Infections and Epidermolysis Bullosa

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Infections and Epidermolysis Bullosa

• Dr. Elena Pope, MSc, FRCPC
• Assistant Professor
• University of Toronto
• The Hospital for Sick Children

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Background

• No data on the magnitude of the problem
• No unified approach for recognition and treatment
  of infection in EB
• Anecdotally
• Severe EB patients have chronic wounds
• Infections are common in EB
• Sepsis is a leading cause of death
• Bacterial resistance develops in almost all
  patients

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Outline

• Wound infection continuum
• Diagnosis of infection
• Management of infection
• Infections and EB

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Infection Continuum
Contamination
Colonization
Critical colonization
Infection
BACTERIA
HOST
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Infection Continuum
Bug
Bug
Bug
Bug
Bug
Host defense
Bacteria
INFECTION (Inoculum X Virulence) Potentiating
Factors Host Resistance
OWM 200349(7A)1-7
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Wound Contamination
Air-borne
hands
Oral or nasal mucosa
Fomites
Feces, peri-rectal
Surface Sampling
Polymicrobial Ecosystem
Viable Tissue Biopsy
Courtesy of Gary Sibbald
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How much is too much?

• Bacteria related factors
• Count
• gt105 cells/gm tissue
• Military Medicine 196913419-24
• Virulence
• Number of species

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How do you diagnose infection?
Infection
Critical colonization
Colonization
Contamination
Red Hot Tender Swollen
Clean
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How do you diagnose infection?
Infection
Critical colonization
Colonization
Contamination
Red Hot Tender Swollen
Clean
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How do you diagnose infection?

• Diagnosing infection is a clinical, not a
  technical skill
• TREAT IF INFECTION IS SUSPECTED
• Gold standard for culture is a skin biopsy
• Wound swab
• Bacterial identification
• Antibiotic sensitivity
• OWM 200349(5)8-13

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How do you diagnose infection?

• Clean/debride wound
• Zig Zag and rotate 360O
• Swab on granulation tissue, press lightly and
  rotate 360O
• If dry, moisten swab in transport media first
• Avoid debris and frank pus
• OWM 200349(5)8-13

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Bacterial Bioburden
Pseudomonas E. Coli Proteus klebsiella
Staph aureus GAS
Bacteroides
6 (weeks)
2
4
0
Acute infection
Chronic infection
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Why is Bacterial Bioburden Problematic?

• metabolic load
• Produces endotoxins and proteases
• Stimulates a pro-inflammatory wound environment
• Wounds dont heal

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How do you diagnose infection in chronic wounds?
Infection
Critical colonization
Colonization
Contamination
Stuck wound
Exudate Granulation tissue Pain Smell Size
Healing cessation
Clean
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Infection in chronic wounds

• Cutting and Harding clinical criteria
• Deterioration of the wound
• Increased pain
• Friable tissue
• Foul odor
• Bridging/pocketing
• Discoloration
• No response to therapy
• Wound Care Journal 1994

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Infection in chronic wounds

• Deterioration of the wound
• Increased pain
• Friable tissue
• Foul odor
• Gardner, Frantz, Doebbeling WWR 2001
• Probes to bone
• Grayson JAMA 1994

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Critical Colonization and Infection in chronic
wounds

• NERDS Critical colonization
• Non-healing wounds
• Exudate
• Red/bleeding
• Debris
• Smell

• STONES Infection
• Size bigger
• Temperature
• Os/probes
• New breakdown
• Exudate/edema/erythema
• Smell

Sibbald 2003
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Critical Colonization and Infection in chronic
wounds

• NERDS Critical colonization

• STONES Infection

Sibbald 2003
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Management of infection
Contamination
Colonization
Critical colonization
Infection
NERDS
STONES
Clean Remove debri Moisture control
Antimicrobials Reassess dressings
Systemic antibiotics
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Chronic Infections and EB
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Management of infection in EB
Contamination
Colonization
Critical colonization
Infection
Clean - Remove debri Moisture control
Antimicrobials Reassess dressings Systemic
antibiotics
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Management of infection in EB

• Antimicrobials
• Microbicidal
• Topical antibacterials
• Systemic antibacterials

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Management of infection in EB

• Antimicrobials
• Microbicidal
• Not routinely recommended
• Potential toxicity
• Impairs wound healing
• Topical antibacterials
• Systemic antibacterials

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Management of infection in EB

• Antimicrobials
• Microbicidal
• Topical antibacterials
• SSD, polysporin cr, mupirocin, metronidazole
• alternate every 2 months to prevent resistance
• Systemic antibacterials

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Rule of 3

• Alternate every few months
• Avoid using the same preparation topically and
  systemically
• Avoid potential sensitizers

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Management of infection in EB

• Antimicrobials
• Microbicidal
• Topical antibacterials
• Systemic antibacterials
• To treat infection
• Wound progression
• Cellulitis
• Sepsis
• To treat inflammation

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Antiinflammatory Antibacterials in EB

• Arch Dermatol 1999
• 2 EBS-DM treated with 1.5 g/d Tetracycline
• Decreased number of blisters
• Dose response curve
• Challenge/rechallenge
• BJD 2004
• DB cross over trial, Tetracycline
• Intended to have 12 pts
• Attrition rate 50
• Results
• No adverse events
• Reduced blister count
• Sustained response

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Antiinflammatory Antibacterials in EB

• SickKids Anecdotal experience
• Alternating cycles (2 mos duration)
• TMP- 2mg/kg/day
• Erythromycin- 20 mg/kg/day
• Well tolerated, no side-effects
• No bacterial resistance noted over 3 years
• Positive outcomes
• Decreased number of new blisters
• Enhanced healing of the existing blisters