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LL’’antibioticoterapia nei protocolli antibioticoterapia nei protocolli
di trattamento delle ulcere cutaneedi trattamento delle ulcere cutanee
L. BerrinoL. Berrino
The reasons for using topical rather than oral therapy include the
reduced risk of systemic side effects, the avoidance of resistance
selection in the gut microflora, the higher achievable concentration of
antibiotic at the site of action and the overall usage of less drug.
Opinions regarding the clinical efficacy of topical antibiotics are
conflicting, and for most indications alternative oral therapies are
available.
It is well known that many antibiotics, when used topically, especially
for prolonged periods, select for antibiotic-resistant staphylococci at the
skin surface.
Drugs Exp Clin Res. 1990;16(8):423-33
Topical antibiotic therapy: current status and future prosp ects .Eady EA , Cove JH .Department of Microbiology, University of Leeds, UK.
J Antimicrob Chemother. 1986 Feb;17(2):135-7.
The effect of antiseptics and topical antimicrobial s on wound healing.Leaper DJ , Simpson RA .
From the Family Physicians Inquiries Network
Do topical antibiotics improve wound healing?Sabina Diehr, MDAndrew HampBarbara Jamieson, MLS Medical College of Wisconsin, MilwaukeeDal Sito www.jfponline.com pubblicato nel Febbraio 2007
The use of topical triple-antibiotic ointments significantly
decreases infection rates in minor contaminated wounds
compared with a petrolatum control. Plain petrolatum
ointment is equivalent to triple-antibiotic ointments for sterile
wounds as a post-procedure wound dressing (strength of
recommendation [SOR]: A, based on randomized controlled
trials [RCTs]).
From the Family Physicians Inquiries Network
Do topical antibiotics improve wound healing?Sabina Diehr, MDAndrew HampBarbara Jamieson, MLS Medical College of Wisconsin, MilwaukeeDal Sito www.jfponline.com pubblicato nel Febbraio 2007
Mupirocin cream is as effective as oral cephalexin in the treatment
of secondarily infected minor wounds and, because of better
tolerability, is the treatment of choice for the prevention and
treatment of Staphylococcus aureus and Staphylococcus pyogenes
infections. Emerging resistance, including methicillin-resistant S
aureus (MRSA), makes it prudent to check for clinical response in
24 to 48 hours.
From the Family Physicians Inquiries Network
Do topical antibiotics improve wound healing?Sabina Diehr, MDAndrew HampBarbara Jamieson, MLS Medical College of Wisconsin, MilwaukeeDal Sito www.jfponline.com pubblicato nel Febbraio 2007
Major contaminated wounds requiring parenteral
antibiotics do not appear to additionally benefit from
topical antibiotics (SOR: A, based on RCTs). Topical
antibiotics may also aid in the healing of chronic wounds
(SOR: B, based on a systematic review of low-quality
RCTs).
ClinClin InfectInfect DisDis. 2008 . 2008 DecDec 15;47(12):153715;47(12):1537--4545
Topical versus Systemic Antimicrobial Therapy for Treating MildlTopical versus Systemic Antimicrobial Therapy for Treating Mildly y
Infected Diabetic Foot Ulcers:Infected Diabetic Foot Ulcers: RandomizedRandomized, , ControlledControlled, , DoubleDouble--
BlindedBlinded,,Multicenter Trial of Multicenter Trial of PexigananPexiganan CreamCreamBenjamin A. Lipsky,1,2 Kenneth J. Holroyd,3 and Michael Zasloff4
1Veterans Affairs Puget Sound Health Care System and 2University of Washington School of Medicine, Seattle; 3Vanderbilt University School of
Medicine, Nashville, Tennessee; and 4Georgetown University School of Medicine, Washington, DC
Topical antimicrobial therapy of infected diabetic foot ulcers can focus
on the wound and avoid the adverse effects of systemic anti-infective
agents. We compared the efficacy of outpatient treatment using an
investigational topical antimicrobial peptide( 22- amino acid synthetic
analogue of the peptide magainin II), pexiganan acetate cream, with the
efficacy of systemic therapy using an oral fluoroquinolone antibiotic,
ofloxacin, for mildly infected diabetic foot ulcers.
