[Principles of antisepsis, disinfection and sterilization]

This article aims to provide a brief review of the main concepts on which the prevention and control of infection are based. Antisepsis comprises a set of techniques aimed at the total sterilization, or at most, disinfection, removing germs that contaminate an environment. Both procedures must be preceded by an environmental cleanup in the location in which they intend to be applied. The disinfection is carried out using biocides or germicides. Antimicrobial chemicals, that have mechanisms of action and resistances very similar to antibiotics, are generating concern due to the possibility of crossing genetic information that aggravates the problem of bacterial resistance. Most biocides can act as antiseptics, and applied to skin tissue, or disinfectants on inanimate materials. The spectrum of action of germicides depends on the product itself and external controllable factors: temperature, concentration, exposure time, etc. Sterilization techniques are primarily physical, by exposing the material to steam, or sterilizing gas, using autoclaves. Major advances are the use of low temperatures with shorter exposure times, in parallel with technological advances in instrumentation in order to avoid high temperatures and high use rotations due to workload.

Acetic Acid, the active component of vinegar, is an effective tuberculocidal disinfectant

Effective and economical mycobactericidal disinfectants are needed to kill both Mycobacterium tuberculosis and non-M. tuberculosis mycobacteria. We found that acetic acid (vinegar) efficiently kills M. tuberculosis after 30 min of exposure to a 6% acetic acid solution. The activity is not due to pH alone, and propionic acid also appears to be bactericidal. M. bolletii and M. massiliense nontuberculous mycobacteria were more resistant, although a 30-min exposure to 10% acetic acid resulted in at least a 6-log10 reduction of viable bacteria. Acetic acid (vinegar) is an effective mycobactericidal disinfectant that should also be active against most other bacteria. These findings are consistent with and extend the results of studies performed in the early and mid-20th century on the disinfectant capacity of organic acids. IMPORTANCE Mycobacteria are best known for causing tuberculosis and leprosy, but infections with nontuberculous mycobacteria are an increasing problem after surgical or cosmetic procedures or in the lungs of cystic fibrosis and immunosuppressed patients. Killing mycobacteria is important because Mycobacterium tuberculosis strains can be multidrug resistant and therefore potentially fatal biohazards, and environmental mycobacteria must be thoroughly eliminated from surgical implements and respiratory equipment. Currently used mycobactericidal disinfectants can be toxic, unstable, and expensive. We fortuitously found that acetic acid kills mycobacteria and then showed that it is an effective mycobactericidal agent, even against the very resistant, clinically important Mycobacterium abscessus complex. Vinegar has been used for thousands of years as a common disinfectant, and if it can kill mycobacteria, the most disinfectant-resistant bacteria, it may prove to be a broadly effective, economical biocide with potential usefulness in health care settings and laboratories, especially in resource-poor countries.

Citric acid treatment of post operative wound infections in HIV/AIDS patients

The normal cellular immunity is required for normal wound healing. The HIV infection affects wound healing adversely. Wound infections in HIV/AIDS patients are difficult to manage because of compromised immunity. The result is delayed wound healing and increased susceptibility to wound infection. Here we report two cases of HIV positive patients who had developed the post operative wound gape, not responding to the conventional treatment, treated simply by local application of three percent citric acid ointment.

Use of a fibrin-based system for enhancing angiogenesis and modulating inflammation in the treatment of hyperglycemic wounds

The complex pathophysiology of chronic ulceration in diabetic patients is poorly understood; diabetes-related lower limb amputation is a major health issue, which has limited effective treatment regimes in the clinic. This study attempted to understand the complex pathology of hyperglycemic wound healing by showing profound changes in gene expression profiles in wounded human keratinocytes in hyperglycemic conditions compared to normal glucose conditions. In the hyper-secretory wound microenvironment of hyperglycemia, Rab18, a secretory control molecule, was found to be significantly downregulated. Using a biomaterial platform for dual therapy targeting the two distinct pathways, this study aimed to resolve the major dysregulated pathways in hyperglycemic wound healing. To complement Rab18, and promote angiogenesis eNOS was also targeted, and this novel Rab18-eNOS therapy via a dynamically controlled 'fibrin-in-fibrin' delivery system, demonstrated enhanced wound closure, by increasing functional angiogenesis and reducing inflammation, in an alloxan-induced hyperglycemic preclinical ear ulcer model of compromised wound healing.

Citric acid treatment of chronic nonhealing ulcerated tophaceous gout with bursitis

The ulceration associated with gout tophi is very difficult to treat because of impaired and halted local inflammatory response resulting from the gout treatment regimen. We report chronic nonhealing tophaceous gout with bursitis in an 80-year-old male, not responding to conventional treatment modality for months together. This nonhealing ulcer was treated successfully with local application of 3% citric acid ointment for 22 days.

Acetic acid treatment of pseudomonal wound infections--a review

PURPOSE

Pseudomonas aeruginosa is a significant cause of burn wound infections and, skin and soft tissue infections. The antiseptic management is an integral part of the management of wound infections and is essential to control wound infection. Although commonly used, concerns have been raised.

RESULTS

Available experimental data suggest that many commonly used antiseptic agents may be toxic to the cells involved in wound healing process and may affect the process of normal tissue repair. In view of this, the present review summarized the various organic acids commonly used as a substitute for antiseptics to control pseudomonal wound infections with special reference to acetic acid and their role in the process of wound healing.

