References
Effect of four-layer dressing on the microbiological profile of venous leg ulcer
Abstract
Objective:
Venous leg ulcer (VLU) is a chronic disease and has periods of exacerbation and remission. Various bandage systems—single-layered, double-layered and multiple-layered with elastic and non-elastic components—have been developed. The requirement for sustained pressure brought about the introduction of the four-layer bandage. We studied the bacteriology of VLUs and the effect of four-layer bandages on their healing.
Method:
Clinical details of all patients, with wound size measurement by gauze piece, wax paper and scale, were recorded. The wounds were initially debrided and photographic records of all patients were maintained. Patients were followed up every week, when the dressings and four-layer bandages were changed.
Results:
A total of 60 patients were recruited to the study with four patients having bilateral disease and so a total of 64 VLUs were evaluated. Of these, 60 (93.8%) healed completely, one (1.6%) healed partially and three (4.7%) did not heal. After excluding the four VLUs that did not fully heal, 10 (16.7%) had recurrence while 50 (83.3%) had no recurrence in the follow-up period, which lasted for one year. During the first visit (baseline), meticillin-resistant Staphylococcus aureus (MRSA) was isolated in 29 (45.31%) VLUs and Pseudomonas spp. in 20 (31.25%) VLUs. With subsequent dressing, the VLU size decreased and the culture of the VLU was sterile from the third culture onwards in 45 cases. There was a significant correlation (p<0.001) between VLU size and the number of dressings.
Conclusion:
Compression therapy is the mainstay of treatment of VLU, with rapid healing and improvement in bacteriological profile. Compression in the range of 30–40mmHg is the most effective treatment for uncomplicated VLUs with adequate arterial competency.
The majority of leg ulcers are secondary to chronic venous insufficiency (CVI), the vascular insufficiency caused by valvular insufficiency in either the deep venous system or the superficial venous system. The resulting venous hypertension leads to leakage of fluid and fibrinogen from the stretched veins into tissue, forming a pericapillary fibrin cuff, which leads to reduced diffusion of oxygenated blood to the tissue, resulting in ulceration. There is also a reduced pressure gradient between the arteriolar and venular ends of the capillaries, resulting in sluggish movement of the blood within them and adherence of blood cells to the endothelium. Inflammatory mediators and reactive oxygen species are released, leading to obliteration of functioning capillary loops, thus aggravating ischaemia and resulting in ulceration. Capillaries can also be occluded by microthrombi and exhibit long intracapillary stasis, which in turn reduces nutrition and oxygenation of the skin and leads to ulceration.
Venous leg ulcer (VLU) is a chronic disease and has periods of exacerbation and remission. It takes a long time to heal, resulting in physical and psychological discomfort, thereby negatively affecting the functional status of the patient. These hard-to-heal ulcers are susceptible to microbial invasion and this probably contributes to the hard-to-heal nature of the VLU. These secondarily infected VLUs pose a challenge for clinicians and patients. Regular dressings or antimicrobial bandages have been effective in controlling them to some extent. However, the results are not satisfactory.
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