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					9b3a2ca6-71fe-44b7-aeb4-9b233ac664cd.doc                                                                                                          Page 1 of 14

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              WORKSHEET for PROPOSED Evidence-Based GUIDELINE RECOMMENDATIONS
NOTE: Save worksheet using the following filename format: Taskforce.Topic.Author.Date.Doc where Taskforce is a=ACLS,
b=BLS, p=Pediatric, n=neonatal and i=Interdisciplinary. Use 2 or 3 letter abbreviation for author’s name and 30Jul03 as
sample date format.
Worksheet Author: Mary Fry Davis, David Markenson &    Taskforce/Subcommittee: __BLS __ACLS __PEDS __ID __PROAD
Carol Spizzirri
                                                       _X_Other: First Aid Task Force
Author’s Home Resuscitation Council:
_X_AHA __ANZCOR __CLAR __ERC __HSFC                                        Date Submitted to Subcommittee:
                                                                            September 12, 2004, Revised 12 Dec 2004
__HSFC __RCSA            ___IAHF       ___Other:

STEP 1: STATE THE PROPOSAL. State if this is a proposed new guideline; revision to current guideline; or deletion of current guideline.
Existing guideline, practice or training activity, or new guideline:
This is a proposed new guideline. Topical antibiotic ointment should be applied to cutaneous abrasions/wounds after cleansing.
Step 1A: Refine the question; state the question as a positive (or negative) hypothesis. State proposed guideline recommendation as a specific,
positive hypothesis. Use single sentence if possible. Include type of patients; setting (in- /out-of-hospital); specific interventions (dose, route); specific
outcomes (ROSC vs. hospital discharge).
Initial first aid management of a cutaneous abrasion or wound with topical antibiotics after cleansing the wound has been proven effective.
Step 1B: Gather the Evidence; define your search strategy. Describe search results; describe best sources for evidence.
EMBASE –All years (Wound* OR injuries) AND ('emergency treatment'/exp/mj OR 'first aid'/exp/mj) AND [english]/lim AND [humans]/lim. 195
articles found.
EMBASE – All years (‘Skin injury’/ exp OR laceration* AND ‘skin abrasion’) AND (‘emergency treatment’/exp/mj OR ‘first aid’/expmj OR
‘wound therapy’ OR ointment* OR cleaning) - 42 articles found.
MEDLINE – All years Cutaneous abrasions AND Antibiotic Ointment textword in abstract - 1 article found
MEDLINE – All years Cutaneous abrasions AND treatment in abstract – 15 articles found.
MEDLINE – All years Lacerations AND Wound Care in abstract; 265 articles found; 8 applied
MEDLINE – All years Cutaneous injury AND Wound Care in abstract – 188 articles found.
Cochrane Review – 0 Reviews
AHA Master Library – 0 articles
Best additional resource was review of references from articles
List electronic databases searched (at least AHA EndNote 7 Master library [http://ecc.heart.org/], Cochrane database for systematic reviews and Central Register
of Controlled Trials [http://www.cochrane.org/], MEDLINE [http://www.ncbi.nlm.nih.gov/PubMed/ ], and Embase), and hand searches of journals, review articles,
and books.
AHA Master Library, Medline, EMBASE, Cochrane database (reviews & trials) and hand searches of journals, review articles were reviewed along
with their references.
• State major criteria you used to limit your search; state inclusion or exclusion criteria (e.g., only human studies with control group? no animal studies? N subjects
  > minimal number? type of methodology? peer-reviewed manuscripts only? no abstract-only studies?)
Human studies and animal studies were reviewed.
• Number of articles/sources meeting criteria for further review: Create a citation marker for each study (use the author initials and date or Arabic numeral, e.g.,
“Cummins-1”). . If possible, please supply file of best references; EndNote 6+ required as reference manager using the ECC reference library.
 Nine studies met criteria for detailed review.



                       STEP 2: ASSESS THE QUALITY OF EACH STUDY
 Step 2A: Determine the Level of Evidence. For each article/source from step 1, assign a level of evidence—based on
 study design and methodology.
     Level of                                                          Definitions
     Evidence                                                (See manuscript for full details)
      Level 1     Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effects
      Level 2     Randomized clinical trials with smaller or less significant treatment effects
      Level 3     Prospective, controlled, non-randomized, cohort studies
      Level 4     Historic, non-randomized, cohort or case-control studies
      Level 5     Case series: patients compiled in serial fashion, lacking a control group
      Level 6     Animal studies or mechanical model studies
      Level 7     Extrapolations from existing data collected for other purposes, theoretical analyses
      Level 8     Rational conjecture (common sense); common practices accepted before evidence-based guidelines
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    Step 2B: Critically assess each article/source in terms of research design and methods.
    Was the study well executed? Suggested criteria appear in the table below. Assess design and methods and provide an overall
    rating. Ratings apply within each Level; a Level 1 study can be excellent or poor as a clinical trial, just as a Level 6 study could be
    excellent or poor as an animal study. Where applicable, please use a superscripted code (shown below) to categorize the primary
    endpoint of each study. For more detailed explanations please see attached assessment form.

 Component of
 Study and Rating                           Excellent                       Good                   Fair                   Poor            Unsatisfactory
 Design &                             Highly appropriate          Highly appropriate         Adequate,            Small or clearly       Anecdotal, no
                                      sample or model,            sample or model,           design, but          biased population or   controls, off
                                      randomized, proper          randomized, proper         possibly biased      model                  target end-points
                                      controls                    controls
 Methods                              AND                         OR                         OR                   OR                     OR
                                      Outstanding                 Outstanding accuracy,      Adequate under       Weakly defensible in   Not defensible in
                                      accuracy,                   precision, and data        the                  its class, limited     its class,
                                      precision, and data         collection in its class    circumstances        data or measures       insufficient data
                                      collection in its                                                                                  or measures
                                      class

A = Return of spontaneous circulation                        C = Survival to hospital discharge                E = Other endpoint
B = Survival of event                                        D = Intact neurological survival

    Step 2C: Determine the direction of the results and the statistics: supportive? neutral? opposed?