CONCLUSION

Acetic acid is to be kept in mind as one of the alternatives when infection is caused by multiple antibiotic resistant strains of P. aeruginosa. At a time when bacterial resistance to antibiotics is a matter of increasing concern, the value of topical agents such as acetic acid should not be forgotten.

Simple and effective approach for the treatment of traumatic wounds in non-diabetic patients: a prospective open study

Infection is one of the most important obstacles in the wound-healing process. Conventional methods used for the treatment of wound infections have their own limitations and hence, are difficult to control. If infection is not addressed well in time, it will further increase morbidity and cost of treatment. An attempt was made to develop a simple and effective treatment modality by using citric acid as the sole antimicrobial agent to control bacterial infections of traumatic wounds. A total of 259 cases of traumatic wounds infected with a variety of bacteria were investigated for culture and susceptibility, and susceptibility to citric acid. Citric acid ointment (3%) was applied to traumatic wounds to determine its efficacy in their treatment of traumatic wounds. In a culture and susceptibility study, a total of 369 aerobic bacteria and 7 fungi were isolated, with Staphylococcus aureus (30.31%) being the most common isolate and ciprofloxacin (61.43%) being the most effective agent. All the isolates were found to be inhibited by citric acid in in vitro studies (minimum inhibitory concentration--500-2500 µg/ml). Citric acid ointment was found effective in controlling infections. Out of 259 cases, 244 (around 95%) were healed completely in 5-25 applications of 3% citric acid. As citric acid has antibacterial activity and wound-healing property; hence it is the best alternative for the treatment of traumatic wounds. Besides these properties, citric acid has no adverse effects and it is a good dressing agent.

Isolated gastric Crohn’s disease

Crohn’s disease (CD) is a chronic idiopathic inflammatory disease of gastrointestinal tract characterized by segmental and transmural involvement of gastrointestinal tract. Ileocolonic and colonic/anorectal is a most common and account for 40% of cases and involvement of small intestine in about 30%. The stomach is rarely the sole or predominant site of CD. To date there are only a few documented case reports of adults with isolated gastric CD and no reports in the pediatric population. Isolated stomach involvement is very unusual presentation accounting for less than 0.07% of all gastrointestinal CD. The diagnosis is difficult to establish in cases of atypical presentation as in isolated gastroduodenal disease. In the absence of any other source of disease and in the presence of nonspecific upper GI endoscopy and histological findings, serological testing can play a vital role in the diagnosis of atypical CD. Recent studies have suggested that perinuclear anti-neutrophil cytoplasmic antibody and anti-Saccharomycescervisia antibody may be used as additional diagnostic tools. The effectiveness of infliximab in isolated gastric CD is limited to only a few case reports of adult patients and the long-term outcome is unknown.

Tuberculous inguinal lymphadenitis with multiple discharging sinuses-an unusual presentation

We report an unusual presentation of inguinal TB lymphadenitis in a 16-years old unmarried female with multiple discharging sinuses.

Topical treatment for facial burns

BACKGROUND

Burn injuries are an important health problem. They occur frequently in the head and neck region - the area central to a person's identity, that provides our most expressive means of communication. Topical interventions are currently the cornerstone of treatment of partial-thickness burns to the face.

OBJECTIVES

To assess the effects of topical interventions on wound healing in people with facial burns of any depth.

SEARCH METHODS

We searched the Cochrane Wounds Group Specialised Register (searched 12 November 2012); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); Ovid MEDLINE (1950 to November Week 1 2012); Ovid MEDLINE - In-process & Other Non-Indexed Citations (searched November 12, 2012); Ovid EMBASE (1980 to 2012 Week 45); and EBSCO CINAHL (1982 to 9 November 2012) for relevant trials. We did not apply date or language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that evaluated the effects of topical treatment for facial burns were eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed and included the references identified by the search strategy. Included trials were assessed using a risk of bias form, and data were extracted using a standardised data extraction sheet. For dichotomous and continuous outcomes, we calculated risk ratios and mean differences, respectively, both with 95% confidence intervals (CI).

MAIN RESULTS

We included five RCTs, comprising a total of 119 participants. Two studies compared two different antimicrobial agents and three compared a biological or bioengineered skin substitute with an antimicrobial agent. All studies had small sample sizes and were at high risk of bias. Heterogeneity of interventions and outcomes prevented pooling of data. In three studies time to complete wound healing was significantly shorter for those using a skin substitute than for those using an antibacterial agent, but the quality of the evidence was low. Pain was significantly reduced with the use of skin substitutes in both studies that reported this outcome in all groups, range mean differences -2.00 (95% CI -3.82 to -0.18) to -4.00 (95% CI -5.05 to -2.95) on a 10-point scale.

AUTHORS' CONCLUSIONS

There is insufficient high quality research and evidence to enable conclusions to be drawn about the effects of topical interventions on wound healing in people with facial burns.

Treatment of lepromatous ulcers using citric acid as a sole antimicrobial agent

A prospective study was carried out to assess the role of citric acid as a sole antimicrobial agent in the management of lepromatous ulcers. Thirty-four known cases of lepromatous ulcers not responding to conventional antibiotic therapies for long duration were investigated for culture and susceptibility studies. Staphylococcus aureus (25·00%) and Klebsiella spp. (23·43%) were found to be the most common isolates. Amikacin (68·75%) and ciprofloxacin (67·18%) were found to be the most effective antimicrobial agents. Topical application of citric acid ointment resulted in complete healing in 25 (73·52%) cases. In eight cases (26·48%), there was elimination of infective agent from ulcer site and formation of healthy granulation, but no complete healing of ulcer was seen. Results indicate that citric acid is the best alternative for the effective management of lepromatous ulcers when other therapies are exhausted.