TopicalTopical pexigananpexiganan mightmight bebe anan effectiveeffective alternative alternative toto oraloral antibioticantibiotic
therapytherapy in in treatingtreating diabeticdiabetic patientspatients withwith a a mildlymildly infectedinfected footfoot ulcerulcer, ,
and and mightmight reduce the reduce the riskrisk ofof selectingselecting antimicrobialantimicrobial--resistantresistant bacteriabacteria..
Canadian Family Physician • Le Médecin de famille cana dien d VOL 5 ����: OCTOBER • OCTOBRE 2005
Approach to infected skin ulcersChristopher Frank, MD, CCFP Imaan Bayoumi, MD, CCFP Claire Westendorp, BNSC, RN
Bacteria in skin ulcers act along a continuum from
contamination through colonization and critical colonization to
infection. Critical colonization is not always associated with
overt signs of infection but can result in failure to heal, poor-
quality granulation tissue, increased wound friability, and
increased drainage. Iodine and silver-based dressings,
topical antibiotics, and systemic antibiotics can be
helpful.
AGENT MICROBIAL COVERAGE COMMENTS
Mupirocin (Bactroban) Gram-positive organisms • 2% cream or ointment
• Good against methicillin resistant
Staphylococcus aureus when clinically
indicated
Fusidic acid (eg, Fucidin) Staphyloccocus, Streptococcus • Comes as 2% gel, ointment, cream, or
impregnated dressing
• Contains lanolin that can cause
sensitization
Neomycin sulfate Gram-negative organisms and
Pseudomonas
• Usually comes with bacitracin and
polymyxin B sulfate (eg, Neosporin
ointment)
• Can cause sensitization
• Can be ototoxic if large areas of skin are
involved
Gentamicin (eg, Garamycin) Gram-negative organisms and
Pseudomonas
• Cream or gel
• Can be ototoxic if large areas of skin
are involved
Bacitracin (eg, Baciguent) Gram-positive organisms • Comes as ointment
• Can cause sensitization
Bacitracin, polymyxin B, and
gramicidin (Polysporin Triple
Antibiotic)
Gram-positive organisms, Gram
negative organisms, and
Pseudomonas
• Cream or ointment
Metronidazole Anaerobes • Gel is most commonly used but also is
available as cream • Useful for odour
Topical antibiotics for infected skin ulcers (Table 2)
Activity of antibiotics
TIME -DEPENDENT
CONCENTRATION -DEPENDENT
BetalactamsGlycopeptidesLincosamidesNatural macrolides
Oxazolidinones
AminoglycosidesFluoroquinolonesMetronidazole
Quinopristin/dalfopristinClarithromycinAzithromycin
Ketolides
0
40
30
10
20
Cmax/MIC
PK-PD correlationsC
once
ntra
tion
(mg/
L)
0 248 16
MIC
JM Hyatt et al., 1995
T > MIC
AUC/MIC
0,5 10
Hours
PAEBetalactams
OxazolidinonesErythromycin
AminoglycosidesFluoroquinolones
VancomycinAzithromycin
ClarithromycinKetolides
Mutant prevention concentration and mutant selection window
MIC MPCC-8-methoxy
Mutantselectionwindow
C-8-hydrogen
MIC MPC
Drug concentration (log 10)
Fra
ctio
nof
colo
nies
reco
vere
d(lo
g10
)
Cmax
MPC
MIC
Mutantselectionwindow
Time post-administration
Ser
umor
tiss
uedr
ugco
ncen
trat
ion
Drlica K and Schmitz FJ, J Chemother, 2002
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