 DIRECTION of study
 by results & statistics:                  SUPPORT the proposal                      NEUTRAL                            OPPOSE the proposal
                                           Outcome of proposed guideline             Outcome of proposed guideline      Outcome of proposed guideline
 Results                                   superior, to a clinically important       no different from current          inferior to current approach
                                           degree, to current approaches             approach

Step 2D: Cross-tabulate assessed studies by a) level, b) quality and c) direction (ie, supporting or neutral/
opposing); combine and summarize. Exclude the Poor and Unsatisfactory studies. Sort the Excellent, Good, and Fair quality
studies by both Level and Quality of evidence, and Direction of support in the summary grids below. Use citation marker (e.g. author/
date/source). In the Neutral or Opposing grid use bold font for Opposing studies to distinguish them from merely neutral studies.
Where applicable, please use a superscripted code (shown below) to categorize the primary endpoint of each study.


                                                                    Supporting Evidence
              Initial first aid management of a cutaneous abrasion or wound with topical antibiotics after cleansing the
                                                  wound has been proven effective.
 Quality of Evidence




                                   Berger 2000e
                       Excellent   Leveden 1987e
                                                   Hendley
                                                   1991e
                                   Maddox 1985e




                        Good                       Atiyeh 2002e
                                                                     Hendley                                                                  Flemming
                                                                     1988e                                                                    1967
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                         Fair



                                   1           2                 3               4               5                6               7               8
                                                                          Level of Evidence
A = Return of spontaneous circulation                  C = Survival to hospital discharge              E = Other endpoint
B = Survival of event                                  D = Intact neurological survival
                                                Neutral or Opposing Evidence
              Initial first aid management of a cutaneous abrasion or wound with topical antibiotics after cleansing the
                                                  wound has been proven effective.


                       Excellent
 Quality of Evidence




                        Good              Hood 2004e




                         Fair                                                                                                                VanZyl
                                                                                                                                             2002e



                                   1           2                 3               4               5                6               7               8
                                                                          Level of Evidence
A = Return of spontaneous circulation                  C = Survival to hospital discharge              E = Other endpoint
B = Survival of event                                  D = Intact neurological survival


 STEP 3. DETERMINE THE CLASS OF RECOMMENDATION. Select from these summary
 definitions.
                    CLASS                                    CLINICAL DEFINITION                       REQUIRED LEVEL OF EVIDENCE
    Class I                                        • Always acceptable, safe                   • One or more Level 1 studies are present (with rare
    Definitely recommended. Definitive,            • Definitely useful                           exceptions)
    excellent evidence provides support.           • Proven in both efficacy & effectiveness   • Study results consistently positive and compelling
                                                   • Must be used in the intended manner for
                                                     proper clinical indications.
    Class II:                                      • Safe, acceptable                          • Most evidence is positive
    Acceptable and useful                          • Clinically useful                         • Level 1 studies are absent, or inconsistent, or lack
                                                   • Not yet confirmed definitively              power
                                                                                               • No evidence of harm
     • Class IIa: Acceptable and useful            • Safe, acceptable                          • Generally higher levels of evidence
    Good evidence provides support                 • Clinically useful                         • Results are consistently positive
                                                   • Considered treatments of choice
     • Class IIb: Acceptable and useful            • Safe, acceptable                          • Generally lower or intermediate levels of evidence
    Fair evidence provides support                 • Clinically useful                         • Generally, but not consistently, positive results
                                                   • Considered optional or alternative
                                                     treatments
    Class III:                                     • Unacceptable                              • No positive high level data
    Not acceptable, not useful, may be             • Not useful clinically                     • Some studies suggest or confirm harm.
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  harmful                                           • May be harmful.
                                                    • Research just getting started.                   • Minimal evidence is available
  Indeterminate                                     • Continuing area of research                      • Higher studies in progress
                                                    • No recommendations until                         • Results inconsistent, contradictory
                                                      further research                                 • Results not compelling

 STEP 3: DETERMINE THE CLASS OF RECOMMENDATION. State a Class of Recommendation for the Guideline Proposal.
 State either a) the intervention, and then the conditions under which the intervention is either Class I, Class IIA, IIB, etc.; or b) the condition, and then whether
 the intervention is Class I, Class IIA, IIB, etc.

 Indicate if this is a __Condition or _X_Intervention
 Initial first aid management of a cutaneous abrasion or wound with topical antibiotics after cleansing
 the wound has been proven effective.
 Final Class of recommendation: _X_Class I-Definitely Recommended (Antibiotic Ointment) _X_Class
 IIa-Acceptable & Useful; good evidence (Triple antibiotic preferable) __Class IIb-Acceptable &
 Useful; fair evidence __Class III – Not Useful; may be harmful     __Indeterminate-minimal evidence
 or inconsistent


REVIEWER’S PERSPECTIVE AND POTENTIAL CONFLICTS OF INTEREST: Briefly summarize your professional background, clinical
specialty, research training, AHA experience, or other relevant personal background that define your perspective on the guideline proposal. List any potential
conflicts of interest involving consulting, compensation, or equity positions related to drugs, devices, or entities impacted by the guideline proposal. Disclose any
research funding from involved companies or interest groups. State any relevant philosophical, religious, or cultural beliefs or longstanding disagreements with an
individual.
 Mary Fry- Clinical Nurse Educator and staff nurse in the emergency department of Benefis Healthcare (290 bed hospital) in Great Falls, Montana.
 During the past four years served on the American Heart Association’s Emergency Cardiovascular Care Committee and on the PROAD
 subcommittee for the previous four years. Served as ACLS national faculty for 4 years. Current regional faculty for ACLS and PALS. ACLS &
 BLS instructor since 1979. PALS instructor since 2000. No conflicts to disclose
 Spizzirri – President of Non for Profit. No conflicts to disclose
 Markenson – Pediatric Critical Care Physician and Co-Chair of First Aid Task Force. No conflicts to disclose.