D-Amino acid oxidase-induced oxidative stress, 3-bromopyruvate and citrate inhibit angiogenesis, exhibiting potent anticancer effects

Angiogenesis is critical for cancer growth and metastasis. Steps of angiogenesis are energy consuming, while vascular endothelial cells are highly glycolytic. Glioblastoma multiforme (GBM) is a highly vascular tumor and this enhances its aggressiveness. D-amino acid oxidase (DAO) is a promising therapeutic protein that induces oxidative stress upon acting on its substrates. Oxidative stress-energy depletion (OSED) therapy was recently reported (El Sayed et al., Cancer Gene Ther, 19, 1-18, 2012). OSED combines DAO-induced oxidative stress with energy depletion caused by glycolytic inhibitors such as 3-bromopyruvate (3BP), a hexokinase II inhibitor that depleted ATP in cancer cells and induced production of hydrogen peroxide. 3BP disturbs the Warburg effect and antagonizes effects of lactate and pyruvate (El Sayed et al., J Bioenerg Biomembr, 44, 61-79, 2012). Citrate is a natural organic acid capable of inhibiting glycolysis by targeting phosphofructokinase. Here, we report that DAO, 3BP and citrate significantly inhibited angiogenesis, decreased the number of vascular branching points and shortened the length of vascular tubules. OSED delayed the growth of C6/DAO glioma cells. 3BP combined with citrate delayed the growth of C6 glioma cells and decreased significantly the number and size of C6 glioma colonies in soft agar. Human GBM cells (U373MG) were resistant to chemotherapy e.g. cisplatin and cytosine arabinoside, while 3BP was effective in decreasing the viability and disturbing the morphology of U373MG cells.

A retrospective study of 22 patients with necrotising fasciitis treated at the University Clinical Center of Kosovo (2005-2010)

Necrotising fasciitis (NF) is a destructive invasive infection of skin, subcutaneous tissue and deep fascia. The aim of the study is to determine the causative agents of NF, its localisation, predisposing factors and comorbid conditions, duration of treatment and distribution of NF in different age groups and over the years. We conducted a retrospective study including 22 patients with NF from 2005 to 2010 in the University Clinical Center of Kosovo. The data were collected and analysed from the archives and protocols of the University Clinical Center of Kosovo. The average age of patients was 56·9 years. In eight cases or 36·4% of total patients studied, NF was caused by monobacterial agents with a predominance of Pseudomonas aeruginosa (five cases or 22·7% of total infections). Polybacterial agents were responsible for NF infection in other 14 cases (63·6%). Majority of the patients had other comorbidities like diabetes, trauma and prior history of surgical interventions. Diabetes was present in 17 patients or 77·3%. The remaining five patients (22·7%) had previous trauma and recent surgical intervention. Average length of treatment was 43 days. The hospital mortality rate in our case series was 22·6%. Early identification and diagnosis of NF significantly improves outcome and reduces mortality.

Synovial sarcoma of the buttocks presenting with a non-healing wound and rapid progression after local resection: a case report

Synovial sarcoma is a malignant mesenchymal neoplasm that is frequently misdiagnosed as a benign condition because of its small size, slow growth, and well-delineated appearance. Rapid spread and early death occur rarely. Here we report a case of synovial sarcoma of the buttocks presenting with a non-healing wound and rapid progression after local resection in a 23-year-old woman. She initially found a slightly painful subcutaneous mass in the left buttock and underwent local excision. Postoperatively, she developed a non-healing wound that did not respond to conventional antibiotic therapy and local wound care, and pitting edema of the lower extremities. A magnetic resonance imaging scan revealed a large heterogeneous, irregular mass in the buttocks with regional lymph node involvement. Histological and immunohistochemical analyses suggested the diagnosis of a poorly differentiated synovial sarcoma. Her condition deteriorated dramatically shortly thereafter; she developed systemic edema and died of respiratory failure. This case suggests that synovial sarcoma may be fatal within months of recognition if improperly managed and stresses the importance of adequate pre-surgical evaluation and postoperative pathological analysis in the management of a subcutaneous mass.

Plectranthus amboinicus and Centella asiatica Cream for the Treatment of Diabetic Foot Ulcers

Effects of a topical cream containing P. amboinicus (Lour.) Spreng. (Lamiaceae) and C. asiatica (L.) Urban (Umbelliferae) were evaluated and compared to effects of hydrocolloid fiber wound dressing for diabetic foot ulcers. A single-center, randomized, controlled, open-label study was conducted. Twenty-four type 1 or type 2 diabetes patients aged 20 years or older with Wagner grade 3 foot ulcers postsurgical debridement were enrolled between October 2008 and December 2009. Twelve randomly assigned patients were treated with WH-1 cream containing P. amboinicus and C. asiatica twice daily for two weeks. Another 12 patients were treated with hydrocolloid fiber dressings changed at 7 days or when clinically indicated. Wound condition and safety were assessed at days 7 and 14 and results were compared between groups. No statistically significant differences were seen in percent changes in wound size at 7- and 14-day assessments of WH-1 cream and hydrocolloid dressing groups. A slightly higher proportion of patients in the WH-1 cream group (10 of 12; 90.9%) showed Wagner grade improvement compared to the hydrocolloid fiber dressing group but without statistical significance. For treating diabetic foot ulcers, P. amboinicus and C. asiatica cream is a safe alternative to hydrocolloid fiber dressing without significant difference in effectiveness.

