Ultraviolet Light C in the Treatment of Chronic Wounds with MRSA: A Case Study
- 0 Comments
- 23596 reads
A worldwide development of virulent bacteria that are resistant to multiple antimicrobial treatments is occurring.1 One strain of antibiotic-resistant bacteria currently receiving attention is methicillin-resistant Staphylococcus aureus (MRSA). In many hospitals in the United States and Europe, the prevalence of MRSA has increased from less than 3% in the early 1980s to rates as high as 40% in the 1990s.2-5 Since the first report of MRSA in Canada in 1981, the number of MRSA cases has increased dramatically, and cases of community-acquired MRSA also have been documented.6-15 Methicillin-resistant S. aureus bacteria colonize the skin and open wounds and may interfere with wound healing.16
Artificially produced ultraviolet light (UVL) was introduced as a therapeutic treatment for skin disorders at the beginning of the 20th century.17 Cell culture and animal studies that have examined mechanisms by which UVL augments wound repair propose that UVL can stimulate cell proliferation,18 epidermal thickness,19 blood flow in the cutaneous capillaries,20 and wound debridement.21 A particular wavelength of UVL of between 200 nm and 290 nm called ultraviolet light C (UVC) has been shown to have bactericidal effects.22-26
Recent studies indicate that UVC can kill antibiotic-resistant strains of bacteria such as MRSA in laboratory cells and in animal tissue.24,26 However, whether UVC can kill these bacteria when applied to human chronic wounds, using suggested clinical protocols, is not known. The purpose of this case study was to evaluate the potential role of UVC in reducing wound bioburden and improving wound status in chronic ulcers infected with MRSA.
UVC treatment protocol. Using an application technique that has been previously described by Nussbaum et al,21 UVC was applied at a distance of 1 inch and perpendicular to the wound using premeasured disposable spacers. Before treatment, a 254-nm, cold quartz UVC generator, approved for clinical use in Canada (supplied by Medfaxx Inc., Raleigh, NC) was warmed for 5 minutes before being placed over the wound. The ulcer was cleansed with sterile saline, a thick layer of petroleum jelly was applied to the surrounding periulcer skin and any healthy granulation tissue, and the wound edges were covered with a drape.
The UVC generator was applied to the wound for 180 seconds per wound site. This length of time is recommended for the treatment of infected ulcers21 and was selected based on the MRSA killing rates reported in a previous in vitro study.24 To shield the eyes from UVC, the therapist and patient wore protective goggles. All products applied to the patient were sterilized or discarded after a single use. Equipment that had to be reused was decontaminated using appropriate protocols.
Subject recruitment. Approval for research involving human subjects was obtained from appropriate institutional review boards. The purpose, method, risks, and benefits of UVC treatment were explained to the patients and/or their substitute-decision makers and informed consent was obtained. Patients included in this case series had a chronic ulcer present for at least 3 months that was infected with MRSA. By definition, an infected wound has a positive swab culture and clinical signs of infection, including: marked redness extending beyond the wound margins; increased pain; and increased amounts of foul smelling, purulent wound exudates. Oral antibiotic or topical antimicrobial therapy may or may not be required.27
1. McGeer A, Low D, Conly J, et al. Methicillin-resistant Staphylococcus aureus in Ontario. Can Commun Dis Rep. 1997;23:45-46.
2. Boyce JM, Causey WA. Increasing occurrence of methicillin-resistant Staphylococcus aureus in the United States. Infection Control. 1982;3:377-383.
3. Haley RW, Hightower AW, Khabbaz, RF, et al. The emergence of methicillin-resistant Staphylococcus aureus infections in United States hospitals. Possible role of the house staff-patient transfer circuit. Ann Intern Med. 1982;97:297-308.
4. Panlilio AL, Culver DG, Gaynes RP, et al. Methicillin-resistant Staphylococcus aureus in US hospitals 1975-1991. Infection Control Hospital Epidemiology. 1992;13:582-586.
5. Voss A, Milatovic D, Wallrauch-Schwarz C, et al. Methicillin-resistant Staphylococcus aureus in Europe. European Journal Clinical Microbiology Infectious Disease. 1994;13:50-55.
6. Low DE, Garcia M, Callery S, et al. Methicillin-resistant Staphylococcus aureus in Ontario. Canada Disease Weekly Report. 1981;7:249-250.
7. Dammann TA, Wiens RM, Taylor GD. Methicillin-resistant Staphylococcus aureus identification of a community outbreak by monitoring hospital isolates. Can J Public Health. 1988;79:312-315.
8. Taylor G, Kirkland T, Kowalewska-Grochowska K, et al. A multistrain cluster of methicillin-resistant Staphylococcus aureus based in a native community. Canadian Journal Infectious Disease. 1990;1:121-126.
9. Vortel JJ, Bell A, Farley JD, et al. Methicillin-resistant Staphylococcus aureus (MRSA) in a British Columbia hospital - 1990. Canada Disease Weekly Report. 1991;17:71-72.
10. Boyd N, Gidwani R. Colonization of methicillin-resistant Staphylococcus aureus in southwestern Ontario. Canada Disease Weekly Report. 1991;17:72-73.
