Wound care

Question1

a ) Explain why a booster tetanus injection was given to Mrs Stone

Since Mrs . Stone was gardening , the wound that she sustained could have caught microorganisms from the soil and one of these could be Clostridium tetani , the bacteria which causes Tetanus

Tetanus is a toxigenic infection of anaerobic tissue . Under anaerobic conditions the spores germinate and the organism produces a powerful neurotoxin that prevents release of the inhibitory neurotransmitter in the spinal cord . The toxin is an A-B type toxin with a domain that binds to target nerve cells

at the interneuronal junction in the spinal chord and an active or enzymatic portion which crosses the presynaptic nerve membrane and acts internally to prevent the release of the neurotransmitter . The A or active portion of the toxin has been found to be a zinc dependent metalloprotease which cleaves proteins required for the docking and fusion of the synaptic vesicles so that these vesicles containing the neurotransmitter cannot be released . At the inhibitory interneuronal junction this causes a lack of inhibition of contraction of an opposing muscle when one muscle contracts . This causes opposing pairs of muscles to contract at the same time , leading to spastic paralysis . Typically there is a deep puncture wound that becomes contaminated with the tetanus spores that are common inhabitants of soil

In to prevent tetanus , Mrs . Stone should receive a booster According to Dr . Gary Sy (2007 , the CDC recommends that adults receive a booster vaccine every ten years , and standard care in many places is to give the booster to any patient with a puncture wound who is uncertain of when he or she was last vaccinated , or if the patient has had fewer than 3 lifetime doses of the vaccine

In a study by Fatunde Familusi (2001 , they concluded that the current Expanded Programme on Immunization (EPI ) recommended by the WHO for developing countries of which three doses of DPT are given during infancy with no provision for booster doses , is inadequate for tetanus prevention during childhood . It is suggested that a clause be added to the EPI schedule , advising two extra doses of TT between ages four to six years and 11 to 12 years (entry into primary school and secondary school , respectively ) for all children . In to ensure compliance these booster doses of TT could be made prerequisites for entry prior to schooling

b ) Describe the physiological basis of her wound observations

Mrs . Stone 's sutured wound , as stated in the case had the ff : wound edges were slightly red , small amount of hemo-serous ooze , warm to touch , and minimal swelling . The of her wound tells us that it is inflamed and this is because her wound has started healing

Wound healing starts immediately after damage has occurred , but the mechanism and speed of wound healing , and the eventual nature of the regenerated tissue , depend on the type of the wound . The three main stages of healing are inflammation , repair and maturation

According to Lee Bishop (2006 , once an injury has occurred , several events takes place , leading to the activation or release of a variety of chemicals . These chemicals are responsible for the physiological events that occur in inflammation and are called the chemical mediators of inflammation . derived from a variety of sources , the most important are histamine , kinins , prostaglandins , leukotrienes , tumor necrosis factor and complement . many of these mediators cause dilation of the arterioles in the area of damage . This causes more blood to flow into the area accounting for the redness and warmth of inflamed tissue

Some mediators increase permeability of local capillaries and post capillary venules by causing retraction of the endothelial cells of these vessels . As a result , plasma fluids and proteins , such as clotting factors , complement and antibodies , are able to move from the bloodstream into the tissue spaces . This fluid is called an exudate and its accumulation in tissue causes edema or swelling

According to Keast Orsted (2001 , Clinically inflammation , the second stage of wound healing presents as erythema , swelling and warmth often associated with pain , the classic rubor (erythema ) et tumor (swelling cum calore (heat ) et dolore (pain . This stage usually lasts up to 4 days post injury . Cessation of blood flow from the wound is achieved by vasoconstriction of the wound site and clot formation (hemostasis Immediately following injury , platelets , endothelial cells , fibrin , and fibronectin aggregate and release coagulation factors , cytokines , and growth factors that are vital for hemostasis and initiation of the wound healing process . In the wound healing analogy the first job to be done once the utilities are capped is to clean up the debris . This is a job for non-skilled laborers . These non-skilled laborers in a wound are the neutrophils or PMN 's (polymorphonucleocytes . The inflammatory response causes the blood vessels to become leaky releasing plasma and PMN 's into the surrounding tissue4 . The neutrophils phagocytize debris and microorganisms and provide the first line of defense against infection . They are aided by local mast cells . As fibrin is broken down as part of this clean-up the degradation products attract the next cell involved