A new approach to isolating siderophore-producing actinobacteria

AIMS

This study was conducted to investigate the application of 2,2'-dipyridyl as a new approach to isolating siderophore-producing actinobacteria.

METHODS AND RESULTS

Isolation of actinobacteria from soil was conducted by a soil dilution plate technique using starch-casein agar. Iron starvation was fostered by the incorporation of the iron chelator 2,2'-dipyridyl in the isolation medium. Pretreatment of the samples at an elevated temperature (40°C) ensured that the majority of nonsporulating bacteria were excluded. The survivors of this treatment were largely actinobacteria. Of the viable cultures grown in the presence of 2,2'-dipyridyl, more than 78-88% (average of three separate studies) were reported to produce siderophore-like compounds compared to 13-18% (average of three separate studies) when grown on the basic media in the absence of the chelating agent. The most prolific producers as assessed by the chrome azurol sulphate (CAS) assay were further characterized and found to belong to the genus Streptomyces.

CONCLUSIONS

Selective pressure using 2,2'-dipyridyl as an iron-chelating agent in starch-casein media increased the isolation of siderophore-producing actinobacteria compared to the unamended medium.

SIGNIFICANCE AND IMPACT OF THE STUDY

The study described represents a new approach to the isolation of siderophore-producing actinobacteria using a novel procedure that places a selection on cell population based upon the incorporation of a chelating agent in the medium.

Effectiveness of oral hygiene interventions against oral and oropharyngeal reservoirs of aerobic and facultatively anaerobic gram-negative bacilli

BACKGROUND

Aerobic and facultatively anaerobic gram-negative bacilli (AGNB) are opportunistic pathogens and continue to cause a large number of hospital-acquired infections. AGNB residing in the oral cavity and oropharynx have been linked to nosocomial pneumonia and septicemia. Although AGNB are not considered members of the normal oral and oropharyngeal flora, medically compromised patients have been demonstrated to be susceptible to AGNB colonization.

METHODS

A literature search was conducted to retrieve articles that evaluated the effectiveness of oral hygiene interventions in reducing the oral and oropharyngeal carriage of AGNB in medically compromised patients.

RESULTS

Few studies have documented the use of mechanical oral hygiene interventions alone against AGNB. Although a number of studies have employed oral hygiene interventions complemented by antiseptic agents such as chlorhexidine and povidone iodine, there appears to be a discrepancy between their in vitro and in vivo effectiveness.

CONCLUSION

With the recognition of the oral cavity and oropharynx as a reservoir of AGNB and the recent emergence of multidrug and pandrug resistance in hospital settings, there is a pressing need for additional high-quality randomized controlled trials to determine which oral hygiene interventions or combination of interventions are most effective in eliminating or reducing AGNB carriage.

The year in burns 2010

For 2010, roughly 1446 original burn research articles were published in scientific journals using the English language. This article reviews those with the most impact on burn treatment according to the Editor of one of the major journals (Burns) and his colleagues. As in previous reviews, articles were divided into the following topic areas: epidemiology, demographics of injury, wound characterisation and treatment, critical care, inhalation injury, infection, metabolism and nutrition, psychological considerations, pain and itching management, rehabilitation and long-term outcomes, and burn reconstruction. Each paper is considered very briefly, and the reader is referred to full manuscripts for details.

Multiple drug resistance patterns in various phylogenetic groups of uropathogenic E.coli isolated from Faisalabad region of Pakistan

The objective of this work was the phylogenetic characterization of local clinical isolates of uropathogenic E. coli with respect to drug resistance. A total of 59 uropathogenic E. coli responsible for community acquired urinary tract infections were included in this study. A triplex PCR was employed to segregate each isolate into four different phylogenetic groups (A, B1, B2 and D). Drug resistance was evaluated by disc diffusion method. The drugs used were ampicillin, aztreonam, cefixime, cefoperazone, ceftriaxone, cephradine among β-lactam group; amikacin, gentamicin, and streptomycin among aminoglycosides; nalidixic acid and ciprofloxacin from quinolones; trimethoprim-sulfomethoxazole, and tetracycline. Among 59 uropathogenic E. coli isolates majority belonged to phylogenetic group B2 (50%) where as 19% each belonged to groups A and B1, and 12% to group D. All the isolates were multiple drug resistant (MDR). Most effective drugs against Group A, B1, and B2 were gentamicin, amikacin and cefixime; ceftriaxone and quinolones; and ceftriaxone and amikacin, respectively. Group D isolates were found to be highly resistant to all drugs. Our results have shown emergence of MDR isolates among uropathogenic E. coli with dominance of phylogenetic group B2. However, it was found that group D isolates were though less frequent, more drug resistant as compared with group B2. Groups A and B1 were relatively uncommon. Amikacin, ceftriaxone and gentamicin were the most effective drugs in general.