REVIEWER’S FINAL COMMENTS AND ASSESSMENT OF BENEFIT / RISK: Summarize your final evidence integration and the rationale for
the class of recommendation. Describe any mismatches between the evidence and your final Class of Recommendation. “Mismatches” refer to selection of a class
of recommendation that is heavily influenced by other factors than just the evidence. For example, the evidence is strong, but implementation is difficult or
expensive; evidence weak, but future definitive evidence is unlikely to be obtained. Comment on contribution of animal or mechanical model studies to your final
recommendation. Are results within animal studies homogeneous? Are animal results consistent with results from human studies? What is the frequency of
adverse events? What is the possibility of harm? Describe any value or utility judgments you may have made, separate from the evidence. For example, you
believe evidence-supported interventions should be limited to in-hospital use because you think proper use is too difficult for pre-hospital providers. Please include
relevant key figures or tables to support your assessment.
 Goals of wound management are: avoid infection and achieve a functional and aesthetically pleasing scar. These goals may be
 achieved by reducing tissue contamination, debriding devitalized tissue, restoring perfusion in poorly perfused wounds and
 establishing a well-approximated skin closure. Controlling infection in open wounds will enhance wound healing. Topical agents
 reduce the number of germs but do not obliterate them. Improved wound healing decreases the pain and scarring that contribute to
 wound related physical impairments. In addition to fighting superficial infection, most topical agents will help soften wound eschar,
 which will assist with debridement of tissue. In several studies (Berger, Leyden and Maddox) which evaluated naturally occurring
 wounds or study induced abrasions and blisters the use of antibiotic ointment lead to better wound healing and reduced infection
 rates. In an additional study by Atiyeh which was designed the benefit of moist burn ointment which was superior to antibiotic
 ointment but the study also showed that in actual post-surgical wounds triple antibiotic ointment was superior to no therapy in terms
 of wound healing. Additional studies using human skin evaluated eradication of infection and in some these studies quantified the
 level of eradication and the depth of skin from which bacteria were eradicated. These studies (Hendley) showed that triple antibiotic
 ointment was superior to single and double agent ointment in eradication of coagulase negative strep from the sin and to a greater
 depth. In one study by Hood of emergency room patients with wounds that received standard ED care and suturing it was shown
 that although triple antibiotic ointment was superior to single agent statistically there was no difference.
Preliminary draft/outline/bullet points of Guidelines revision: Include points you think are important for inclusion by the person assigned to
write this section. Use extra pages if necessary.

 Publication:
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 Topic and subheading:
 Consensus on Science Statement:
 Evidence from 3 level 1, 3 level 2 and one level 3 and additional level 7 and 8 studies document improvement in wound healing ,
 decreased wound infection and eradication of baceteria from the skin when a topical antibiotic ointment is administered by lay
 rescuers to patients with cutaneous abrasion or wounds in the out of hospital setting. In addition evidence from three level one
 studies, two level 2 studies and one level three study showed that triple antibiotic ointment was superior to single agent and double
 antibiotic ointment in terms of wound healing and eradication of bacteria from the skin. Although one level 2 study showed no
 difference between triple antibiotic ointment and single agent for eradication of bacteria from the skin.

 Treatment Recommendation:
 Therefore, administration of antibitotic ointment for patients with cutaneous abrasion or wounds by lay rescuers is recommended
 (Class I Recommendation). The use of triple antibiotic ointment over double or single agent antibiotic ointment by a lay rescuer for
 cutaneous abrasions or wounds is recommended (Class IIa).




Attachments:
       Bibliography in electronic form using the Endnote Master Library. It is recommended that the bibliography be provided in annotated
        format. This will include the article abstract (if available) and any notes you would like to make providing specific comments on the
        quality, methodology and/or conclusions of the study.

                                                               Citation List
       Citation Marker                                                             Full Citation*
Atiyeh 2002                          Atiyeh, B. S., J. Ioannovich, et al. "Improving scar quality: a prospective
                                     clinical study." 470-6, 2002 Nov-Dec.
                                             Following traumatic or surgical injury to the skin, wounds do not heal
                                     by tissue regeneration but rather by scar formation. Though healing is
                                     definitely a welcomed event, the resultant scar, very often, is not
                                     aesthetically pleasing, and not infrequently, may be pathologic causing
                                     serious deformities and contractures. Management of problematic scars
                                     continues to be a frustrating endeavor with less than optimal results.
                                     Prophylactic methods of wound management to minimize serious scarring
                                     are being developed. In a previously published study, we have
                                     demonstrated improved healing of split thickness skin graft donor sites
                                     following treatment with Moist Exposed Burn Ointment (MEBO, Julphar
                                     Gulf Pharmaceutical Industries, Ras Al-Khaimah, UAE). At present, we are
                                     reporting the results of a comparative clinical prospective study evaluating
                                     scar quality following primary healing of elective surgical and traumatic
                                     facial wounds with prophylactic MEBO application, topical antibiotic
                                     ointment application, and no topical therapy at all. Scars were evaluated
                                     according to the Visual Analogue Scale for scar assessment. Statistical
                                     analysis of scar assessment scores demonstrated marked prevention of
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                                     unfavorable scars with improved cosmetic results following MEBO
                                     prophylactic therapy.
                                     Summary – While the authors conclusions were based on their desire toe
                                     valuate the MEBO, they did find significant improvement in wound healing
                                     and scar appearance with antibiotic ointment versus no ointment.
                                     LOI 2
                                     Quality - Good

