Nieprawidłowe i nadmierne stosowanie antybiotyków w leczeniu ran zakażonych jest jedną z przyczyn rosnącej na całym świecie oporności drobnoustrojów. Dlatego w praktyce klinicznej zaleca się unikanie stosowania antybiotyków w leczeniu ran. Istnieją jednak przypadki, w których antybiotykoterapia jest ostatnią opcją terapeutyczną. Jakie są najważniejsze zasady stosowania antybiotyków w przypadku ran zakażonych?
W praktyce klinicznej wdrożenie antybiotykoterapii w leczeniu ran zakażonych powinno być poprzedzone oceną mikrobiologiczną stanu rany, a także oceną objawów i rozległości zakażenia. Zaleca się, by antybiotyki były podawane drogą inną niż miejscowa i tylko w momencie, gdy zakażenie rozprzestrzenia się i występują objawy ogólnoustrojowe.
Które drobnoustroje są najczęściej odpowiedzialne za zakażenia ran?
W ranach przewlekłych najczęściej dochodzi do zakażenia bakteriami tlenowymi, takimi jak Staphylococcus aureus, gronkowce koagulazoujemne, paciorkowce beta-hemolizujące, Enterococcus sp., Corynebacterium sp., Escherichia coli, Klebsiella sp., Enterobacter sp., Proteus sp. i Pseudomonas aeruginosa. Infekcję, zwłaszcza w przypadku głębszych ran, mogą również powodować bakterie beztlenowe z rodzaju Peptostreptococcus, Clostridium, Bacteroides, Prevotella, Porphyromonas, Fusobacterium oraz Propionibacterium acnes. Czynnikiem etiologicznym zakażenia ran są również grzyby, szczególnie z rodzaju Candida.
Jakie są czynniki zwiększające ryzyko infekcji?
Na zakażenie najbardziej narażone są rany pierwotnie zanieczyszczone, np. w czasie wypadku drogowego, z obecnością ciała obcego, a także rozległe urazy (np. oparzenia) i rany pooperacyjne. Czynnikami zwiększającymi zakażenie rany są również niedobory odporności (wrodzone lub nabyte), podeszły wiek lub wczesny okres życia, choroby przewlekłe, np. cukrzyca, niedożywienie oraz otyłość. Ryzyko rozwoju infekcji zwiększają również czynniki lokalizacyjne, środowiskowe (np. zawodowe), niezdrowy styl życia, używki, złe standardy opieki leczenia ran i niektóre leki.
Istotną przeszkodą w diagnostyce oraz w terapii infekcji jest możliwość wytwarzania przez ranę biofilmu, czyli warstwy, w której znajduje się wiele drobnoustrojów odpornych na działania zwalczające. Biofilm występuje w większości ran z obecnością zakażenia (w 60-100 proc. przypadków), a jego struktura uniemożliwia penetrację antybiotyków. Obecność biofilmu znacznie opóźnia, a nawet całkowicie hamuje proces gojenia.
Jakie badania diagnostyczne należy wykonać w kierunku wykrycia rodzaju zakażenia?
Badania laboratoryjne powinny zostać wykonane tylko wtedy, kiedy rozważane jest wdrożenie antybiotykoterapii w leczeniu rany. Ponadto próbki powinny zostać pobrane, gdy nie zaobserwowano poprawy leczenia antyseptykami i opatrunkami antybakteryjnymi, a także w przypadku obecności objawów zakażenia ogólnoustrojowego. Podstawową metodą identyfikacji bakterii jest posiew drobnoustrojów w warunkach laboratoryjnych. Do tego badania konieczne jest pobranie wymazu z rany. W przypadku podejrzenia zakażenia ogólnoustrojowego pacjenta zalecane jest również wykonanie posiewu z krwi.
Rozpoznanie zakażenia niejednokrotnie jest utrudnione, ponieważ ww. metody hodowli bakterii pozwalają na wykrycie tylko części gatunków infekujących ranę. Zwłaszcza bakterie beztlenowe, a także niehodowlane lub trudno hodowlane, są trudne do zidentyfikowania. Dlatego tak istotna jest również ocena objawów towarzyszących zakażeniu.
Jakie są objawy zakażenia rany?
