Australian Prescriber Volume 46 Number 2 August 2023 PDF

August 2023 Volume 46 Number 2 AN INDEPENDENT REVIEW australianprescriber.tg.org.au CONTENTS EDITORIAL Limitations of randomised controlled trials as evidence of drug safety TRJ Thynne, GM Gabb 22 ARTICLES Medicines stewardship E Su, DFL Liew, J Donnelly, RA Elliott 24 An update on wound mana...

August 2023 Volume 46 Number 2 AN INDEPENDENT REVIEW australianprescriber.tg.org.au CONTENTS EDITORIAL Limitations of randomised controlled trials as evidence of drug safety TRJ Thynne, GM Gabb 22 ARTICLES Medicines stewardship E Su, DFL Liew, J Donnelly, RA Elliott 24 An update on wound management G Sussman 29 EXPERIMENTAL AND CLINICAL PHARMACOLOGY Chimeric antigen receptor T-cell therapy C Burge, V Vanguru, PJ Ho 36 NEW DRUGS 40 Brexucabtagene autoleucel for mantle cell lymphoma, B-cell precursor acute lymphoblastic leukaemia Opicapone for Parkinson’s disease VOLUME 46 : NUMBER 2 : AUGUST 2023 EDITORIAL Limitations of randomised controlled trials as evidence of drug safety Tilenka RJ Thynne Clinical pharmacologist and Endocrinologist1,2 Genevieve M Gabb Senior staff specialist1,2,3,4 Division of Medicine, Cardiac and Critical Care, Flinders Medical Centre, Bedford Park, South Australia 1 College of Medicine and Public Health, Flinders University, Bedford Park, South Australia 2 Acute and Urgent Care, Royal Adelaide Hospital 3 Discipline of Medicine, School of Medicine, Faculty of Health Science, University of Adelaide 4 Keywords adverse drug reaction reporting, clinical trials, drug safety, ethnic and racial minorities Aust Prescr 2023;46:22–3 https://doi.org/10.18773/ austprescr.2023.005 The pinnacle of the hierarchy of evidence is the systematic review and meta-analysis. One step below this is the randomised controlled trial. These are ‘gold standard’ measures of medical knowledge, assessing outcomes and the efficacy of healthcare interventions. However, they rarely provide ‘gold standard’ information on adverse drug effects and drug safety. Randomised controlled trials involve a carefully vetted and selected patient population who are exposed to treatment for a relatively short duration. Drugs are later used in practice in a much wider group of patients, who may have multiple comorbidities, and over a much longer period of time. There are numerous examples of now well-established adverse drug reactions that were not apparent when the drug entered the market. For example, ACE inhibitorassociated angioedema was recognised only after marketing. In the years after ACE inhibitors were marketed, the rates of emergency department presentations with angioedema markedly rose.1 Generally, randomised controlled trials are statistically powered to assess efficacy, but usually underpowered to assess harm, especially those events that are infrequent or rare. For drugs that are widely used for common conditions, rare adverse effects can have serious clinical impacts. For example, euglycaemic ketoacidosis with sodium-glucose co-transporter 2 inhibitors is rare, but potentially life-threatening. It was not recognised as a complication in the original cardiovascular outcome trials.2 Recognition of this adverse drug reaction, and its precipitants, has allowed risk mitigation strategies to be implemented.3 Randomised controlled trials, even for common conditions, under-represent many groups in our society. Women remain significantly underrepresented in lipid-lowering trials compared to their relative burden of disease.4 When included, it is often only postmenopausal women or surgically sterile women who meet inclusion criteria. No data are therefore available for menstruating women or those who are pregnant or lactating. Similarly, there is limited inclusion of older adults in clinical trials of drugs to treat ischaemic heart disease, despite the high incidence of disease in older people.5 There are large disparities in racial and ethnic representation in randomised controlled trials, 22 This article is peer-reviewed despite government regulatory bodies recommending targets to enhance the inclusion of minorities in clinical trials. Without representation, unrecognised harm can occur. African Americans respond poorly to ACE inhibitors,6 and ACE inhibitor-associated angioedema is more prevalent and possibly more severe in African Americans than Caucasians.7 Australian pharmacovigilance guidelines do not have special requirements to report adverse effects for specific