Berger 2000                          Berger, R. S., A. S. Pappert, et al. "A newly formulated topical triple-
                                     antibiotic ointment minimizes scarring.[erratum appears in Cutis 2000
                                     Nov;66(5):382]." 401-4, 2000 Jun.
                                             A randomized study of polymyxin B sulfate-bacitracin zinc-neomycin
                                     sulfate versus simple gauze-type dressings in dermabrasion wounds
                                     assessed the effects that each treatment had on scarring. Each of three
                                     uniform dermabrasion wounds created on the upper backs of 70 subjects
                                     was treated concurrently with a triple-antibiotic ointment (polymyxin B-
                                     bacitracin-neomycin), a double antibiotic (polymyxin B-bacitracin), or a
                                     simple, non-occlusive, gauze-type dressing, twice daily for up to 14 days.
                                     Pigmentary changes and textural changes (scarring) appearing after
                                     healing at the skin surface test sites were compared to adjacent normal
                                     skin at 45 and 90 days post-dermabrasion. These changes were graded
                                     visually utilizing fluorescent light, long-wave ultraviolet light, and by clinical
                                     color photography. The triple-antibiotic ointment was superior to simple
                                     gauze-type dressing alone in minimizing the scarring observed in
                                     dermabrasion wounds. The benefit of this new ointment was more
                                     pronounced in its effect on pigmentary changes.
                                     Summary – In this study the investigators showed that triple antibiotic
                                     ointment was superior to double antibiotic ointment or no antibiotic
                                     ointment and that double antibiotic ointment was superior to none in wound
                                     healing. This was a well done randomized and controlled study with
                                     significant effect.
                                     LOI 1
                                     Quality - Excellent

Bolton (1994)                        Bolton L, Fattu AJ. Topical agents and wound healing. Clin Dermatol. 1994;12:95-
                                     120.
                                     Background: Through recorded history, wounds have been treated with topical
                                     medications, with the goals of speeding repair, preventing or curing infection and
                                     reducing pain or removing dead tissue. Results were variable and treatments
                                     more prolific than effective.
                                     Objective: Review the status of current scientific knowledge of how topical
                                     medications affect wounds, focusing on results relevant to clinical use.
                                     Methodology: Effects described in the review are based on controlled clinical and
                                     in vivo studies, mainly English-language references from a literature search of
                                     publications since, 1966, with greater emphasis on the more recent findings. All
                                     controlled clinical studies the authors could find were included, whereas animal
                                     studies were included only when needed to supplement controlled clinical
                                     evidence.
                                     Conclusions: A few antimicrobial or antibiotic agents durably kill or inhibit broad-
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                                     spectrum bacterial proliferation in wounds without measurably damaging the
                                     healing wound. These include silver sulfadiazine 1% cream, combination
                                     antibiotic ointments and propylene glycol. If foreign matter is present, a narrow-
                                     spectrum antimicrobial agent or a single antibiotic may kill the organisms causing
                                     the initial infection, but leave the wound prey to a wide variety of opportunistic
                                     organisms. For example, a gramicidin-neomycin sulfate combination was more
                                     effective than either agent alone in reducing colony forming units (CFUs) and
                                     clinical signs of infection in tape-stripped wounds.
                                     Combined topical antibiotics, including polymyxin B sulfate, zinc bacitracin and
                                     usually neomycin in ointment or spray formulations were reported to be safe and
                                     effective in treating blisters, burns, excisions, pyoderma and venous ulcers. They
                                     also reduce infection rates in surgical incisions and traumatic wounds and aid in
                                     remission of symptoms in steroid-treated dermatitis. Topical antibiotic ointment
                                     can reduce the likelihood of infection of dirty, contaminated wounds when applied
                                     up to 4 hours after insult.
                                     Evidence: Supporting
                                     Quality of Evidence:Good
                                     Level of Evidence: 8
Brinker (2003)                       Brinker D, Hancox JD, Bernardon SO. Assessment and initial treatment of
                                     lacerations, mammalian bites, and insect stings. AACN Clin Issues. 2003;14:401-
                                     410.
                                     Millions of wounds are seen in emergency rooms across the United States each
                                     year. The goals of wound care for all ages are to avoid infection and achieve an
                                     esthetically pleasing and functional scar. This article reviews the care needs
                                     associated with acute traumatic wounds.
                                     Cleansing: Most wounds are anesthetized before cleansing. Because the skin
                                     surrounding the wound can harbor bacteria, it is important to cleanse to remove
                                     any contaminants and dried blood. Scrubbing inside a wound has a potential for
                                     causing tissue damage. It is done only when there are visible contaminants.
                                     Providone-iodine is active against gram positive, gram negative, fungi and
                                     viruses. A 1% solution is generally not considered tissue toxic. Isopropyl alcohol
                                     and hydrogen peroxide should not be used as cleaning agents because of their
                                     tissue toxicity.
                                     Irrigation is considered the most effective method of reducing bacterial counts and
                                     removing debris and contaminants on wound surfaces. The cleansing capacity
                                     depends on the hydraulic pressure under which the fluid is delivered. An effective
                                     method is to use a 35cc syringe with an 18-gauge needle or catheter. The
                                     solution is directed into the wound at a angle perpendicular to the wound surface
                                     and as close to the wound as possible. Amount of irrigation fluid will vary with the
                                     size and contamination of the wound, but should be a minimum of 100cc of sterile
                                     saline. Some studies suggest that tap water is just as effective for irrigation.
                                     Pressure is more important component of irrigation than volume of solution. The
                                     wound is covered with a sterile sponge unit it will be repaired.
                                     Evidence: Supporting
                                     Quality of Evidence: ???
                                     Level of Evidence: 8
Fleming 1967                         Fleming, J. M. and A. O. Mansfield "The place of a topical antibiotic
                                     ointment in the treatment of common skin infections." 529-31, 1967 Oct.
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                                     Summary – Review clinical practice article supporting the use of antibiotic
                                     ointment in improving wound healing and reducing bacterial infection rates.
                                     LOI 8
                                     Quality Good
Hendley 1988                         Hendley, J. O. and K. M. Ashe "Eradication of resident bacteria of normal
                                     human skin by antimicrobial ointment." 1988-90, 2003 Jun.
                                            The application of a topical triple-antibiotic ointment (containing
                                     neomycin, polymyxin, and bacitracin) eradicated resident bacteria through
                                     25 layers of the stratum corneum and prevented repopulation of bacteria
                                     overnight but not at 1 week. Through 15 layers, mupirocin had some effect,
                                     whereas a double-antibiotic ointment had none. The reservoir of resident
                                     bacteria in the sebaceous glands is not affected by a topical antibiotic.