Recent advances in the treatment of necrotizing fasciitis

With four types of necrotizing fasciitis (NF) now recognized, the diagnosis and management of NF becomes more challenging as physicians face more unusual pathogenic and atypical presentations. With few published guidelines and little evidence base to justify therapies, much of the literature is pragmatic or provides limited evidence with small underpowered studies and disparate case reports.

Citric acid treatment of postoperative wound in an operated case of synovial sarcoma of the knee

A 40-year-old female presented with history of swelling at the upper and middle of the left leg since 6 months was confirmed as post cancer surgery non healing wound not responding to conventional antibiotic therapy and local wound care in an operated case of synovial sarcoma of the knee, monophasic fibrous type with no lung metastasis. Post surgical non healing wound not responding to conventional therapy was treated successfully with local application of 3% citric acid ointment for 25 days.

Interventions for wound healing among diabetic patients infected with Staphylococcus aureus: a systematic review

CONTEXT AND OBJECTIVE

Staphylococcus aureus is the most frequent agent isolated in diabetic foot infections and may be associated with changes to wound healing times. The aim of this study was to perform a systematic review of the literature, including studies that assessed the efficacy of any clinical or surgical intervention, as well as oral or topical therapy for diabetic ulcers infected with S. aureus.

DESIGN AND SETTING

Systematic review with a search conducted in databases.

METHODS

We conducted a systematic review with a comprehensive search in the Lilacs, SciELO, PubMed/Medline, Old Medline, Embase and Cochrane Library databases, for articles published from 1966 to 2010. The articles selected were limited to studies on diabetic patients with wounds infected with S. aureus for whom their healing was followed up, with the use of either antibiotics or experimental treatments. Animal studies and those that did not report the wound healing, as well as review articles, were excluded.

RESULTS

Five studies that met the inclusion and exclusion criteria were analyzed.

CONCLUSIONS

There are few studies reporting the healing of wounds infected with S. aureus in diabetic patients, although this is the most commonly found pathogen in this type of wound and it frequently consists of methicillin-resistant S. aureus (MRSA). There is insufficient evidence to support early use of broad-spectrum antibiotics against MRSA to promote healing of diabetic ulcers, since antibiotic resistance may develop from such treatment. This highlights the need for further studies on the subject.

Mechanical robustness of Pseudomonas aeruginosa biofilms

Biofilms grow on various surfaces and in many different environments, a phenomenon that constitutes major problems in industry and medicine. Despite their importance little is known about the viscoelastic properties of biofilms and how these depend on the chemical microenvironment. Here, we find that the mechanical properties of Pseudomonas aeruginosa (P.a.) biofilms are highly robust towards chemical perturbations. Specifically, we observe that P.a. biofilms are able to fully regain their initial stiffness after yielding is enforced, even in the presence of chemicals. Moreover, only trivalent ions and citric acid significantly affect the biofilm elasticity, the first of which also alter the texture of the material. Finally, our results indicate that biofilm mechanics and bacteria viability inside the biofilm are not necessarily linked which suggests that targeting bacteria alone might not be sufficient for biofilm removal strategies.

Recurrent aphthous stomatitis: do we know what patients are using to treat the ulcers?

OBJECTIVES

The objectives of this study were to determine prevalence and types of treatments used by patients with recurrent aphthous stomatitis (RAS), and to study the sources of information about treatments used.

METHODS

The study was a cross-sectional survey. The participants were 530 students who had a history of RAS and were studying at the University of Jordan, Amman.

RESULTS

Of the 530 patients, 267 (50.4%) have attempted treatment of RAS. Of those who treated RAS, 86 (32.2%) have used alternative treatments (ATs). Topical anaesthetics/analgesics, antiseptic mouthwashes, and topical steroids represented 84.5% of the conventional medicines used. Of those who used ATs, 34 (39.5%) used tahini, 21 (24.4%) used salt/salt and warm water mouthrinse, and 7 (8.1%) used lemon/lemon salt. The tendency to treat RAS or not was not significantly affected by sociodemographic variables, but ATs were more significantly used by students living in rural areas. Relatives were the most frequently cited source of information about treatment (44.6%), followed by medical practitioners (22.9%), and only 9.4% sought treatment advice from dentists. Interestingly, 7% of the ATs were recommended by health care providers and 38.7% of the conventional treatments were recommended by non-health-care providers including 15 cases of topical steroids.

CONCLUSIONS

This survey revealed a high prevalence of ATs use among Jordanian patients with RAS. There is a need to educate patients with RAS on the treatment options available to reduce their distress and to improve their quality of life. Health care providers such as medical practitioners and pharmacists are frequently consulted by patients with oral lesions, so they should provide patients with better education in the diagnosis and treatment of oral diseases. Randomized clinical trials are needed to examine the potential usefulness of the commonly used ATs in this study such as tahini/sesame oil in the treatment of RAS.

Simple, effective and affordable approach for the treatment of burns infections

OBJECTIVE

The aim of the present study was to develop a simple and effective treatment modality using citric acid as a sole antimicrobial agent to control infections in burns patients not responding to conventional treatment.

METHODS

Forty-six cases with 5-60% superficial to deep burns in a study group and 20 cases with 10-70% superficial to deep burns in a control group were investigated for culture and susceptibility. The isolates in study group were further tested for susceptibility to citric acid. Three percent citric acid gel was applied to burns wounds in study group; however, the control group received conventional antibiotic therapy and local wound care.

