Oral Antibiotics For Leg Ulcers

Establishing Severity Of Infection

The severity of the infection determines the appropriate antibiotic regimen and route of administration. It also is the primary consideration in determining the need for hospitalization and the indications and timing for any surgical intervention. A practical and simple approach to classifying diabetic foot infection is provided in Table 2.3

What Are Arterial Ulcers

A condition called peripheral arterial disease can reduce blood flow to your extremities. When this happens, your foot tissue may start to die. The ulcers that form from reduced blood flow are called arterial ulcers.

The word arterial means relating to arteries. Arteries are blood vessels that transport blood from your heart to the rest of your body, including your feet and toes. Anyone can get an arterial ulcer, but people who smoke or have diabetes, high blood pressure or high cholesterol are at higher risk.

Unlike neurotrophic ulcers, arterial ulcers can form on many parts of your body, including:

• On the tips of your toes.
• Between your toes .
• The bony parts of your feet and toes that rub against bed sheets, socks or shoes.

Arterial ulcers are:

• An unusual walk that puts too much pressure on one part of your foot or toe.
• Friction when your foot or toe rubs against the toe box of your shoe.

Although they dont cause ulcers, foot and toe ulcers are often found alongside toe conditions such as hammertoe, mallet toe and claw toe.

Do Not Take A Swab Or Use Antibiotics For The Management Of A Leg Ulcer Without Clinical Infection

Lower leg ulcers, most commonly venous ulcers are often treated with oral antibiotics, even in the absence of evidence of clinical infection. There is no evidence to support this use, except if screening for carriage of multi-resistant organisms. Also a swab for microscopy and culture, in the absence of signs of infection is not recommended. Unnecessary antibiotics and swabbing will add to healthcare costs, antimicrobial resistance and patient allergy.

Supporting evidence

• OMeara S, Al-Kurdi D, Olugun Y, Antibiotics and antiseptics for Venus ulcers. Cochrane Database Systematic Review 2014 CD003557.
• Hansson C, Hoborn J, Moller A, Swanbeck G. The microbial flora in venous leg ulcers without clinical signs of infection. Repeated culture using a validated standardised microbiological technique. Acta Dermato Venereologica 1995 75:24.

An initial list of 10 low value interventions was compiled by the Lead Fellow of the Australasian Society for Infectious Diseases Inc following an online discussion in ASIDâs discussion forum, Ozbug. The Royal Australasian College of Physicians then facilitated a consultation of all ASID members via a survey distributed through the societys e-newsletter. In the survey, members were asked to rank the 10 suggested interventions and suggest additional items for consideration. A subsequent shortlist of items was created by selecting the top 7 interventions as ranked by the members from the initial list.

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Compression Treatment Of Leg Ulcers: A Systematic Review

To estimate the clinical and cost effectiveness of compression systems for treating venous leg ulcers, 19 electronic databases including Medline, CINAHL, Embase, relevant journals, and conference proceedings included 24 randomised controlled trials which demonstrated that compression systems improve healing of venous leg ulcers and should be routinely used in uncomplicated venous ulcers. High compression is more effective than low compression, but should only be used in the absence of significant arterial disease. There are no clear differences in the effectiveness of different types of compression systems have been shown. Intermittent pneumatic compression appears to be a useful adjunct to bandaging. Rather than advocate one particular system, the increased use of any correctly applied high compression treatment should be performed. Compression bandages and stockings in the treatment of venous leg ulcers as reviewed by Cochrane Wounds Review Group, demonstrated that multilayer high compression bandages were significantly more effective than a single layer bandage. The direct comparisons of the healing rates were described in the two observational studies as 40% in 12 weeks and 42% of people attending a leg ulcer clinic. The limitations for use of four layer bandaging in a community clinic include the fact that some people are unable to leave their home due to immobility and cannot tolerate or do not like the treatment.

Looking After Yourself During Treatment

The following advice may help your ulcer heal more quickly.

• Try to keep active by walking regularly. Sitting and standing still without elevating your legs can make venous leg ulcers and swelling worse.
• Whenever youâre sitting or lying down, keep your affected leg elevated.
• Regularly exercise your legs by moving your feet up and down, and rotating them at the ankles. This can help encourage better circulation.
• If youâre overweight, try to reduce your weight with a healthy diet and regular exercise.
• Stop smoking and moderate your alcohol consumption. This can help the ulcer heal faster.
• Be careful not to injure your affected leg, and wear comfortable, well-fitting footwear.

You may also find it helpful to attend a local healthy leg club, such as those provided by the Lindsay Leg Club Foundation, for support and advice.