                                     Summary – This study showed that triple antibiotic ointment eradicated bacteria
                                     form 25 layers of the stratum corneum. Mupirocin also eradicated bacteria but to
                                     a lesser extent.
                                     LOI 3
                                     Quality Good
Hendley 1991                         Hendley, J. O. and K. M. Ashe "Effect of topical antimicrobial treatment on
                                     aerobic bacteria in the stratum corneum of human skin." 627-31, 1991 Apr.
                                             The efficacy of antimicrobial agents applied topically to the skin
                                     surface in eradicating coagulase-negative staphylococci (CNS) residing in
                                     the stratum corneum underlying the surface was examined. Glabrous skin
                                     was sampled with a 26-cm2 contact plate containing Trypticase soy agar.
                                     Five antiseptic solutions and four antimicrobial ointments were evaluated.
                                     The antiseptic solutions (10% povidone-iodine, 2% aqueous iodine, 2%
                                     tincture of iodine, 70% ethanol, and 0.5% chlorhexidine-ethanol) were
                                     applied for 15 s with a gauze sponge. The antimicrobial ointments
                                     (iodophor, silver sulfadiazine, mupirocin, and a triple-antibiotic ointment
                                     containing neomycin, polymyxin, and bacitracin) were applied and covered
                                     for 6 h with gauze. After treatment, the surface was sampled, 15 to 25
                                     keratinized layers were subsequently removed by sequential stripping with
                                     cellophane tape, and the stratum corneum was sampled. All agents were
                                     effective in eradicating CNS from the surface (80 of 88 trials). However,
                                     only 2% iodine (17 of 20 trials), iodophor (8 of 12), mupirocin (6 of 10), and
                                     the triple-antibiotic ointment (9 of 11) eradicated CNS from the stratum
                                     corneum reliably (greater than or equal to 50% of trials). The stratum
                                     corneum was repopulated with resident flora within 24 h of treatment with
                                     2% iodine (4 of 4 trials), iodophor (6 of 7), or mupirocin (5 of 6), but
                                     repopulation occurred in only 1 of 7 trials with the triple-antibiotic ointment.
                                     Topical treatment of skin with antimicrobial agents usually eradicates CNS
                                     from the skin surface but may not eradicate CNS from the stratum
                                     corneum. Only the triple-antibiotic ointment eradicated CNS from the
                                     stratum corneum and prevented repopulation with resident flora.

                                     Summary – In this study of skin infection with coagulase negative
                                     sterptococus different agents were effective at eradicating the CNS fro the
                                     surface but only the triple antibiotic ointment eradricated it from the
                                     strateum corneum.
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                                     LOI 2
                                     Quality Excellent

