I have a patient who had a failed mesh placement and a panniculectomy and who has developed at least three separate fistulas with a very large amount of output (3-4 L/24 hrs). Any suggestions? I am using an Eakin wound management pouch hooked up to wall suction.
A Prospective, Descriptive Study to Identify the Microbiological Profile of Chronic Wounds in Outpatients
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Abstract Indiscriminate use of antibiotics for infected chronic wounds is a global problem that may contribute to delayed healing and the development of drug-resistant micro-organisms. A prospective, descriptive cohort study of 50 male and female outpatients (mean age 52.50 [± 14.84] years, range 18–90) with 52 chronic wounds was conducted to investigate the microbiological profile and prevalence of drug-resistant strains in chronic nonhealing wounds to develop an evidence-based approach to antibiotic therapy until drug sensitivity reports are available. Mean wound duration was 8.23 (± 12.35) months (range 1.5–72), average wound size was 29.70 (± 37.83) cm, and most patients had a lower extremity wound and diabetes mellitus (n = 20). Pus and tissue samples were cultured and tested. Most (45) wounds contained a single organism and nine different genera were isolated. Of those, 39 were Gram-negative and 11 were Gram-positive (z = 5.50, P =<0.001). The most common organisms were Pseudomonas (21 wounds) and Escherichia coli (eight wounds). Pseudomonas aeruginosa was more common in patients with diabetes mellitus, in lower extremity ulcers, and in ulcers >20 cm2 (z-test, P <0.05). The presence of two organisms was more commonly observed in postsurgical/traumatic wounds. Ten (10) out of 55 pathogens (18.18%) isolated were drug-resistant, including Pseudomonas (seven), methicillin-resistant Staphylococcus aureus (one), and extended-spectrum beta lactamase (two — E. coli and Citrobacter). Most (70%) drug-resistant pathogens were obtained from persons with diabetes mellitus. Overall sensitivity to piperacillin and tazobactum combination was high. Because the prevalence of monomicrobial flora in chronic wounds is high, if a wound infection is suspected, empiric therapy should target the most prevalent flora. The high rate of drug-resistant Pseudomonas and MRSA strains should discourage antibiotic use in chronic ulcers before obtaining culture results.
When progress stalls during any stage of the healing process, a chronic wound (ie, a wound of >6 weeks’ duration) may develop.1 Such wounds are associated with great physical and psychological patient burden in terms of pain, wound discharge, infection, and resources, 2 demanding extensive therapy and increased dependence on nursing services. 3 Literature on microbial populations that colonize chronic wounds reflects the diversity of patient demographics, underlying wound etiology (eg, venous ulcers, diabetic foot ulcers), duration of treatment, technique used to collect specimens, and species. 4,5 The microflora is usually polymicrobial and complex and has been found in vivo to range from 1.6 to 4.4 species per ulcer, 6 with the potential to change over time. 7 In various prospective and retrospective studies, Staphylococcus aureus and coagulase-negative Staphylococcus are the species most commonly isolated, occurring in frequencies ranging from 43% of infected leg ulcers8 to 88% of nonsymptomatic ulcers. 9 Pseudomonas aeruginosa has been identified in 7% to 33% of ulcers. 9 Other aerobic species including Klebsiella, Escherichia coli, Proteus species, Enterobacter, and Enterococci8-10 make the list extensive and complex. Anaerobic organisms are also frequently identified, ranging in prevalence in chronic wounds from as low as 6% to as high as 88%8,11 and include Peptostreptococcus, Prevotella, Finegoldia magna, and Bacteroides. 11 
Although not exhaustive, this list demonstrates the wide range of microbial flora that may colonize a chronic wound.
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