ethnic or cultural groups. There are very little data from Australian indigenous populations about adverse drug reactions and potential harmful effects. This limits strategies to mitigate future adverse events. Even the way adverse drug reactions are described can be problematic if racial and ethnic groups are not adequately represented. ‘Red man syndrome’, an infusion-related reaction to vancomycin, describes the reaction in a Caucasian man. This description does not consider what the infusion reaction appears like on the skin of a different patient population. If the syndrome is misdiagnosed as an ‘allergy’, this can affect future clinical decision making and limit effective treatment options.8 In medicines safety, observational studies, including case reports, clinical trial registries, case series and case-controlled studies, are important sources of information about adverse drug reactions and the risk of harm. For individual patients, temporal relationships of events to drug exposure, and experience with drug challenge and rechallenge (if safe to do), are important to consider when looking at relationships between medicines exposure and outcomes. From a practitioner point of view, keeping an open mind and listening to patients can be key. When using new drugs, remember many patients with comorbidities would never have met the strict inclusion and exclusion criteria of clinical trials. Both the efficacy and adverse effects may differ from those seen in the trials. The importance of adverse drug reaction reporting to the Therapeutic Goods Administration (TGA) cannot be emphasised enough (Box). Pharmaceutical companies are mandated to report adverse drug reaction data, however reporting for health professionals is voluntary. Concerningly, adverse drug reaction reports to the TGA are declining.9 © 2023 Therapeutic Guidelines Ltd VOLUME 46 : NUMBER 2 : AUGUST 2023 EDITORIAL While randomised controlled trials and metaanalyses best provide the answer to whether a drug is effective, they are unlikely to determine whether or not the drug is safe for any individual patient. It is therefore important that practitioners, together with patients, consider whether an event may represent an adverse drug reaction. Reporting adverse drug reactions helps bridge the gap in our knowledge and build a picture of what drug safety looks like for the wider Australian community. Conflicts of interest: Tilenka Thynne is a member of the Australian Prescriber Editorial Executive Committee. Box Reporting an adverse drug reaction to the Therapeutic Goods Administration ‘You don’t need to be certain, just suspicious!’ The Therapeutic Goods Administration particularly needs to know about all suspected adverse drug reactions involving: • new therapeutic goods • medicine and vaccine interactions • unexpected reactions (that is, adverse drug reactions that do not appear in the Product Information, Consumer Medicine Information or product labelling) • serious reactions, such as: – death – danger to life – admission to hospital – prolongation of hospitalisation – absence from productive activity – increased investigational or treatment costs – birth defects. To report an adverse drug reaction, see Therapeutic Goods Administration Australian Adverse Drug Reaction Reporting System. REFERENCES 1. 2. 3. 4. 5. Gabb GM, Ryan P, Wing LM, Hutchinson KA. Epidemiological study of angioedema and ACE inhibitors. Aust N Z J Med 1996;26:777-82. https://doi.org/10.1111/ j.1445-5994.1996.tb00624.x Zinman B, Wanner C, Lachin JM, Fitchett D, Bluhmki E, Hantel S, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med 2015;373:2117-28. https://doi.org/10.1056/NEJMoa1504720 Meyer EJ, Gabb G, Jesudason D. SGLT2 inhibitor-associated euglycemic diabetic ketoacidosis: a South Australian clinical case series and Australian spontaneous adverse event notifications. Diabetes Care 2018;41:e47-e49. https://doi.org/ 10.2337/dc17-1721 Khan SU, Khan MZ, Raghu Subramanian C, Riaz H, Khan MU, Lone AN, et al. Participation of women and older participants in randomized clinical trials of lipid-lowering therapies: a systematic review. JAMA Netw Open 2020;3:e205202. https://doi.org/10.1001/jamanetworkopen.2020.5202 Bourgeois FT, Orenstein L, Ballakur S, Mandl KD, Ioannidis JPA. Exclusion of elderly people from randomized clinical trials of drugs for ischemic heart disease. J Am Geriatr Soc 2017;65:2354-61. https://doi.org/10.1111/ jgs.14833 6. 7. 8. 