Rozwój infekcji w ranie może manifestować się poprzez jej nieprzyjemny zapach czy zaczerwienienie tkanek wokół rany. Pacjenci mogą również odczuwać ból w ranie, z której może sączyć się wydzielina. Proces gojenia jest wówczas nieznacznie zaburzony. Kolejne etapy rozwoju infekcji mogą objawiać się poprzez zaczerwienienie miejsca urazu lub tkanek wokół rany, obrzęk, ropny wysięk, a także ból. O infekcji w ranie świadczy także pieczenie w ranie, uczucie pulsowania i zwiększona temperatura w ranie. Dalsze etapy infekcji miejscowej to zajęcie sąsiadujących tkanek, zapalenie tkanki łącznej, naczyń chłonnych i tkanek otaczających. W najcięższym stadium infekcji rany dochodzą również objawy ogólnoustrojowe, czyli gorączka, osłabienie, leukocytoza. Ten etap zakażenia może prowadzić do rozwoju sepsy.
Objawy zakażenia w przypadku ran trudno gojących się mogą być jednak nieco inne, zwłaszcza w początkowym stadium infekcji. Pacjenci mogą odczuwać wyższy poziom bólu, obserwować zwiększony wysięk z rany, zaburzenia gojenia czy uszkodzenia tkanek przyrannych. Ponadto może dojść do zmiany zabarwienia łożyska rany, pojawienia się krwawienia lub kruchej ziarniny, a także stwardnienia tkanek, kieszonkowania oraz mostkowania.
Antybiotykoterapia w leczeniu ran
Wdrożenie antybiotykoterapii zalecane jest, gdy infekcja zaczyna się rozprzestrzeniać w tkankach, naciek zapalny przekracza 5 cm obszaru wokół rany oraz pojawiają się ogólnoustrojowe objawy zakażenia. W praktyce klinicznej w leczeniu ran zakażonych zaleca się podawanie antybiotyków celowanych, drogą inną niż miejscowa, po wykonaniu odpowiednich badań mikrobiologicznych. Wybór antybiotyku powinien być uzależniony od ciężkości infekcji i dodatkowych czynników, które mogą wpływać na rozwój zakażenia. Antybiotykoterapię celowaną zaleca się ponadto w przypadku martwiczego zapalenia powięzi, zgorzeli gazowej, które mogą prowadzić do wstrząsu toksycznego, a także ran kąsanych zadanych przez zwierzęta, gdzie ryzyko zakażenia może wynosić nawet do 50 proc.
Oprócz podawania antybiotyków istotna jest również prawidłowa pielęgnacja rany polegająca na oczyszczaniu rany z zastosowaniem bezpiecznych dla tkanek środków przeciwdrobnoustrojowych, a także stosowanie odpowiednio dobranych opatrunków z substancją przeciwdrobnoustrojową oraz antyseptyków w płynie, żelu maści lub opatrunku.
Antybiotykoterapia miejscowa w leczeniu ran – dlaczego nie jest wskazana?
Antybiotykoterapia miejscowa zalecana jest wyłącznie w szczególnych okolicznościach, np. w przypadku ran z odsłoniętymi kośćmi lub ranami penetrującymi do kości i może być przeprowadzana tylko przez wysoce wykwalifikowany zespół terapeutyczny.
Nie istnieją dowody naukowe mówiące o skuteczności miejscowego leczenia ran antybiotykami. Natomiast zgodnie z obecnym stanem wiedzy – miejscowo stosowany antybiotyk nie jest w stanie przedostać się przez warstwę biofilmu, a więc osiągnięcie terapeutycznego stężenia antybiotyku w ranie nie jest możliwe. Ponadto bakterie w kontakcie z antybiotykiem wytwarzają oporność na jego działanie.
Więcej tematów związanych z zakażeniami będzie poruszanych na konferencji II Forum Zakażeń, która odbędzie się w dniach 12-14 maja w Jachrance. Serdecznie zapraszamy do rejestracji!
Źródła:
Interdyscyplinarna grupa ekspertów, M. Bartoszewicz, T. Banasiewicz, K. Bielecki i wsp., „Zasady postępowania miejscowego i ogólnego w ranach/owrzodzeniach przewlekłych objętych procesem infekcji” w: „Forum Zakażeń” 2019;10(1), str. 1-30
U. Zielińska, Borkowska, A. Zdun, „Miejsce antybiotykoterapii w leczeniu ran” w: „Pielęgniarstwo w Anestezjologii i Intensywnej Opiece” 2019;5(4), str. 121-125
B. Kowalska-Krochmal, „Miejsce antybiotyków w zakażeniach skóry i tkanek miękkich” w: „Forum Zakażeń” 2013;4(5), str. 291-297
W. Hryniewicz, J. Kulig, T. Ozorkowski i wsp., „Stosowanie antybiotyków w wybranych zakażeniach skóry i tkanek miękkich”, Narodowy Program Ochrony Antybiotyków, Ministerstwo Zdrowia, str. 5-6
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