Antimicrobial use in traumatic wounds: local and/or systemic?

With increasing multi-drug resistance especially in hospitalised patients¹ gone are the days where we can rely on antimicrobials alone to treat infected wounds. Culture‐guided antimicrobial selection has become vitally important to ensure appropriate antimicrobial treatment and to reduce antimicrobial resistance. MALDI-TOF (matrix-assisted laser desorption ionization time-of-flight) mass spectrometry can reveal the causative organisms in less than 24 hours² .

It is also important to ensure correct sampling technique of wounds for culture submissions to minimise contaminants. Genuine polymicrobial infections are rare and, although polymicrobial culture results are commonly reported, it is more likely that there is a single predominant isolate driving the infection while the other bacteria are passive visitors³ . Sampling of contaminants may lead to susceptibility results which will erroneously guide the clinician to unnecessarily escalate the antimicrobial selection to high priority critically important antimicrobials (HPCIAs) such as 3^rd/4^th generation cephalosporins and fluroquinolones. Wound biopsies, although slightly more invasive, often provide more accurate culture and susceptibility results⁴ . 

Not every traumatic wound requires antimicrobials and each case should be weighed-up carefully on factors such as size, depth and location of the wound, synovial involvement, age and immune status of the patient and the degree of infection present. A small superficial traumatic wound will heal adequately without antimicrobials in an otherwise healthy patient whereas a wound with synovial contamination is likely to be life threatening and it would be inappropriate not to administer antimicrobials. [...]