9. Exner DV, Dries DL, Domanski MJ, Cohn JN. Lesser response to angiotensin-converting-enzyme inhibitor therapy in black as compared with white patients with left ventricular dysfunction. N Engl J Med 2001;344:1351-7. https://doi.org/ 10.1056/NEJM200105033441802 Weber MA, Messerli FH. Angiotensin-converting enzyme inhibitors and angioedema: estimating the risk. Hypertension 2008;51:1465-7. https://doi.org/10.1161/ HYPERTENSIONAHA.108.111393 Alvarez-Arango S, Ogunwole SM, Sequist TD, Burk CM, Blumenthal KG. Vancomycin infusion reaction - moving beyond “Red Man Syndrome”. N Engl J Med 2021;384:1283-6. https://doi.org/10.1056/NEJMp2031891 Martin JH, Lucas C. Reporting adverse drug events to the Therapeutic Goods Administration. Aust Prescr 2021;44:2-3. https://doi.org/10.18773/austprescr.2020.077 Full text free online at australianprescriber.tg.org.au 23 VOLUME 46 : NUMBER 2 : AUGUST 2023 ARTICLE Medicines stewardship Elizabeth Su Senior project officer, Medicines Optimisation Service, and Senior pharmacist1 David FL Liew Project lead, Medicines Optimisation Service, and Clinical pharmacologist and Rheumatologist1 PhD candidate2 Jane Donnelly Former national coordinator3 Rohan A Elliott Senior pharmacist, Pharmacy Department1 Adjunct associate professor4 1 Austin Health, Melbourne Department of Medicine, University of Melbourne 2 Council of Australian Therapeutic Advisory Groups 3 Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne 4 Keywords anticoagulation stewardship, antimicrobial stewardship, medicines stewardship, opioid analgesic stewardship, psychotropic stewardship, quality use of medicines Aust Prescr 2023;46:24–8 https://doi.org/10.18773/ austprescr.2023.010 SUMMARY Medicines stewardship refers to coordinated strategies and interventions to optimise medicines use, usually within a specific therapeutic area. Medicines stewardship programs can reduce variations in practice and improve patient outcomes. Therapeutic domains for medicines stewardship are chosen to address frequently used drug classes associated with a high risk of adverse outcomes. Some examples include antimicrobial, opioid analgesic, anticoagulation and psychotropic stewardship. Common elements of successful stewardship programs include multidisciplinary leadership, stakeholder engagement, tailored communication strategies, behavioural changes, implementation science methodologies, and ongoing program monitoring, evaluation and reporting. Medicines stewardship is a continual quality improvement process that requires ongoing support and resources, as well as clinician and consumer engagement, to remain sustainable. It is critical for hospital-based medicines stewardship programs to consider impacts on care in the community when making and communicating changes to patient therapy. This ensures that stewardship efforts are sustained across transitions of care. Introduction Medicines stewardship is a continuous improvement approach within the quality use of medicines which has continued to expand in recent years. Stewards are responsible for managing activities in a structured way, and therefore stewardship in the context of medical policy broadly refers to a structured program of strategies and interventions that address challenges within a specific therapeutic area, and ensure appropriate and efficient use of resources.1-3 Medicines stewardship refers to programs to improve medicines use where there is a high risk of inappropriate prescribing or adverse outcomes. While the definitions and structure vary, medicines stewardship programs focus on improving prescribing and medication management at individual and population levels to ensure consistent, appropriate care. Stewardship uses a strategic approach to support governance, interventions, and tools that guide and optimise practice. Medicines stewardship is often needed because of variations in clinical practice. Clinical decisions might vary from recommendations in guidelines, which are often designed to consider impacts beyond the immediate context. Although some clinical actions appear beneficial to individual patients in the immediate context of the decision, they may lead or contribute to poorer outcomes for the patient or the community. Stewardship programs therefore incorporate a broader perspective, aligning with the quality use of medicines and ethical principles. They 24 This article is peer-reviewed provide mechanisms to ensure accountability for medicines use and outcomes. Outside of