Hollander (1999)                     Hollander JE, Singer AJ. Laceration management. Ann Emerg Med. 1999;34:356-
                                     367.
                                     Background: Lacerations are one of the most commonly encountered problems
                                     in the emergency department. In 1996, almost 11 million wounds were treated in
                                     EDs throughout the United States. Although most lacerations heal without
                                     sequelae regardless of management, mismanagement may result in wound
                                     infections, prolonged convalescence, unsightly and dysfunctional scars and, very
                                     rarely, mortality. The goals of wound management are: avoid infection and
                                     achieve a functional and aesthetically pleasing scar. These goals may be
                                     achieved by reducing tissue contamination, debriding devitalized tissue, restoring
                                     perfusion in poorly perfused wounds and establishing a well-approximated skin
                                     closure.
                                     Objective; The authors review the general principles of wound care and expand
                                     on the use of tissue adhesives for laceration repair.
                                     Irrigation of the laceration: The efficacy of wound irrigation can be correlated with
                                     the pressure at which the irrigant is delivered to the wound. Stevenson clearly
                                     demonstrated the effectiveness of high-pressure irrigation in reducing both
                                     bacterial wound counts and wound infection rates, compared with low-pressure
                                     irrigation. Continuous irrigation is probably just as effective as pulsatile irrigation.
                                     Despite the lack of clinical studies, most authorities recommend irrigation impact
                                     pressures in the range of 5 to 8 psi. Wound impact pressure in the range of 5 to 8
                                     psi can easily be obtained with the use of a 30- to 60-ml syringe and a 19 gauge
                                     needle or Zerowet splash shield.
                                     An observational study comparing wound infection rates and cosmetic
                                     appearance at the time of suture removal demonstrated comparable results when
                                     facial wounds were repaired with and without irrigation. Although these findings
                                     need to be validated by well-designed clinical trial, they suggest that irrigation
                                     may not be required for all low-risk wounds, particularly in an area with good
                                     vascular supply, such as the face.
                                     The choice of an appropriate wound irrigant is more straightforward. Although
                                     many irrigant solutions have been suggested and tested, normal saline solution
                                     remains the most cost-effective and readily available choice. Because of their
                                     tissue toxicity, detergents, hydrogen peroxide and concentrated forms of
                                     providone-iodine should not be used to irrigate wounds.
                                     The volume of irrigation should be determined according to patient and wound
                                     characteristics such as location and cause of the wound.
                                     Evidence: Supporting
                                     Quality of Evidence: ???
                                     Level of Evidence: 8
Holt (2000)                          Holt L. 2000. Wound care. In Dolan G, Holt L (Eds). Accident and Emergency
                                     Theory into Practice. Edinburgh, Bailliere Tindall.
                                     Background: Wound care is abundant in EDs. In 1996, approximately 11 million
                                     wounds were evaluated and treated in the EDs across the United States.
                                     Objective: The author reviews general principles of wound care.
                                     Cleansing: All traumatic wounds should be considered contaminated, it is not
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                                     possible to clinically differentiate on examination which wounds are at risk
                                     because some will appear clean, while others will be obviously contaminated.
                                     Wound cleansing is essential for prevention of infection, tattoo scarring and to
                                     exclude foreign body contaminants, such as grit. Irrigation of the wound is
                                     essential to remove contaminants and reduce infection rates. Topical antiseptic
                                     solutions have been discredited recently, with normal saline coming to the fore as
                                     the optimum cleanser. Antiseptic solutions such as cetrimide and chlohexidine
                                     claim to destroy bacteria and have a detergent effect on wounds. Most of these
                                     solutions require 20 minutes contact time with bacteria to have an effect. There is
                                     little evidence to support the continued use of providone-iodine solution as a first-
                                     line method of wound cleaning; it is not recommended for routine cleansing or
                                     prophylaxis due to it cytotoxic side effects on acute and healing wounds. Other
                                     solutions, such as hydrogen peroxide, were previously thought to have
                                     decontaminating and desloughing properties, but these properties are greatly
                                     reduced once the solutions in contact with blood and pus. Also, the thermal effect
                                     of the solution adversely affects healthy tissue.
                                     Evidence: Supporting
                                     Quality of Evidence: ???
                                     Level of Evidence: 8
Hood 2004                            Hood, R., K. M. Shermock, et al. "A prospective, randomized pilot
                                     evaluation of topical triple antibiotic versus mupirocin for the prevention of
                                     uncomplicated soft tissue wound infection." 1-3, 2004 Jan.
                                            Little data exists comparing the safety and efficacy of triple antibiotic
                                     ointment (TAO) and mupirocin for prevention of uncomplicated soft tissue
                                     wound infections. The purpose of this investigation was to conduct a pilot
                                     study of the relative safety, efficacy, and cost effectiveness of the 2
                                     preparations. This was a randomized, prospective, interventional study to
                                     determine the difference in infection rates of uncomplicated soft tissue
                                     wounds between subjects treated with TAO and mupirocin ointment after
                                     standard wound care and suturing. Subjects were enrolled at presentation
                                     to the ED if they met the study inclusion criteria and were required to make
                                     one follow-up visit to the ED to determine the status of their wound
                                     (infected vs. not infected). A total of 99 patients were enrolled and
                                     assessed at the follow-up visit. The groups had similar rates of self-
                                     reported compliance with wound care and dressing changes. Patients in
                                     the mupirocin group had a greater rate of signs of infection (12% vs. 6.1%),
                                     and infection (4% vs. 0%) compared with patients in the TAO group,
                                     although neither difference achieved statistical significance. There were no
                                     serious adverse effects in either group. This pilot study found a similar rate
                                     of wound infection and adverse events between TAO and mupirocin
                                     ointments. Results should be confirmed in a larger equivalency trial.