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Treatment For Leg Ulcers

• cleaning the wound using wet and dry dressings and ointments, or surgery to remove the dead tissue
• specialised dressings a whole range of products are available to help the various stages of wound healing. Dressings are changed less often these days, because frequent dressing changes remove healthy cells as well
• occlusive dressings ulcers heal better when they are covered. These dressings should be changed weekly
• compression treatment boosts internal pressure, using either elasticised bandages or stockings. This is particularly effective if multiple layers are used
• medication includes pain-relieving medication and oral antibiotics if infection is present
• supplements there is evidence that leg ulcers may heal faster with mineral and vitamin supplements, but only if the person suffers from a deficiency. Zinc, iron and vitamin C may be used
• skin graft is a surgical procedure, where healthy skin is grafted onto the prepared wound site
• skin cancer and infection if ulcers fail to heal or if they increase in size, both these conditions will need to be ruled out
• hyperbaric oxygen this is now an accepted treatment for ulcers that resist other methods of healing, such as diabetic ulcers.

Causes Of Venous Ulcers

Venous ulcers most often form around the ankles.

Venous ulcers typically occur because of damage to the valves inside the leg veins. These valves control the blood pressure inside the veins. They allow it to drop when you walk. If the blood pressure inside your leg veins doesn’t fall as you’re walking, the condition is called sustained venous hypertension. That increase in blood pressure causes ulcers to form on your ankles.

Venous ulcers may also be caused by other problems with your leg veins. These include:

• Varicose veins. These are large, bulging leg veins. They occur when valves in the leg veins dont work well, allowing blood to collect in the lower leg.

• Chronic venous insufficiency. Like varicose veins, this condition occurs when your leg veins cant pump blood back up to your heart. Blood then pools in your lower legs, causing your legs to swell. Since the blood can’t flow well in your legs, the swelling may be extreme. This extreme swelling can put so much pressure on your skin that venous ulcers form.

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What Are Venous Ulcers

A venous skin ulcer is a sore on the leg that heals slowly, usually because of blood flow problems in the leg veins. When leg veins do not push blood back up to the heart as they should, the blood backs up , creating extra pressure in the veins. If the condition is not treated, the increased pressure and excess fluid in the affected area can cause an open sore to form.

Because of the continuous pressure, venous ulcers can linger anywhere from a few weeks to years and lead to more serious problems if untreated. Most venous ulcers occur on the lower leg, above the ankle.

Diagnosis Of Leg Ulcers

• examine the wound
• perform some tests to measure the blood flow in your lower leg, such as the ankle-brachial index. This test compares blood pressure readings taken at the ankle and at the arm using a device called a Doppler machine
• recommend an angiogram for an arterial ulcer, to find out if the artery needs surgery to clear the blockage.

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How Are Venous Ulcers Treated

Venous ulcers need proper care and treatment to prevent infection and to heal. The Lakeland pain management doctors at the Vein Clinic work with each patient to determine the cause of the ulcer and develop an individualized treatment plan. The treatment goals are to relieve pain, speed recovery, and heal the wound. Treatment may include focusing on the circulatory or vein problems causing the ulcers.

The most common treatment to reduce the swelling is a compression bandage or stocking, which can help improve blood circulation in the legs, boosting the bodys ability to heal the sore. Some compression bandages may require the patient to wear them continuously, with a doctor replacing them every few days. Others are worn only during the day, with the patient putting them on and removing them.

In treating venous ulcers, it is essential to keep the site infection-free. Special medication may be applied under the bandages or stockings to help during the healing process.

If a venous ulcer becomes infected by bacteria, the doctor may prescribe antibiotics to kill the infection. A moist dressing may be used to help the ulcer heal more quickly.

Other treatment options for home care include:

Most venous ulcers heal after 3 or 4 months of treatment. However, some can take longer or require a skin graft to close up the opening in the skin. Some may never clear up completely.

Caring For Venous Ulcers

Venous ulcers need proper care and treatment to prevent infection and to heal. It’s important to have any venous ulcers checked right away by your healthcare provider.

Treatment may require focusing on the circulatory or vein problems that are causing the ulcers. Or it may mean removing some tissue around the wound. You may be asked to:

• Clean the wound regularly

• Apply a dressing to the ulcer

• Avoid products that cause skin sensitivity

• Wear compression stockings to prevent blood from pooling in the legs and to speed healing

• Apply an antibacterial ointment or another topical medicine to prevent or treat an infection

• Take oral antibiotic medicines to prevent or treat an infection

• Have allergy testing done

Wearing a compression wrap to keep blood flowing back up to your heart can also help ulcers heal more quickly. In some cases, surgery or a skin graft is needed to close up the opening in the skin.

