Monthly Archives: December 2017

Wound prophylaxis – Should lip lacs get antibiotics (and few others)?

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During my review for 72 hour returns we had a through and through lip laceration come in that returned with a wound infection a few days later.  This prompted me to look up current recommendations as I’m pretty sure that I haven’t been giving antibiotic prophylaxis for this.

Searching literature, Tintinalli and UpToDate…… Most superficial wounds do not require prophylaxis, however, through and through lip lacerations were an area of uncertainty and debate….

Tintinalli  – “matter of provider preference.”

UptoDate – no clear clinical evidence to say that these wounds should receive antibiotic prophylaxis , however, due to the pathogens of the oral cavity, they recommend prophylaxis.

Current literature – Review article in 2008, Annals of Emergency Medicine, Mark DG et al – review of studies do not show a statistically significant benefit; however, the only double-blinded randomized control trial showed a trend toward benefit in patient’s that were compliant with therapy.

Some other stats – Rate of infection in wound treated in the ED (Tintinalli)

Head and neck 1-2%

Upper extremity 4%

Lower extremity 7%

Oral wounds – 9-27%

If giving prophylaxis then Pen VK or Clindamycin is recommended for 3-5 days.

For other oral wounds, <1cm, no need to close. Close if large gap susceptible to food getting trapped, and counsel on good oral hygiene.  Dental and OMFS usually recommend d/c with chlorhexidine gluconate oral rinse (0.12%) (Peridex) and will have patients swish and spit after meals to keep the wound from contamination with food particles.

My take away from this is strongly consider antibiotic prophylaxis with through and through oral wounds as they are higher risk for infection with oral flora; however, not an absolute must based on the current evidence.  Be sure to emphasize good oral hygiene, and as always, close follow up with good return precautions.

Other wounds to strongly consider prophylaxis due to increased risk for infection are mammalian and human bite wounds, crush injury, puncture wounds, and wounds with either fresh or salt water contamination, or patients who are immunocompromised, asplenic, advanced liver disease, associated edema (according to the IDSA).

Open fractures and wounds with joint capsule violation should receive antibiotic prophylaxis.

Reminder: Update Tetanus and simple lacerations do not need antibiotic prophylaxis.

Hepatitis A Outbreak

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All,
In case you haven’t heard, we’re in the midst of a Hepatitis A outbreak in Louisville (there’s been much larger ones elsewhere, including San Diego). I apologize if this is a long post and will try to keep organized but want to get this out sooner rather than later. Some things I think you should know:

  • It’s transmitted via the fecal-oral route (hence why food handlers with HepA should not be working)
  • High risk patients include Homeless patients, IV drug users, and Men who have sex with men (so a big portion of our patients)
  • Consider Hepatitis in patients with: Fever, malaise, N/V/D, abdominal pain + either jaundice or elevated AST or ALT.
  • It requires reporting to the Health Dept
  • Patients should be placed in contact/enteric isolation (similar to C. Diff).
  • Hands must be washed with soap and water (hand sanitizer isn’t good enough)!
  • Rooms must be cleaned by EVS with Bleach. Please clean your stethoscopes as well.
  • The incidence of fulminant hepatic failure is <1% (it’s higher in those with liver disease and with concomitant Hep B or C)
  • Treatment is generally supportive, with hydration and electrolyte replacement as needed. Infection with Hepatitis A generally leads to immunity, thus do not need to vaccinate those with a diagnosis of Acute Hepatitis A.
  • Patients are contagious until ~1 week after appearance of jaundice
  • Patients and family members should be counseled on the route of transmission and should receive a dose of the Hepatitis A Vaccine (they can be directed to the Louisville Metro Dept of Public Health and Wellness at 400 E. Gray St.)
  • There is no chronic Hep A State.
  • The Acute Hepatitis Panel checks for HAV IgM, HepB Core Antibody, IgM, HepB Surface Antigen, and Hepatitis C antibody (thus can tell you if Acute A, and maybe B, but not whether Hep C is acute or chronic). You can order the specific Hep A IgM in Cerner, though it’s probably good to know whether B or C is present also.
  • Those with Altered sensorium, INR > 1.5, a PT > 5 seconds above normal or with concomitant illnesses may require admission.
  •  One of the recommendations is to administer the vaccine to our at risk populations, but PLEASE wait on this until I have further info on our stock/supply of the vaccine.
  • The attached PDF has a questionnaire that the health dept is requesting be filled out and sent to them in order to reduce the spread of HAV, so please be aware of it and remind the nursing staff to try to get it filled out. If they’re unsure about it discuss with charge nurse to get the form.

Sorry this is so long but hope this helps. For any issues just email me and I’ll try to sort it out.

*See the attached PDF for information from the Health Dept/ULH. as well as the CDC link on Hepatitis A

Hep A Provider Recommendations 12.2017

https://www.cdc.gov/hepatitis/hav/havfaq.htm