The task of rebuilding a house is complex and requires someone to direct this activity or a contractor . The cell which acts as contractor ' in wound healing is the macrophage . Macrophages are able to phagocytize bacteria and provide a second line of defense

Question 2

Explain the rationale why the wound was swabbed for culture and sensitivity

The wound was swabbed for culture and sensitivity in to identify the organism responsible for Mrs . Stone 's wound infection . We can say that Mrs . Stone is infected 48 hours after the accident because she was already febrile , and some of her vital signs were also increasing . As we all know , fever is a compensatory mechanism of the body to regulate the body 's thermostat . In to keep up with this change in temperature , cardiac rate , blood pressure and respiratory rate increases . According to Nordenson (2007 , to enable healing and prevent the spread of infection to other body tissues , the infecting microorganisms must be killed . A wound culture discovers which type of microorganism is causing the infection and the best antibiotic with which to kill it

According to Cuzzell (1993 , a wound culture should be done , especially for immunocompromised patients , such as those with AIDS or cancer , in whom the nor mal clinical signs of invasive wound infection are masked or absent ,and paterns of microbe resistance to antibiotics change rapidly . A wound should be cultured , when the amount , consistency or odor of drainage changes significantly , suggesting an infectious process when a patient is soon to be discharged (especially if wound status changes suddenly or the patient is at high rsk for complications and when a newly transferred patient 's wound is draining

A sample of skin , tissue , or fluid is collected from the affected area and placed in a container with a substance (called growth medium or culture medium ) that helps organisms grow . If nothing important grows the culture is negative . If something that can cause infection grows the culture is positive . The type of organisms will be identified with a microscope , chemical tests , or both . If a skin or wound culture is positive , other tests may be done to help choose the best medicine to treat the infection

Question 3

a ) Explain the possible sources of the contamination of the wound and the mode of transmission of the micro organism

Sources of the contamination of the wound include the manure which Mrs Stone was digging into her rosebush and the soil which contains many microorganisms , which largely contain anaerobes

Anaerobes , cannot grow in the presence of oxygen . Oxygen is toxic for them , and they must therefore depend on other substances as electron acceptors . Their metabolism frequently is a fermentative type in which they reduce available organic compounds to various end products such as organic acids and alcohols . The facultative organisms are the most versatile . They preferentially utilize oxygen as a terminal electron acceptor , but also can metabolize in the absence of oxygen by reducing other compounds . Much more usable energy , in the form of high-energy phosphate , is obtained when a molecule of glucose is completely catabolized to carbon dioxide and water in the presence of oxygen (38 molecules of ATP ) than when it is only partially catabolized by a fermentative process in the absence of oxygen (2 molecules of ATP . The ability to utilize oxygen as a terminal electron acceptor provides organisms with an extremely efficient mechanism for generating energy Anaerobes are potentially pathogenic when displaced from normal environments (human colon , soil ) and implanted in dead or dying tissue abscesses , pneumonias , and oral and pelvic infections result (Hentges 2000

Staphylococcus aureus in this setting was transmitted in the bloodstream via the wound that she sustained on her right forearm According to Todar (2005 , human staphylococcal infections are frequent but usually remain localized at the portal of entry by the normal host defenses . The portal may be a hair follicle , but usually it is a break in the skin which may be a minute needle-stick or a surgical wound Foreign bodies , including sutures , are readily colonized by staphylococci , which may makes infections difficult to control . Another portal of entry is the respiratory tract . Staphylococcal pneumonia is a frequent complication of influenza

The localized host response to staphylococcal infection is inflammation characterized by an elevated temperature at the site , swelling , the accumulation of pus , and necrosis of tissue . Around the inflamed area , a fibrin clot may form , walling off the bacteria and leukocytes as a characteristic pus-filled boil or abscess . More serious infections of the skin may occur , such as furuncles or impetigo

b ) Explain why augmentin is one of the appropriate drugs given to Mrs stone

?-lactamase inhibitor and most resistant strains especially MRSA (Methicillin Resistant Staphylococcus Aureus ) are sensitive to it "S aureus intracellular survival appears related to its capability to adopt a discrete behaviour instead of actively duplicating " says Patrice Francois , a Geneva-based member of the research team "S . aureus then benefits from natural or programmed cell death to re-emerge and trigger another episode of infection , leading to chronicity

c ) Discuss the mode of action of augmentin and the common adverse reactions of the drug

to ?-lactamases and inactivate them , thus preventing the destruction of ?-lactam antibiotics that are substrates for these enzymes ?-Lactamase inhibitors are most active against plasmid-encoded ?-lactamases (including the extended- spectrum ceftazidime- and cefotxime-hydrolyzing enzymes , but they are inactive at clinically achievable concentrations against the type I chromosomal ?-lactamases induced in gram negative bacilli by treatment with second- and third generation cephalosporins

