Introduction

On the surface, topical antibiotics may appear to be a safe choice for some wounds, even some infected wounds, when compared to oral or intravenous options. A seemingly less dangerous adverse effect profile, less invasive nature, and potential for cost-effectiveness are logical, appealing features of topical antibiotics. However, a closer look reveals that the choice is not that simple, and, in fact, clinicians must take several points into consideration.

Antimicrobial Stewardship: When to Use Topical Antimicrobials

First, wound care professionals must assess if an antibiotic of any kind is necessary and, if so, how that antibiotic should be administered. An astute clinician will perform a comprehensive wound history and physical to assess if the best course may focus on wound hygiene, antiseptic agents, or if antibiotic therapy is indicated.^1,2 Is the wound inflamed or indeed infected? If there is an infection present, will a topical antibiotic be sufficient, or do the findings warrant oral or intravenous treatment? For patients with multiple comorbidities, spreading infection, or systemic signs of infection, more involved antibiotic treatment may be necessary. In cases where systemic antibiotics are not appropriate, the clinician must determine if a topical antibiotic is necessary or if an antiseptic or wound cleanser is best. If a clinician determines that topical antibiotics may become part of a treatment plan, it is still wise to carefully consider if this decision fits into appropriate parameters. Evidence suggests that clinicians should employ topical antibiotics on a very limited basis.^3,4 Additionally, if a patient receives a topical antibiotic, the clinician should ask the patient to discard any leftover medication properly when treatment is complete. This may prevent anyone affiliated with the patient from re-using the formulation in the future without medical guidance.⁴ A deeper understanding of the pros and cons of topical antibiotic therapy will hopefully assist wound care professionals make informed decisions about their use while practicing antimicrobial stewardship.

Topical Antibiotics: Considering Some of the Benefits and Risks

The use of topical antibiotics has its advantages in wound care. In this form, clinicians can focus the concentration of the agent at the target site, leading to less potential for toxicity or systemic absorption.⁵ Under the right circumstances, topical antibiotics may also eliminate the need for systemic antibiotics. In addition, there is also the ease of application and administration by the patient and/or caregivers.⁵ Despite these advantages, many disadvantages may also arise from this type of treatment, including a lack of clear evidence of effectiveness in clinical trials.⁵ Systemic absorption is still possible, especially in larger wounds. Local hypersensitivity reactions, including contact dermatitis (rash or irritation due to contact between the medication and the skin), may occur.⁵ One must also consider the possibility of systemic allergic reactions, which may appear in the same class of antibiotics in their oral or intravenous forms. ^7,8 Using a topical antibiotic may not penetrate deeply enough into the tissues, and there is also the challenge of accurately assessing dosing.⁵ Topical antibiotics may alter normal cutaneous flora; in fact, one study found an increase in gram-negative bacteria in the wound bed with topical antibiotic use.⁶ Multi-use containers may become contaminated between medication applications, and the necessary frequency of application may prove arduous to patients and/or caregivers.

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Forms of Topical Antibiotics

Another factor one must consider regarding topical antibiotics is the vehicle. For instance, an ointment has different characteristics than a cream formulation, and each may have pros and cons in a given wound environment.⁵ Various forms of topical antibiotics are listed below:

• Ointment
• Cream
• Disinfectant
• Dressings

Think about your goals in choosing a given topical antibiotic. Is it truly to treat an infection, or are the goals accomplishable with another type of topical choice?

Conclusion

Antibiotic therapy does not exist in a vacuum, regardless of the route of administration. When properly employed, topical antibiotic therapy should be part of a comprehensive treatment program, potentially including debridement, source control, evaluation for comorbidities, and offloading, as needed.⁵ Wound care professionals should examine their practices with topical antibiotics and contribute to antimicrobial stewardship by ensuring proper use.

References

1. Tsai J-YC, Anderson P, Broome L, et al. Antimicrobial stewardship using pharmacy data for the nurse-led school-based clinics in Counties Manukau District Health Board for management of group A streptococcal pharyngitis and skin infection. NZMJ. 2016;129:29–38.
2. Cooke J. When antibiotics can be avoided in skin inflammation and bacterial colonization: a review of topical treatments. Curr Opin Infect Dis. 2014;27:125–129.
3. Leitch C, Leitch A, Tidman M. Quantitative evaluation of dermatological antiseptics. Clin Exp Dermatol. 2015;40:912–915.
4. Williamson D, Ritchie S, Best E, et al. A bug in the ointment: topical antimicrobial usage and resistance in New Zealand. NZMJ. 2015;128:103–109.
5. Lipsky BA, Hoey C. Topical antimicrobial therapy for treating chronic wounds. Clin Infect Dis. 2009;49(10):1541-1549.
6. Bryant RA, Nix DP. Acute & Chronic Wounds: Current Management Concepts. (4th ed) St. Louis: Elsevier; 2012.
7. Sasseville D. Neomycin. Dermatitis. 2010;21(1):3-7.
8. Contact Dermatitis Institute. Neomycin Sulfate. Available at: https://www.contactdermatitisinstitute.com/neomycin-sulphate.php . Accessed August 12, 2022.