                                     Summary – This randomized study showed no statistical difference between triple
                                     antibiotic ointment and single agent ointment. No comparison was done with a
                                     control group without antibiotic ointment.
                                     LOI 2
                                     Quality Good
Kirsner (1998)                       Kirsner RS, Froelich CW. Soaps and detergents: understanding their composition
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                                     and effect. Ostomy Wound Manage. 1998;44:62S-69S; discussion 70S.
                                     Background: The spread of disease is often linked to poor hygiene. Cleaning
                                     patients’ skin may also prevent the development of wounds by limiting risk factors
                                     associated with wound development.
                                     For thousands of years, cleaning skin has not only been an integral part of
                                     societal customs, but a part of prayer as well, signifying purity of body and soul.
                                     For example, the priest-physicians in the Temple of Amun of Karnak in Egypt
                                     during the reign of King Ramses (1113-1085 BC) were instructed “to bathe in cold
                                     water twice a day and twice a night and cleanse mouth with natron.” Natron is a
                                     mixture of sodium bicarbonate and sodium carbonate.
                                     The earliest account of soap-making dates back to the third millennium BC where,
                                     in Sumarian clay tablets, soap was described as containing a combination of
                                     water, alkali and oil. Soaps in these times were often used also as wound
                                     cleansers, followed by the application of a dressing.
                                     Objective: The authors review the composition and effects of soaps and
                                     detergents
                                     Use of soaps and detergents as wound cleansers: Despite the early uses of
                                     soaps as wound cleansers, soaps are generally used on intact skin. When used
                                     on and within wounds, the potential negative effects of irritancy and cytotoxicity
                                     are amplified by the lack of barrier protection.
                                     Evidence: Supporting
                                     Quality of Evidence: ???
                                     Level of Evidence: 8
Leveden 1987                         Leyden, J. J. and N. M. Bartelt "Comparison of topical antibiotic ointments,
                                     a wound protectant, and antiseptics for the treatment of human blister
                                     wounds contaminated with Staphylococcus aureus." 601-4, 1987 Jun.
                                             An open, randomized, human-model study was conducted to
                                     compare the effects of topical antibiotics, a wound protectant, and
                                     antiseptics on the rate of wound healing and bacterial growth using a
                                     modification of a method employing ammonium hydroxide-induced
                                     intradermal blisters inoculated with Staphylococcus aureus. Each volunteer
                                     in the study had six blister wounds (three per forearm) to which a triple
                                     antibiotic (neomycin, polymyxin B, bacitracin) ointment or one of four other
                                     test agents was applied twice a day. A control wound remained untreated.
                                     All wounds were covered with an occlusive dressing after treatment. The
                                     time to healing (100 percent epithelialization) was evaluated for each
                                     wound. Wounds were cultured for bacterial growth after two treatments.
                                     Contaminated blister wounds treated with the triple antibiotic ointment
                                     healed significantly faster (mean nine days) than wounds treated with any
                                     antiseptic and those receiving no treatment. Only the neomycin-polymyxin
                                     B-bacitracin combination effectively eliminated bacterial contamination of
                                     the wounds after two applications (within 16 to 24 hours after
                                     contamination with Staphylococcus aureus). The overall clinical
                                     appearance and healing rates of wounds treated with the triple antibiotic
                                     were ranked superior to all treatments (and no treatment) except the other
                                     antibiotic ointment in the study.
                                     Summary – In this study the authors showed that triple antibiotic ointment was
                                     superior to no treatment and single agent in wound infection rates and both single
                                     agent and triple antibiotic ointment were superior to no treatment in wound
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                                     healing rates.
                                     LOI 1
                                     Quality Excellent
Maddox 1985                          Maddox, J. S., J. C. Ware, et al. "The natural history of streptococcal skin
                                     infection: prevention with topical antibiotics." 207-12, 1985 Aug.
                                             An investigation on the natural history of streptococcal skin infection
                                     was done in fifty-nine children in a rural day care setting. A double-blind
                                     study for prevention of streptococcal pyoderma was done during the peak
                                     season for skin infection. Triple antibiotic ointment, containing bacitracin,
                                     polysporin, and neomycin, was compared to placebo ointment. Ointments
                                     were applied thrice daily for minor skin trauma; mosquito bites and
                                     abrasions were predominant. Cultures of normal skin surfaces were taken
                                     for group A streptococci each week of the 15-week study period. Skin
                                     lesions were cultured whenever present. Eighty-one percent of the fifty-
                                     nine patients had positive normal skin cultures on one or more occasions.
                                     Nineteen children (32%) developed streptococcal pyoderma. Infection
                                     occurred significantly more often in children using placebo ointment than in
                                     those using topical antibiotic (47% vs 15%; p = 0.01). The infecting strain
                                     was first recovered from normal skin surfaces in 67% of placebo patients
                                     and in two of the four patients using antibiotic ointment. This study further
                                     confirms the importance of skin carriage of group A streptococci as a
                                     precursor to pyoderma and demonstrates the importance of minor skin
                                     trauma as a predisposing factor. Topical antibiotics may be useful in
                                     preventing streptococcal pyoderma, especially in children known to be at
                                     increased risk for such infection.

                                     Summary – IN this study the investigators showed that triple antibiotic ointment
                                     was superior to ointment without antibiotic in preventing infection following
                                     superficial wounds.
                                     LOI 1
                                     Quality Excellent
Spann (2003)                         Spann CT, Tutrone WD, Weinberg JM, Scheinfeld N, Ross B. Topical
                                     antibacterial agents for wound care: a primer. Dermatol Surg. 2003;29:620-6.
                                     Background: Although often overlooked, topical antibiotic agents play an
                                     important role in dermatology. Their many uses include prophylaxis against
                                     cutaneous infections, treatment of minor wounds and infections, and elimination
                                     of nasal carriage of staphylococcus aureus. For these indications, they are
                                     advantageous over their systemic counterparts because they deliver a higher
                                     concentration of medication directly to the desired area and are less frequently
                                     implicated in causing bacterial resistance. The ideal topical antibiotic has a broad
                                     spectrum of activity, has persistent antibacterial effects, and has minimal toxicity
                                     or incidence of allergy.
                                     Objective: The authors review the principles of topical antibacterial agents for
                                     wound care.