Coamoxiclav , according to Goodman Gilman (2001 , is a combination of amoxicillin and clavulanic acid . Amoxicillin is a ?-lactam antibiotic that has good coverage against gram positive microorganisms while clavulanic acid is a ?-lactamase inhibitor ( suicide inhibitor produced by a wide range of gram positive and gram negative microorganisms thus preventing the destruction of ?-lactam antibiotics that are substrates for these enzymes . Clavulanic acid is derived from Streptomyces clavuligerus . It is biosynthetically generated from the amino acid arginine and the sugar glyceraldehydes-3-phosphate . It is well absorbed by mouth and also can be given parenterally

Common adverse reactions of the drug are mostly from amoxicillin , and these are : hypersensitivity reactions (the most common gastrointestinal reactions (usually gastritis , and rarely , bone marrow depression . It has also been associated with an increased incidence of cholestatic jaundice and acute hepatitis during therapy or shortly after , particularly in men and those aged over 65 years . The associated jaundice is usually self-limiting and very rarely fatal

ctions likely to be caused by amoxicillin-resistant ?-lactamase-producing strains , and that treatment should not normally exceed 14 days (Wikipedia , 2007

References

Cockbill , S (2002 . Wounds : The healing process . Hospital Pharmacist Vol . 9

Retrieved August 21 , 2007 from http /www .pjonline .com /pdf /hp /200210 /hp_200210_wounds_healing .pdf

Cuzzell , J . Z (1993 . The Right Way to Culture A Wound . American Journal of Nursing Vol 93 No . 5 pp . 48-50 . Retrieved August 22 , 2007 from http /links .jstor .org /sici ?sici 0002-936X (199305 )93 3A5 3C48 3ATRWTCA 3 E2 .0 .CO 3B2-C

Fatunde , O .J Familusi , J .B (2001 . Post-neonatal Tetanus in Nigeria : The need for Booster doses of Tetanus Toxoid . Nigerian Journal of Pediatrics Vol . 28 No . 2 . Retrieved August 21 , 2007 from http /www .ajol .info /viewarticle .php ?id 10663

Garzoni , C , Francois ,

, Huyghe , A , Couzinet , S , et . al . HYPERLINK "http /www .biomedcentral .com /1471-2164 /8 /171 " A Global View of Staphylococcus aureus Whole Genome Expression Upon Internalization in Human Epithelial Cells . BMC Genomics 2007 , 8 :171 . Retrieved August 21 2007 from http /www .biomedcentral .com /info /about /pr-releases ?pr

Goodman , A .G (2000 . Goodman Gilman 's The Pharmacological Basis of

Therapeutics : 10th edition . New York , USA : McGraw Hill

Hentges , D (2000 . Anaerobes : General characteristics . Retrieved August 26 , 2007 from

http /www .gsbs .utmb .edu /microbook /ch017 .htm

Keast , D Orsted , H (2001 . The basic principles of wound healing Retrieved

August 18 , 2007 http /www .pilonidal .org /pdfs /Principles-of-Wound-Healing .pdf

Lee , G Bishop ,

(2006 . Microbiology and Infection Control for Health Professionals : 3rd edition . pp .181-182 . Pearson Education Australia

www .medinfo .ufl .edu (2006 . Medical informatics . College of Medicine University of

Florida . Retrieved August 26 , 2007 from http /medinfo .ufl .edu /year2 /mmid /bms5300 /bugs /clostet .html

www .cdc .gov (2006 . Overview of healthcare-associated MRSA (2006 .Retrieved

August 18 , 2007 . http /www .cdc .gov /ncidod /dhqp /ar_mrsa .html

Sy , G (2007 . Tetanus . Manila Bulletin . Retrieved August 18 , 2007

http /www .pchrd .dost .gov .ph /library /index .php ?option com_content task v iew id 490 Itemid 27

Todar , K (2005 . Staphylococcus . HYPERLINK "http /www .textbookofbacteriology .net " Todar 's online textbook of bacteriology

Retrieved August 18 , 2007 . http /textbookofbacteriology .net /staph .html

Wikipedia , the free encyclopedia (2007 ) Retrieved August 26 , 2007 fromhttp /en .wikipedia .org /wiki /Clavulanic_acid ...