Chronic Wound Infection: Bacterial Colonization in the Dermal Pericolostomic Region
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The incidence of septic complications following colostomy surgery varies from 0.5% to 25%.1–6 Wound infections appear to be more common following emergency stoma surgery, increasing the occurrence of sepsis in contaminated cases compared to noncontaminated cases. This can be explained by the contamination of the surgical site, starting from contact of the skin tissue with bacterial flora present in the intestinal lumen, which is not noted during clean procedures or those in which the intestine is not manipulated.7
To determine the prevalence and type of bacteria in the peristomal skin of colostomy patients, a prospective study was conducted among patients at the Department of Surgery of the University of Taubaté, Medical School and Federal University of São Paulo Medical School, São Paulo, Brazil, from October 2000 to September 2002. All patients had a temporary colostomy of at least 7 weeks duration located either in the transverse or in the sigmoid colon due to reconstruction of the intestinal transit. They were admitted or excluded from the study depending on the established criteria and after signing a consent form formulated by the Medical Ethics Committee.
Patients with clinical stage I or II, as defined by the American Society of Anesthesiology, and those with colorectal oncological malignancy (Astler-Coller stage B2 colorectal cancer), ie, who were not in the advanced stage of the disease, were admitted to the study. Excluded from the study were patients exhibiting pericolostomic skin disease (stenosis, cellulitis, prolapse, dermatitis, sepsis) or who had undergone chemotherapy and/or radiotherapy within the previous 30 days; with diabetes mellitus, immune-suppressive, and cachectic disorders; with infectious or inflammatory processes in other tissues, and patients being treated or had been treated with antibiotics and anti-inflammatory medications in the previous 30 days.
Based on these criteria, a group of 34 healthy individuals with colostomies and without complications was formed. In order to obtain the test specimen, the patient’s colon was prepared following the pre-surgical procedure. No oral antibiotic preparation was used. Intravenous antibiotic therapy was initiated only after collection of the test specimens. Antiseptic measures were performed in the pericolostomy region using 0.9% saline solution, polyvinylpyrolidone-iodine, and 10% sodium lauryl ether sulfate, for at least 5 minutes. Two biopsies of the cutaneous tissue were taken next to the lower edge of the colostomy, approximately 0.5 cm from the enterocutaneous anastomosis. The material was transported to the Microbiology Laboratory (Stuart Transportation), and was seeded on specific plates for aerobic bacteria (eosin agar methylene blue, blood agar with acid, and chocolate agar). Anaerobic bacteria (blood supplemented agar and bacteroides-bile-esculin agar) was incubated at 37˚C for 72 hours and kept oxygen-free to facilitate identification. Manual biochemical assays were utilized to identify the bacteria (API 20E, Bactray I, II).
Fisher’s Exact Test and linear-by-linear association were applied to examine the association between the presence of microorganisms and the length of time of the colostomy. The rejection level of the null hypothesis was fixed at 0.1 or 10% (α ≤ 0.1) in all tests. Patients were classified into 4 subgroups (comprising 4 weeks): 7.5 to 12 weeks (10 patients), 12.3 to 16 weeks (9 patients), 16.3 to 20 weeks (5 patients), and > 20 weeks (10 patients).
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