Penrose drains and antibiotics

Re: Penrose drains and antibiotics

Evelyn Barbour-Hill — Tue, 25 Jun 2013 20:51:59 GMT

[quote user="Martin Atkinson"]It still surprises me. Sure if you leave a huge hole and gravity is on your side then the thing will drain but putting a drainage tube in means you can close the wound. There are occasions when a deep inguinal abscess or one on the back for example will benefit. I often put a seton drain in tail wounds - just a loop of bandage to wick and keep the holes open otherwise I find they almost invariably recur and I have to lance again or at least have to do a lot of squeezing which cats usually resent.[/quote]

Well, all I can say is that all that surprises me.

Re: Penrose drains and antibiotics

Martin Atkinson — Tue, 25 Jun 2013 18:07:57 GMT

[quote user="Evelyn Barbour-Hill"]With reference to cat bite abscess: I've never seen one where you can't establish natural drainage, assuming you probe properly, under GA of course. Occasionally seen trouble return on a tail bite or a metacarpal, not exactly return of abscess but failure to resolve properly with single GA treatment (usually, in retrospect, because probing was still not quite vigorous enough or the incisions were not big enough[/quote] It still surprises me. Sure if you leave a huge hole and gravity is on your side then the thing will drain but putting a drainage tube in means you can close the wound. There are occasions when a deep inguinal abscess or one on the back for example will benefit. I often put a seton drain in tail wounds - just a loop of bandage to wick and keep the holes open otherwise I find they almost invariably recur and I have to lance again or at least have to do a lot of squeezing which cats usually resent.

Re: Penrose drains and antibiotics

Ian Battersby — Tue, 25 Jun 2013 17:31:22 GMT

Hi Martin,

I thought I would expand on the urinary catheter and antibiotic usage conundrum you mentioned.

This is an area of interest in human medicine as not only re the use of antibiotics in these patients with indwelling urinary catheters but also when do you treat if you identify bacteria in the urine. There is much interest in trying to establish if it is a catheter associated UTI vs catheter associated bacturia . In the later case it may resolve in a number of cases by removing or changing the catheter. In fact we have had some patient in which we have removed the indewelling has resolved the bacturia without antibiotics

Re prophylaxis antibiotic usage in the indwelling urinary catheter patient. The placement of an indwelling is a risk factor for infection, but by using antibiotics you select for a resistant population of bacteria. So by using antibiotics prophylaxis in these cases you increase the chance of a catheter associated infection being difficult to treat as the bug is multi-resistant due to the selection pressure of the antibiotic. If you do get a catheter associated infection and haven’t used antibiotics prophylaxis then the bacteria in that situation should hopefully be sensitive to first line antibiotics and easier to treat and resolve.

So we don’t use antibiotics in patients with indwelling unless there is another clinical indication to do so.

My explanation for my approach is a little brief so I hope it makes sense.

All the best

Ian

I am going to India to help vaccinate dogs in India with the project Mission Rabies . If you would like to get involved or would like to learn more about the project go to www.missionrabies.com

Re: Penrose drains and antibiotics

Evelyn Barbour-Hill — Tue, 25 Jun 2013 16:59:12 GMT

[quote user="Martin Atkinson"][quote user="Evelyn Barbour-Hill"]I have never ever put a Penrose or any other kind of drain in a treated cat bite abscess. I really can't see why you would want to.[/quote] Sorry I'm late in on this one my new grad. pointed me to it as she was non-plussed. I would ask you Evelyn have you never therefore seen a deeply seated abscess where you can't establish natural drainage or one returned after just lancing and flushing?,[/quote]

With reference to cat bite abscess: I've never seen one where you can't establish natural drainage, assuming you probe properly, under GA of course. Occasionally seen trouble return on a tail bite or a metacarpal, not exactly return of abscess but failure to resolve properly with single GA treatment (usually, in retrospect, because probing was still not quite vigorous enough or the incisions were not big enough): Penrose wouldn't be much help there, might even be counterproductive.