                                     Evidence: Supporting
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                                     Quality of Evidence: ???
                                     Level of Evidence: 8
Van Zyl 2002                         Van Zyl, A., D. Abbott, et al. "Towards evidence based emergency
                                     medicine: best BETs from Manchester Royal Infirmary. Routine use of
                                     antibiotic ointment and wound healing." 556, 2002 Nov.
                                             A short cut review was carried out to establish whether topical
                                     antibiotics improved the outcome of simple wounds. Altogether 71 papers
                                     were found using the reported search, of which one presented the best
                                     evidence to answer the clinical question. The author, date and country of
                                     publication, patient group studied, study type, relevant outcomes, results,
                                     and study weaknesses of this best paper are tabulated. A clinical bottom
                                     line is stated. [References: 1]

                                     Summary – This paper presents a review of several studies of wound care.
                                     According to the authors there is evidence of the benefit of antibiotic ointment.
                                     They then gave a subjective opinion that they still might not change their clinical
                                     practice.
                                     LOI 7
                                     Quality Fair
Ward (1995)                          Ward RS, Saffle JR. Topical agents in burn & wound care. Phys Ther.
                                     1995;75:526-538.
                                     Background: With any open wound, infection may occur. Many factors such as
                                     age and general health status may increase the likelihood of infection, but the size
                                     and depth of the wound are critical factors in determining the chronicity of any
                                     wound. Infection greatly adds to morbidity associated with open wounds. An
                                     infected wound not only heals more slowly, there is also the risk of systemic
                                     infection and even death. Infected wounds also scar more severely and are
                                     associated with more prolonged rehabilitation. Topical therapeutic agents have
                                     been shown to be effective in the management of open skin wounds. These
                                     agents may assist less complicated healing and decrease the conversion of a
                                     partial-thickness injury to a full-thickness injury and thereby reduce wound-related
                                     morbidity
                                     Objective: Common topical agents with suggestion for application are discussed
                                     in this review.
                                     Antiseptics: Antiseptics are used to reduce bacterial contamination by inhibiting
                                     the growth of microorganisms & antiseptics should be applied to intact skin and
                                     not used directly on wounds as topical agents. Antiseptics may increase the
                                     intensity and duration of inflammation and they have also been shown to be toxic
                                     to human keratinocytes and fibroblasts and to retard epithelialization.
                                     Iodine solutions and idophors are often used as antiseptics. Diluted iodine
                                     solutions (iodine solution USP [United States Pharmacopeia] and [2% iodine,
                                     2.5% sodium iodide] and iodine tincture USP [2% iodine, 2.5% sodium iodide,
                                     50% alcohol]), though bactericidal, may irritate tissue, stain the skin and cause
                                     sensitization.
                                     Hydrogen peroxide is very commonly used as an antiseptic on wounds; however,
                                     it has limited bactericidal effectiveness, is toxic to fibroblasts and impairs the
                                     microcirculation of wounds. The mechanical cleansing effect of hydrogen
                                     peroxide often attribute to the “fizzing” (which is caused by its decomposition to
                                     oxygen and water when it comes in contact with blood and tissue fluids) is
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                                     questionable. Given the concerns about the detrimental effects of hydrogen
                                     peroxide on tissue at the wound site, it is not recommended as an antiseptic.
                                     Topical agents: “Topical agents” implies the use of an antimicrobial applied to the
                                     surface of the wound. The importance of a topical application is particularly
                                     apparent in ischemic wounds, in which dependable dispatch of a systemic (i.e.,
                                     bloodstream) antimicrobial to the damaged tissue cannot be assured. Further,
                                     the loss of the stratum corneum decreases the resistance of percutaneous
                                     absorption of the chemical agents.
                                     Ointments: Techniques and Indications for use. Ointments are water-in-oil
                                     preparations in which the amount of oil exceeds the amount of water in the
                                     emulsion. The ointment base of these topical agents is comfortable and soothing
                                     and can be used on both partial- and full-thickness injuries. Ointments are
                                     typically more occlusive and lubricating than other preparations. Ointments
                                     should be applied just thickly enough to cover the wound and keep the wound
                                     moist. A petrolatum gauze is often placed over the ointment-covered wound. The
                                     dressing should be changed routinely, because the antibacterial action of the
                                     ointments will last for only approximately 12 hours. In addition, the ointments
                                     eventually dry and the dressings will then stick to the wound, leading to pain and
                                     damage of cells with removal.
                                     The properties of following ointments were reviewed: bacitracin, polymyxin b
                                     sulfate, neomycin, polysporin & neosporin, povidone-iodine. Silver sulfadizine 1%
                                     cream, mafenide acetate 0.5% cream, nystatin, nitrofurazone 0.2% compound,
                                     gentamicin 0.1% cream, acetic acid 0.5%, sodium hypochlorite, silver nitrate
                                     0.5%, triple antibiotic solution and chlorhexidine gluconate solution were the other
                                     topical agents reviewed.
                                     Conclusion: Because of the availability of several effective topical agents, wound
                                     care protocols may vary and still meet with success. Observation of the wound
                                     along with the appropriate selection of a topical therapeutic agent, can improve
                                     the healing of wounds and lead to decreased patient morbidity.
                                     Evidence: Supporting
                                     Quality of Evidence: ???
                                     Level of Evidence: 8
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                                                               Citation List
    1. Bolton L, Fattu AJ. Topical agents and wound healing. Clin Dermatol. 1994;12:95-120.
    2. Brinker D, Hancox JD, Bernardon SO. Assessment and initial treatment of lacerations, mammalian
       bites, and insect stings. AACN Clin Issues. 2003;14:401-410.
    3. Hollander JE, Singer AJ. Laceration management. Ann Emerg Med. 1999;34:356-367.
    4. Holt L. 2000. Wound care. In Dolan G, Holt L (Eds). Accident and Emergency Theory into Practice.
       Edinburgh, Bailliere Tindall.
    5. Spann CT, Tutrone WD, Weinberg JM, Scheinfeld N, Ross B. Topical antibacterial agents for wound
       care: a primer. Dermatol Surg. 2003;29:620-626.
    6. Ward RS, Saffle JR. Topical agents in burn & wound care. Phys Ther. 1995;75:526-538.

				
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