RESULTS

In the control group, Pseudomonas aeruginosa (44.44%) and Staphylococcus aureus (33.33%) were found to be the commonest bacterial isolates and, amikacin and ciprofloxacin (40.74%) were found to be most effective antibacterial agents. In study group, P. aeruginosa (30.48%) and S. aureus (23.17%) were found to be the commonest bacterial isolates. Ceftazidime (52.43%), ciprofloxacin (47.56%) and amikacin (46.34%) were found to be most effective antibacterial agents. Application of citric acid to burn wounds resulted in complete healing in 40 (86.95%) cases in 7-25 applications (P value 0.145); however, in a control group conventional antibiotic therapy and local wound care resulted in complete healing in nine (45%) patients only.

CONCLUSIONS

Citric acid treatment was found effective in the control of burns infections as compared to conventional therapy. Complete healing in 86.95% cases as compared to 45% in a control group indicates that citric acid is nontoxic, economical and quite effective in the management of burns infections.

Citric acid treatment of necrotizing fasciitis: a report of two cases

Necrotizing fasciitis is a destructive invasive infection of skin, subcutaneous tissue and deep fascia, with relative sparing of muscle. It is a life-threatening condition. Here we report two cases of necrotizing fasciitis, which were not responding to conventional antibiotic therapy and local wound care after aggressive debridement. These two cases were treated simply by local application of 3% citric acid. Thus, citric acid was used to compliment wound management following surgical treatment with antibiotics.

Salvaging diabetic foot through debridement, pressure alleviation, metabolic control, and antibiotics

There is a fatalist perception of diabetic foot because the argument of "small-vessel disease" prevails. This is the report of a cohort study of patients facing a formal recommendation for major foot amputation to assess how many can be saved with a conventional treatment, defined as debridement, pressure alleviation, metabolic control, and antibiotics. The primary efficacy measurement was the salvage of the limb at the follow-up visit between 25 and 35 days after the first consultation. The secondary efficacy measurement was the subsequent epithelization of the ulcerative lesions, following patients for up to 270 days. The cohort consisted of 105 type 2 diabetic patients; 87 (83%) had severe lesions. A total of 71 patients (68%) required hospitalization. By the intention-to-treat analysis, 89 patients (85%) avoided major amputation. A total of 88 patients were evaluated for complete epithelization, reaching median success by day 120. Overall, 51 patients (49%) underwent minor amputations. It was concluded that there is a high rate of unnecessary major foot amputations, because a diabetic foot can be salvaged across the continuum of severity when patients receive care in a multidisciplinary wound clinic.

A simple and effective approach for the treatment of diabetic foot ulcers with different Wagner grades

Diabetic foot infections are the major cause of morbidity. Infection is the common sequel of diabetic foot ulceration that leads to delayed wound healing. These infections are difficult to control. If not addressed well in time, they may lead to amputation of foot. An attempt has been made to develop simple and effective treatment modality by using citric acid as a sole antimicrobial agent to control diabetic foot infections not responding to conventional treatment. Hundred and fifteen cases of diabetic foot ulcers of different Wagner grades infected with a variety of bacteria were investigated for culture and susceptibility, and susceptibility to citric acid. Citric acid gel was applied to ulcer to determine its efficacy in the management of diabetic foot ulcers with different Wagner grades. Citric acid gel was found effective in the control of foot infections; especially in Wagner grades I and II, the success rate was found to be more than 94%. In Wagner grade III also, it was found effective in complete healing of ulcers without deep osteomyelitis. Citric acid treatment is effective in the control of diabetic foot infections and in successful management of diabetic foot ulcers with Wagner grades I and II, and even with Wagner grade III, without deep osteomyelitis.

Psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease

OBJECTIVE

The psychological and coping responses of the noninfected community towards infectious disease outbreaks are relatively understudied. This cross-sectional study sought to determine the prevalence of severe acute respiratory syndrome (SARS)-related psychiatric and posttraumatic morbidities and associated coping styles within the general population visiting community health care services.

METHODS

It was conducted on individuals attending community polyclinics in Singapore within the first week of July 2003, 16 weeks after the first national outbreak of SARS. The General Health Questionnaire-28, Impact of Event Scale-Revised, and Brief COPE were used to determine the prevalence rates of psychiatric and posttraumatic morbidities and employed coping strategies respectively.

RESULTS

The overall response rate was 78.0%. Of the 415 community health care setting respondents, we found significant rates of SARS-related psychiatric (22.9%) and posttraumatic morbidities (25.8%). The presence of psychiatric morbidity was associated with the presence of high level of posttraumatic symptoms [adjusted odds ratio (OR) 2.26, 95% confidence interval (CI) 1.24-4.13, P=.008]. Psychiatric morbidity was further associated with being seen at fever stations (adjusted OR 1.90, 95% CI 1.08-3.34, P=.026), younger age (adjusted OR 0.97, 95% CI 0.94-0.98, P=.021), increased self blame (adjusted OR 1.67, 95% CI 1.22-2.28, P=.001), less substance use (adjusted OR 0.74, 95% CI 0.56-0.98, P=.034) and posttraumatic morbidity was associated with increased use of denial (adjusted OR 1.31, 95% CI 1.04-1.67, P=.024), and planning (adjusted OR 1.51, 95% CI 1.16-1.95, P=.002) as coping measures.

CONCLUSION

These findings could potentially inform the development of practical community mental health programs for future infectious disease outbreaks.