Re: Penrose drains and antibiotics

Martin Atkinson — Tue, 25 Jun 2013 14:50:57 GMT

[quote user="Evelyn Barbour-Hill"]I have never ever put a Penrose or any other kind of drain in a treated cat bite abscess. I really can't see why you would want to.[/quote] Sorry I'm late in on this one my new grad. pointed me to it as she was non-plussed. I would ask you Evelyn have you never therefore seen a deeply seated abscess where you can't establish natural drainage or one returned after just lancing and flushing?, because if so you have been very fortunate. Had one this very morning deep in the neck, penrose drain placed and will be removed in 48 hrs or when there is no further purulent discharge whichever is the later.

My overall take on all of this is that given the choice of drainage OR antibiotics than drainage takes precedence but I would normally do both. I can't quite see the logic behind not giving antibiotics to a cat with an indwelling urinary catheter other than some idealistic attitude to not giving antibiotics until an infection is proven, I would have thought it was more important due to the risk of ascending infection. Or maybe I'm getting the wrong end of the stick.

Re: Penrose drains and antibiotics

Oli_J — Fri, 21 Jun 2013 11:56:14 GMT

'I'm guessing the question is extrapolating from guidance relating to not giving antibiotics while urinary catheters are in place (unless there is an indication other than the fact that a urinary catheter has been placed...).'

Exactly. It was just a thought I had today. I am mainly talking about infected/dirty wounds where there may be worry that complete closure could seal in infection, a cat bite abscess was just an example. Rather then clean surgical wounds where I would probably chose another option, such as a closed suction drain.

I don't routinely place drains in these cases either, usually leave to heal by 2nd intention following good debridement with wet to dry dressings etc but there is the odd dirty wound that ends up with a penrose drain (and is currently also given antibiotics at the same time) so was just wondering if this is the best thing to be doing...

Thanks for the thoughtful comments!

Re: Penrose drains and antibiotics

John Flynn — Fri, 21 Jun 2013 11:42:02 GMT

[quote user="Evelyn Barbour-Hill"]I'm not sure I see the logic of not giving an antibiotic, but starting one after the drain has been removed. But I may not be up to date with current thinking.[/quote]

I'm guessing the question is extrapolating from guidance relating to not giving antibiotics while urinary catheters are in place (unless there is an indication other than the fact that a urinary catheter has been placed...).

I guess the same underlying concept probably exists in the situation of a penrose drain placed in a clean wound where bacterial adherence to the foreign material may provide a "protected" space for the bacteria and antibiotics dosing may only help in selecting for resistant strains in theory, but all sounds pretty theoretical to me.

I don't normally place on anitbioitcs if I place a penrose drain on clean procedure eg after a mammary strip. I don't dress these and change them in sterile fashion, though I see the logic from those who recommend this. I don't routinely place a penrose drain in an infected wound, though I have very rarely such as an awkwardly located cat bite abscess that is prone to close over before infection cleared and recur - eg above the eye in a ?FIV cat or something - in such a case I would give antibiotics from the start as I felt required.

Re: Penrose drains and antibiotics

Evelyn Barbour-Hill — Fri, 21 Jun 2013 11:09:17 GMT

I have never ever put a Penrose or any other kind of drain in a treated cat bite abscess. I really can't see why you would want to.

However, that's by the by.

I've never really thought about this question. My reasoning would be that if you wish to give an antibiotic, in order to discourage or suppress bacteria, then you do so. I don't think the presence or absence of a drain has much bearing on it.

Are you reasoning that the drain might provide a route in for secondary infection? Yes, that would indicate antibiotic cover. But in such a situation, maybe you should not be placing a drain at all?

If you are placing the drain because there has been severe contamination, as for instance when you have treated a nasty dog bite, you'd surely be giving an antibiotic anyway?

If you are placing the drain after some clean surgical operation that by its nature requires drainage afterwards, yes I guess I'd be using an antibiotic as a precautionary preventive.

I'm not sure I see the logic of not giving an antibiotic, but starting one after the drain has been removed. But I may not be up to date with current thinking.

I believe we have some wound healing experts on this forum. I hope one of them will be along soon.