11. Nicolle LE, Bialkowska-Hobrzanska H, Romance L, et al. Clonal diversity of methicillin-resistant Staphylococcus aureus in an acute-care institution. Infection Control Hospital Epidemiology. 1992;13:33-37.
12. Embil J, Ramotar K, Romance L, et al. Methicillin-resistant Staphylococcus aureus in tertiary care institutions on the Canadian prairies 1990-1992. Infection Control Hospital Epidemiology. 1994;15:646-651.
13. Simor AE, Augusin A, Ng J, et al. Control of MRSA in a long-term care facility. Infection Control Hospital Epidemiology. 1994;15:69-70.
14. Green K, Low DE. MRSA in Ontario - results of questionnaire survey. Laboratory Proficiency Testing Program Newsletter No. 181, June 25, 1996:1-3.
15. McGeer A, Low DE, Conly J, et al. The rapid emergence of a new strain of MRSA in Ontario: laboratory and infection control implications. Laboratory Proficiency Testing Program Newsletter No. 190, October 29, 1996:1-4.
16. Rao GG. Risk factors for the spread of antibiotic-resistant bacteria. Drugs. 1998;55(3):323-330.
17. Licht S. History of Ultraviolet Therapy in Therapeutic Electricity and Ultraviolet Radiation. Baltimore, Md.: Waverly Press;1967:191.
18. Eaglstein WH, Weinstein GD. Prostaglandin and DNA synthesis in human skin: possible relationship to ultraviolet light effects. J Invest Dermatol. 1975;64(6):386-389.
19. Agin PP, Rose AP, Lane CC, Akin FJ, Sayre RM. Changes in epidermal forward scattering absorption after UVA or UVA-UVB irradiation. J Invest Dermatol. 1981;76(3):174-177.
20. Greaves MW, Sondergaard J. Pharmacologic agents released in ultraviolet inflammation studied by continuous skin perfusion. J Invest Dermatol. 1970;54:365-367.
21. Nussbaum EL, Biemann I, Mustard B. Comparison of ultrasound/ultraviolet-C and laser for treatment of pressure ulcers in patients with spinal cord injury. Phys Ther. 1994;74 (9):812-825.
22. High A, High J. Treatment of infected skin wounds using ultra-violet radiation: an in vitro study. Physiotherapy. 1983;69:359-360.
23. Burger A, Jordaan AJ, Schoombee GE. The bactericidal effect of ultraviolet light on infected pressure sores. South African Journal of Physiotherapy. 1985;41(2):55-57.
24. Conner-Kerr TA, Sullivan PK, Gaillard J, Franklin ME, Jones RM. The effects of ultraviolet radiation on antibiotic-resistant bacteria in vitro. Ostomy/Wound Management. 1998;44 (10):50-56.
25. Sullivan PK, Conner-Kerr TA, Smith ST. The effects of UVC irradiation on group A streptococcus in vitro. Ostomy/Wound Management. 1999;45(10):50-54, 56-58.
26. Conner-Kerr TA, Sullivan PK, Keegan BS, Reynolds W, Sagemuehl T, Webb A. UVC reduces antibiotic-resistant bacterial numbers in living tissue. 1999 SAWC Selected Abstracts. Ostomy/Wound Management. 1999; 45(4):84.
27. Sibbald RG, Williamson D, Orsted HL, Campbell KE, Keast DH, Krasner D, Sibbald D. Preparing the Wound Bed - Debridement, Bacterial Balance, and Moisture Balance. Ostomy/Wound Management. 2000; 46(11):14-35.
28. Levine NS, Lindberg RB, Mason AD. The quantitative swab culture and smear: a quick simple method for determining the number of viable aerobic bacteria on open wounds. J Trauma. 1976;16:89-94.
29. Maklebust J, Sieggreen M. Pressure ulcers: Guidelines for Prevention and Nursing Management. West Dundee, Ill.: S-N Publications;1991.
30. Cuzzell JZ. The right way to culture a wound. Am J Nurs. 1993;93:48- 50.
31. Alvarez O, Rozint J, Meehan M. Principles of moist wound healing: indications for chronic wounds. In: Krasner D, ed. Chronic Wound Care: A Clinical Source Book for Health Care Professionals. King of Prussia, Pa.: Health Management Publications, Inc.; 1990:266-281.
32. Bates-Jensen BM. The Pressure Sore Status Tool a few thousand assessments later. Advances in Wound Care. 1997;10(5):65-73.
33. Wills EE, Anderson TW, Beattie BL, Scott A. A randomized placebo-controlled trial of ultraviolet light in the treatment of superficial pressure sores. J Am Geriatr Soc. 1983;31(3):130-33.
34. Dow G, Browne A, Sibbald RG. Infection in chronic wounds: controversies in diagnosis and treatment. Ostomy/Wound Management. 1999;45(8):23-40.
35. Herruzo-Cabrera R, Vizcaino-Alcaide MJ, Pinedo-Castillo C. Diagnosis of local infection of a burn by semiquantitative culture of the eschar surface. Journal of Burn Care and Rehabilitation. 1992;13:639-641.