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Can Venous Leg Ulcers Be Prevented

There are several ways to help prevent a venous leg ulcer in people at risk, such as:

• wearing compression stockings
• losing weight if youâre overweight
• exercising regularly
• elevating your leg when possible

This is particularly important if youâve previously had a leg ulcer once a leg has suffered a venous ulcer, youâre at risk of further ulcers developing within months or years.

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What Are Foot And Toe Ulcers

An ulcer is an open wound or sore that will not heal or keeps returning. When you have ulcers on your feet and toes, it can be related to diabetes specifically, a complication called neuropathy that causes you to lose feeling in your feet. A scrape, cut or puncture in your skin can turn into an ulcer, but you might not know its there if you have neuropathy.

Ulcers can lead to infections. Sometimes, the infection wont go away and you may need to have part of your foot or toe surgically removed . About 15% of people with diabetes will get a foot or toe ulcer. Around 14% to 24% of people with diabetes in the U.S. need an amputation after they get an ulcer.

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Summary Of The Evidence

This is a summary of the evidence. For full details see the evidence review and expert testimony.

The review protocol included a population of adults, young people and children with infected leg ulcers. There was minimal evidence for this population , therefore the population was expanded to people with leg ulcers that had an unclear infection status or were not infected. For antiseptic and antibiotics, the results have been presented separately for people with:

• an infected leg ulcer

• a leg ulcer with unclear infection status

• an uninfected leg ulcer.

All the evidence is based on 1 systematic review of antibiotics and antiseptics for venous leg ulcers , which included 45 randomised controlled trials . Nine of these were not included in the review because 8 contained ineligible interventions and 1 study was withdrawn from publication. Seven RCTs included people exclusively with leg ulcer infection 14 RCTs included people with leg ulcers of unclear infection status and 15 studies included people with leg ulcers that were not infected.

No studies included in the review stated that they included children. The committee discussed that leg ulcer infection in children and young people is extremely rare, and usually a result of an underlying illness that requires specialist management. Therefore, they agreed not to extrapolate the evidence to children and young people.

How Can I Reduce My Risk Of Foot And Toe Ulcers

There are several things you can do to help reduce your risk of getting foot and toe ulcers. Sometimes, adopting these habits can even stop them from coming back. Try to:

• Manage your diabetes. If you have diabetes you should wear appropriate footwear and never walk barefoot.
• Examine your legs as well as the tops and bottoms of your feet and the areas between your toes every day. Look for any blisters, cuts, cracks, scratches or other sores. Also check for redness, increased warmth, ingrown toenails, corns and calluses. Use a mirror to view your leg or foot if necessary. If its difficult to see, ask a family member to look at the area for you. See a healthcare provider immediately if you notice any problems.
• Talk to your healthcare provider about ways you can stop smoking.
• Manage your blood pressure.
• Control your cholesterol and triglyceride levels by changing your diet. Limit salt in your diet.
• Care for your toenails frequently. Cut your toenails after bathing, when they are soft. Cut toenails straight across and smooth with a nail file. Take care of ingrown toenails.

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How Do I Take Care Of My Foot And Toe Ulcers

Your healthcare provider might teach you how to care for your ulcers at home. You might be instructed to:

• Wash the affected area with mild soap.
• Keep the wound clean and dry.
• Change the bandages as directed.
• Take prescribed medications as directed.
• Drink plenty of fluids. Ask your healthcare provider how much water you should drink every day.
• Follow a healthy diet, as recommended by your healthcare provider.
• Exercise regularly, under your healthcare providers care.
• Wear appropriate shoes.
• Wear compression wraps as directed.

Diagnosis And Treatment Of Venous Ulcers

LAUREN COLLINS, MD, and SAMINA SERAJ, MD, Thomas Jefferson University Hospital, Philadelphia, Pennslyvania

Am Fam Physician. 2010 Apr 15 81:989-996.

Patient information: See related handout on venous ulcers, written by the authors of this article.

Venous ulcers, or stasis ulcers, account for 80 percent of lower extremity ulcerations.1 Less common etiologies for lower extremity ulcerations include arterial insufficiency prolonged pressure diabetic neuropathy and systemic illness such as rheumatoid arthritis, vasculitis, osteomyelitis, and skin malignancy.2 The overall prevalence of venous ulcers in the United States is approximately 1 percent.1 Venous ulcers are more common in women and older persons.36 The primary risk factors are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis.7

Venous ulcers are often recurrent, and open ulcers can persist from weeks to many years.810 Severe complications include cellulitis, osteomyelitis, and malignant change.3 Although the overall prevalence is relatively low, the refractory nature of these ulcers increase the risk of morbidity and mortality, and have a significant impact on patient quality of life.11,12 The financial burden of venous ulcers is estimated to be $2 billion per year in the United States.13,14

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