Emergence of Burkholderia pseudomallei and pandrug-resistant non-fermenters from southern Karnataka, India

Melioidosis has recently gained the status of an emerging disease in India. Multidrug-resistant (MDR) Gram-negative bacteria, however, are already responsible for treatment failure and mortality. In addition, pandrug-resistant (PDR) Gram-negative bacteria have emerged as a new threat to modern medicine. The treatment, clinical follow up, and outcome of 25 patients with melioidosis and 46 patients with MDR non-fermenters (Pseudomonas aeruginosa and Acinetobacter spp.) infection were documented during the period 2005 2007. Pandrug resistance status of the MDR strains was evaluated with the minimum inhibitory concentration breakpoint of colistin. Skin and soft-tissue involvement (16%), liver abscess (16%) and bone and joint involvement (16%) were the most common presentations of melioidosis in diabetic patients. The presence of septicaemia (44%) and major organ failure (48%) resulted in death. Relapse was seen in patients with inappropriate treatment. Clinical cure was observed in five cases infected with PDR strains; colistin was used in only one case. Comorbid conditions may have contributed to the high fatality (82.7%). More awareness among clinicians and laboratory staff, and environmental investigations of soil are required for accurate diagnosis and prompt treatment of melioidosis. For MDR strains, colistin is the 'last resort' and should be used with caution; resistance should be monitored both globally and locally.

A profile of drug resistance genes and integrons in E. coli causing surgical wound infections in the Faisalabad region of Pakistan

Escherichia coli are one of the leading causes of infection in wounds. Emerging multiple drug resistance among E. coli poses a serious challenge to antimicrobial therapy for wounds. This study was conducted to ascertain a baseline profile of antimicrobial resistance in E. coli isolates infecting surgical wounds. A total of 64 pus samples from hospitalized patients were screened and 29 (45.3%) were found to have E. coli, which were identified biochemically and confirmed by molecular methods. Using the disc diffusion method, antimicrobial resistance was observed toward tetracycline (100%), cefradine (100%), nalidixic acid (93.1%), ampicillin (86.2%), gentamicin (86.2%), cefixime (82.8%), ceftriaxone (82.8%), aztreonam (82.8%), ciprofloxacin (75.9%), streptomycin (72.4%), cefoperazone (65.5%), chloramphenicol (58.6%) and amikacin (58.6%). In an effort to find relevant genes, 11 different genes were targeted by PCR. Among these, the mutated gyrA gene was found to be the most prevalent (82.8%), followed by the TEM (72.4%), catP (68.9%), catA1 (68.9%), tetB (62.1%), blt (58.6%), bla(CTX-M-15) (27.6%), bla(TEM) (20.7%), bla(OXA) (17.2%), tetA (17.2%) and aadA1 (13.8%) genes. The presence of integrons was also studied among these isolates. The prevalence of class 1 integrons was the highest (44.8%), followed by class 2 (27.6%). Three (10.3%) isolates carried both class 1 and class 2 integrons (first report from E. coli infecting wounds). The high incidence of integrons points toward their facilitation for carriage of antimicrobial resistance genes; however, in nearly 37% isolates, no integrons were detected, indicating the significance of alternative mechanisms of gene transfer. Another salient finding was that all isolates were multidrug-resistant E. coli.

A simple and effective approach for the treatment of chronic wound infections caused by multiple antibiotic resistant Escherichia coli

Antimicrobial resistance is a major problem in present-day therapy. Despite the advent of newer antimicrobial agents with a broad spectrum of activity, multiple antibiotic resistant pathogens are difficult to eliminate from infected sites. The present study was carried out to develop an approach, using citric acid as a sole antimicrobial agent, for the treatment of chronic wound infections caused by multiresistant Escherichia coli (MAREC). A total of 34 cases of chronic wound infections yielding MAREC isolates on culture were studied. The antibacterial effect of citric acid against MAREC was evaluated in vitro by broth dilution method. Three percent citric acid gel was applied to each wound once daily until it healed completely. All 34 isolates were inhibited by citric acid with minimum inhibitory concentrations in the range of 1500-2000 microg/ml. Topical application of 3% citric acid to wounds 7-42 times resulted in elimination of MAREC from infected sites and successful healing of wounds in all 34 patients. This treatment modality was simple, reliable, non-toxic and effective. Hence, the use of citric acid for the cost-effective treatment of wound infections caused by MAREC is recommended.

Biofilm reduction by a new burn gel that targets nociception

AIMS

To compare the ability of an amorphous first aid topical gel containing vinegar, citric acid and EDTA (RescuDerm(TM); RESC) and various derivative formulations to eradicate Pseudomonas aeruginosa (PSEUD) and Staphylococcus epidermidis (STAPH) biofilms.

METHODS AND RESULTS

24-h biofilms prepared using the Minimum Biofilm Elimination Concentration (MBEC) Assay System were exposed for 4 or 24 h to the different gel formulations. Citric acid-free, acetic acid-free or acetic acid-free/sodium acetate-supplemented RESC gels reduced PSEUD and STAPH biofilm formation as effectively as RESC. Substituting the weak organic acids with equivalent concentrations of glacial acetic acid reduced the effectiveness of gel against PSEUD and STAPH biofilms by half, but viable bacterial counts still remained below 4 log(10) CFU/peg. Removal of gelling agent and/or EDTA enhanced efficacy against PSEUD but not STAPH biofilms. An acidified placebo gel formulation generated an only marginal bactericidal effect compared to that of RESC.

