Do we use antibiotics judiciously enough? A study in Accident & Emergency Department of tertiary care hospital in Pakistan

Objective: To determine whether antibiotics are necessary for all minor wounds presenting to the Accident and Emergency Department at a tertiary care Centre in Pakistan. Methods: One hundred and five patients presenting to the Accident & Emergency Department, Jinnah Postgraduate Medical Centre, Karachi, with open wounds were included in the study and divided into two: Groups A (study) and B (control), with Group-A receiving conservative therapy. Eighty-four patients were included in the final analysis as the rest were lost to follow up. Follow up was done after one week to see how many patients had developed infection. Results: The average age of patients was 27.3 +/-9.7 years with similar baseline characteristics. From these, 51% had superficial wounds; average number of wounds was 1.63 +/-0.99, with an average length of 2.7 +/-1.6 cm. A total of 10 out of 84 patients developed infection at 7-10 days after presentation to the A&E. From these, 3 patients receiving conservative treatment (A, 10%, OR=0.107), and seven patients receiving prophylactic antibiotics (B, 12.96%, OR=0.149) developed an infection. Calculated odds ratio for increased risk of infection in Group-A = 0.72. Conclusion: A conservative approach to antibiotic prescription for minor trauma may be appropriate despite absence of strict asepsis during emergency wound care.


INTRODUCTION
Patients commonly present to the Emergency Department after minor trauma, usually secondary to falls or other trivial accidents. Traditionally, it is felt that, due to absence of strict asepsis during wound care, as well as multiple patient factors ,all patients with open wounds regardless of severity should be prescribed prophylactic antibiotics to prevent wound infection.
In contrast to this, the World Health Organization (WHO) 1 , as well as other regional organizations (e.g. IDSA 2 ), employs stringent guidelines for antibiotic prophylaxis and treatment after trauma to curtail unnecessary use. These guidelines largely apply to more severe wounds that would require management in an OR, since prophylactic antimicrobials are not generally administered for superficial wounds. This is because uncontrolled use of antibiotics is potentially harmful -it exposes patients to the unnecessary risk of antibiotic associated side effects (including anaphylaxis and GI symptoms), as well as increases the risk of emergence of antibiotic resistance within local pathogens. 3 In this study, we aimed to determine the effectiveness of conservative antibiotic prescription approach in local population. Prescription of antibiotics on discharge for: 1. All contaminated and/or infected wounds 1 2. All human bite wounds and deep animal wounds 4 3. All wounds > 5cm in length or receiving > 7 sutures 4. All wounds > 1 cm in depth 5. Wounds older than 12 hours 1 6. Crush injuries not treated by delayed closure 4 7. Injuries to high-risk regions (intra-oral, on hands/feet) 6 Patients in Group-A not meeting the above criteria were discharged without an antibiotic prescription. Drugs used: Co-Amoxiclav, 625 mg to 1 g BID. The exact dose was left to the physician's discretion, on the infection risk based on history, presentation, number of wounds, etc. After treatment in the ER, all the patients were instructed on wound care methods and told to change the dressing every second day.

RESULTS
We enrolled 105 patients, 21 of whom were lost to follow-up, or did not comply with given instructions on antibiotic use. Of the remaining 84 patients (mean age 27.3 years, N=84), 30 (35.7%) had been assigned to Group-A, and 54 (64.3%) had been randomly assigned to Group-B.

Classification of Depth Definition
Superficial Through the epidermis, with intact dermis Partial Thickness Partially through dermis, with deeper portion still intact Full Thickness Through dermis, with underlying structures exposed  total of 10 patients developed infection at 7-10 days after presentation to the A&E (Table-IV).
Of the patients that developed infection, 7/10 had changed their dressing on a daily basis; 8/10 had injuries to an extremity (which is considered a high-risk region); 1/10 had a scalp laceration and 1/10 had an injury to the earlobe. Partial thickness wounds were present in 7 patients, two patients had full thickness wounds and one had a superficial wound.

DISCUSSION
It is our observation that, in Pakistan, patients presenting to ER with minor lacerations, or even abrasions, due to any cause are generally prescribed antibiotics prophylactically, though we were unable to find exact statistics in the literature regarding the prevalence of this practice in the country. Studies carried out in other parts of the world show that Emergency Room physicians tend to prescribe antibiotics despite lack of evidence of their efficacy. 7 In Pakistan, this is possibly due to the belief that the majority of population (which is impoverished) is at a greater risk of infection. There are many factors which contribute to this belief, including generally poor hygiene, wide spread malnutrition, lack of knowledge regarding proper wound care, and closure of wounds in the absence of aseptic precautions.
However studies have shown that wound closure for minor wounds need not be done in a sterile environment, as long as techniques for surgical cleanliness are used. 8,9 Hygienic practices and proper wound care can be addressed at discharge and is not a suitable reason to prescribe antibiotics. International guidelines, opinions and consensus statements 1,10-12 advise against antibiotics for minor open wounds as they have no proven benefit. Larger penetrating wounds, however, should be managed with prophylactic antibiotics. Older wounds (>12 hours), and obvious infection also warrant antibiotics. Other high-risk wounds including crush injuries and lacerations of oral mucosa may also require antibiotic therapy (as mentioned earlier). Here the question arises, "why not prescribe antibiotics for small wounds just to be safe?" Any prescription must be given after careful analysis of the benefit-to-risk ratio. 12 In the absence Use of antibiotics in emergency of any obvious protective benefit, the prescription of prophylactic antibiotics cannot be justified. Side effects of antibiotics range from mild GI irritation 13 to acute kidney injury 14 , C. difficle colitis 15 , Stevens -Johnson syndrome/Toxic Epidermal Necrolysis 16 , and life-threatening anaphylaxis. 17 Furthermore, uncontrolled use of antibiotics contributes to development of resistant pathogens. This is rapidly becoming a major concern worldwide. Prescription of unnecessary medication puts a further strain on non-affording patients as well. We chose to exclude patients at extremes of age, and those with co-morbids that generally predispose to infections, as we felt that this subset of patients is beyond the scope of this study.

CONCLUSION
Judicious use of antibiotics in otherwise healthy patients with minor wounds seems to be safe and offers the benefits of decreased side effects and prevention of development of antibiotic-resistant bacteria. We believe that antibiotic prescription should be avoided in patients with minor trauma and no specific risk factors for wound infection due to the potential for great benefit not just for these patients, but also for the community at large.