were assessed during the 3-week postoperative visit. Thirteen (13) patients in the control group (1%) and none of the patients in the treatment group developed mediastinitis (chi2 [1, N = 1,600] = 3.88, P <0.05). Study findings support the need for a large, prospective, controlled clinical study to confirm the effects of these dressings on mediastinitis, resultant morbidity, and costs of care.

Alteration in prehospital drug concentration after thermal exposure.

OBJECTIVE: The aim of the study was to determine the remaining concentration of 23 commonly carried emergency medical services medications used in the United States after they have experienced thermal extremes that have been documented in the prehospital environment for a period of 1 month. METHODS: Pharmaceuticals were thermally cycled (-6 degrees C and 54 degrees C) every 12 hours and then assayed by high-performance liquid chromatography. RESULTS: Eight (35%) of 23 prehospital pharmaceuticals revealed ending concentrations of less than 90% with strong correlation to thermal exposure time. These included lidocaine, diltiazem, dopamine, nitroglycerin, ipratropium, succinylcholine, haloperidol, and naloxone. CONCLUSION: A decrease in concentration was found to be statistically significant in 8 (35%) of 23 commonly carried emergency medical services pharmaceuticals. These results provide new information and perspective regarding stability of emergency drugs in the prehospital environment by evaluating a broad range of pharmaceuticals as well as by using thermal exposure points that have been documented in the United States.

Wound closure after split-thickness skin grafting is accelerated with the use of continuous direct anodal microcurrent applied to silver nylon wound contact dressings.

Wound healing after graft closure of excised burn wounds is a critical factor in the recovery process after thermal injury. Processes that speed time to stable wound closure should lead to improved outcomes, shorter lengths of hospital stays, and decreased complications. A randomized clinical trial to test the ability of continuous direct anodal microcurrent application to silver nylon wound contact dressings was designed. Time for wound closure after split-thickness skin grafting was observed. Thirty patients with full-thickness thermal burns were randomized into two groups. The control group received postoperative dressing care using moistened silver nylon fabric covered with gauze after tangential burn wound excision and split-thickness skin grafting. The study group received an identical protocol with the addition of continuous direct anodal microcurrent application. Time to 95% wound closure was measured using digital photography. The digital photographs were evaluated by a burn surgeon blinded to the patient's randomization. An independent t-test was used to analyze the data. The study group experienced a 36% reduction in time to wound closure (mean of 4.6 days) as compared to the control group (mean of 7.2 days). This was statistically significant at a P value of <.05. The use of continuous direct anodal microcurrent decreased time to wound closure after split-thickness skin grafting.

Validating the theoretical structure of the Treatment Self-Regulation Questionnaire (TSRQ) across three different health behaviors.

Nearly 40% of mortality in the United States is linked to social and behavioral factors such as smoking, diet and sedentary lifestyle. Autonomous self-regulation of health-related behaviors is thus an important aspect of human behavior to assess. In 1997, the Behavior Change Consortium (BCC) was formed. Within the BCC, seven health behaviors, 18 theoretical models, five intervention settings and 26 mediating variables were studied across diverse populations. One of the measures included across settings and health behaviors was the Treatment Self-Regulation Questionnaire (TSRQ). The purpose of the present study was to examine the validity of the TSRQ across settings and health behaviors (tobacco, diet and exercise). The TSRQ is composed of subscales assessing different forms of motivation: amotivation, external, introjection, identification and integration. Data were obtained from four different sites and a total of 2731 participants completed the TSRQ. Invariance analyses support the validity of the TSRQ across all four sites and all three health behaviors. Overall, the internal consistency of each subscale was acceptable (most alpha values >0.73). The present study provides further evidence of the validity of the TSRQ and its usefulness as an assessment tool across various settings and for different health behaviors.