CONCLUSIONS

RESC is a promising new antimicrobial agent. Its weak organic acid content, rather than merely acidic pH, mediates its considerable in vitro bactericidal efficacy against bacterial biofilms.

SIGNIFICANCE AND IMPACT OF THE STUDY

These data, taken together with the observation that RescuDerm possesses broad in vitro bactericidal activity against other pathogen species, suggest the potential usefulness of this product for controlling biofilm formation on a variety of cutaneous traumatic and surgical wounds.

Intestinal parasitism and Vibrio cholerae infection among diarrhoeal patients in Kolkata, India

In this study, we have analysed the epidemiological significance of the concurrent infections caused by Vibrio cholerae and intestinal parasites among different age groups of hospitalized diarrhoeal patients in Kolkata. A total of 3556 stool samples collected during 1996-2004 were screened for vibrios and parasites. The seasonality of V. cholerae and parasitic infections were studied in detail. The detection rates for Ascaris lumbricoides and Giardia lamblia infection were more than for the hookworm, Trichuris trichiura and Entamoeba histolytica. V. cholerae O1 was identified as the predominant serogroup among diarrhoeal patients. The highest rates for V. cholerae infection were in the 2-5 years age group and combined infection of V. cholerae and parasites was recorded among children aged between 2 and 10 years.

Management of bioburden with a burn gel that targets nociceptors

AIM

To assess the effectiveness of RescuDerm, an amorphous, water-soluble burn gel in controlling Pseudomonas aeruginosa growth in rat full-thickness wounds contaminated with 10(3), 10(5) or 10(7) CFU/g tissue.

METHOD

Wounds were treated daily for 72 hours with a placebo gel, a 5% w/w mafenide acetate gel (MAF), or with four modalities of RescuDerm application.

RESULTS

All RescuDerm treatments were equally effective within 24 hours in preventing further Pseudomonas aeruginosa growth in wounds contaminated with 10(3) CFU/g tissue. Pseudomonas aeruginosa levels remained at or below this baseline count for 72 hours in all but one of the RescuDerm treatments. The bioburdens in MAF-treated wounds were negligible, averaging 0.14 +/- 0.09 log10 CFU/g tissue. While RescuDerm and MAF remained bacteriostatic in wounds contaminated with 10(5) CFU/g tissue, this property disappeared at higher bioburdens.

CONCLUSION

RescuDerm can be used for the management of cutaneous injuries sustained in environments deemed marginally or moderately contaminated. Heavily contaminated wounds would require irrigation prior to application to reduce their bioburden below 10(5) CFU/g tissue.

In vitro bactericidal efficacy of a new sun- and heat burn gel

We assessed the in vitro bactericidal efficacy of a new sunburn gel (Rescudermtrade mark; RESC) against planktonic and sessile Pseudomonas aeruginosa (PSEUD) and Staphylococcus epidermidis (STAPH). While PSEUD levels were 4log(10) lower than those of STAPH within 24h of adding RESC to contaminated nutrient broths, all bacterial counts were comparable by 48h. PSEUD and STAPH levels were then measured after applying either a single or three consecutive aliquots of RESC to polyurethane sponges. Gel was removed after 5 or 20min, or left on for 72h. Bacterial counts in placebo-treated sponges had plateaued by 24h to values above 9log(10)CFU/mL. In contrast, six out of seven of the RESC application modalities reduced bacterial levels below 4log(10)CFU/mL for 72h. RESC remained effective against STAPH despite up to a 24h treatment delay, irrespective of the number of applications. Repeated RESC applications were required to maintain PSEUD below 4log(10)CFU/mL when the delay exceeded 7h. These data demonstrate the differential susceptibility of planktonic and sessile bacteria to RescuDermtrade mark. This product might be a good candidate for reducing the opportunity for wound infection, especially in burns.

Melioidosis: epidemiology, pathophysiology, and management

Melioidosis, caused by the gram-negative saprophyte Burkholderia pseudomallei, is a disease of public health importance in southeast Asia and northern Australia that is associated with high case-fatality rates in animals and humans. It has the potential for epidemic spread to areas where it is not endemic, and sporadic case reports elsewhere in the world suggest that as-yet-unrecognized foci of infection may exist. Environmental determinants of this infection, apart from a close association with rainfall, are yet to be elucidated. The sequencing of the genome of a strain of B. pseudomallei has recently been completed and will help in the further identification of virulence factors. The presence of specific risk factors for infection, such as diabetes, suggests that functional neutrophil defects are important in the pathogenesis of melioidosis; other studies have defined virulence factors (including a type III secretion system) that allow evasion of killing mechanisms by phagocytes. There is a possible role for cell-mediated immunity, but repeated environmental exposure does not elicit protective humoral or cellular immunity. A vaccine is under development, but economic constraints may make vaccination an unrealistic option for many regions of endemicity. Disease manifestations are protean, and no inexpensive, practical, and accurate rapid diagnostic tests are commercially available; diagnosis relies on culture of the organism. Despite the introduction of ceftazidime- and carbapenem-based intravenous treatments, melioidosis is still associated with a significant mortality attributable to severe sepsis and its complications. A long course of oral eradication therapy is required to prevent relapse. Studies exploring the role of preventative measures, earlier clinical identification, and better management of severe sepsis are required to reduce the burden of this disease.