Antibiotics in the treatment of wounds

In selecting an antibiotic, considerations include the sensitivity of the pathogen, drug distribution to the site of infection, bacteriostatic or bactericidal action under the existing tissue conditions, safety, and cost. Ideally, in vitro susceptibility of the pathogen can be obtained. In addition, cytologic evaluation, including a Gram stain, may be helpful in directing the initial course of therapy. Antibiotic sensitivity does not by itself guarantee satisfactory results. The terms "sensitive" and "resistant" are relative terms based on achievable blood levels of antimicrobial agents. The term "sensitive" implies that the level necessary to inhibit bacterial growth is achieved when an adequate dose is given at appropriate intervals. The distribution of the drug and, in turn, the level achieved at the site of infection depends on a number of factors, including molecular size, protein binding, and lipid solubility. Because, in most cases, specific tissue concentrations are not known, serum concentrations are used to represent the levels in the extracellular fluid space, which is the site of most bacterial infections. The local environment can further enhance or hinder antimicrobial penetration and activity. The antibiotic concentration achieved in the blood affects the concentration at the site of infection because simple passive diffusion appears to be the method of transport for most antibiotics. The antibiotic activity after reaching the site of infection is influenced by environmental conditions. Local production of enzymes, purulent and fibrinous exudate, and pH changes can adversely affect drug action. With many of these variables being difficult to predict, knowledge of etiologic agents is the cornerstone of rational use of the antimicrobial drugs. A reasonable suspicion based on clinical signs and knowledge of likely pathogens can guide the initial choice of antimicrobial therapy. Since both aerobic and anaerobic organisms may be involved in wound infections, and because antibiotic sensitivity of many of these pathogens is unpredictable, broad-spectrum antimicrobial therapy is often warranted initially.