formal stewardship programs, strategies and interventions in specific therapeutic areas may be implemented to improve medicines use, but these typically focus on specific clinical interactions in isolation. While these may lead to incremental benefits in that context, they do not necessarily support a broader strategy of whole-system improvement. For example, guidelines or strategies (e.g. default quantities in prescribing software) recommending specific opioid quantities are of limited effectiveness without tools to support clinicians to better assess and treat patients’ pain with appropriate alternatives.4 Strategic planning and structures that support holistic delivery and monitoring of health care are needed, and stewardship is a key method of achieving this. Stewardship has been adopted in many therapeutic domains. Antimicrobial stewardship is mandated in hospitals and is now being adopted by community providers, including residential care facilities. Similar programs have subsequently targeted opioid analgesics, anticoagulants and antipsychotics, with an interest in other therapeutic areas as well. Until recently, the absence of a readily applicable framework has resulted in programs inappropriately adopting a stewardship label. The principles of stewardship should be the same, regardless of the therapeutic area. The commonalities between stewardship programs are often greater than the commonalities between © 2023 Therapeutic Guidelines Ltd VOLUME 46 : NUMBER 2 : AUGUST 2023 ARTICLE therapeutic areas. Specific approaches and skills are necessary to build effective interventions for a broader stewardship plan across multiple therapeutic domains. Therapeutic-agnostic approaches that reflect fundamental principles of quality use of medicines rather than simply disease-specific therapeutic considerations should be incorporated. These may be developed through the crossdisciplinary pollination of ideas or engaging teams dedicated to program development (usually within quality improvement or medicines optimisation services). This ensures that these actions have the best chance of improving the function of the whole system to benefit practitioners in hospitals and the community across the whole patient journey. Elements of successful medicines stewardship programs Successful medicines stewardship programs are underpinned by aims that align with the quality use of medicines. This means that programs aim to enable clinicians and consumers to select and use treatment options wisely, safely and effectively. While medicines stewardship programs may differ in size, scope and therapeutic targets, they share common fundamental elements (Table).5-8 Antimicrobial stewardship programs Antimicrobial stewardship programs emerged in the late 1990s and were the earliest coordinated programs to steward the use of a specific class of high-risk medicines. Antimicrobial stewardship programs are now well established in Australian health care and promote the judicious use of antimicrobials to improve patient care while also reducing the risk of antimicrobial resistance and healthcare-associated infections. In hospital settings, these programs have been shown to reduce antimicrobial resistance by 34%, reduce mortality by 35% through adherence to treatment guidelines, and improve patient safety by avoiding drug-related adverse events.5 Accordingly, antimicrobial stewardship programs are a required standard for all Australian health service organisations.9 Established antimicrobial stewardship programs have demonstrated better concordance with prescribing guidelines compared to when antimicrobial stewardship programs were in their infancy.10 Opioid analgesic stewardship programs Stewardship programs for other high-risk medicines emulate the antimicrobial stewardship model and are becoming more common in Australian hospitals. Opioid analgesic stewardship programs aim to prevent excessive or inappropriate opioid prescribing to reduce the risk of opioid-related harm, such as opioid-induced ventilatory impairment, persistent opioid use, and diversion.11,12 This is supported by the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, which particularly targets opioid prescribing in emergency departments and for postoperative pain.12 Interventions can include patient education, opioid prescribing guidelines, prescriber education or feedback, pharmacist-assisted prescribing, leveraging reporting and decision support in electronic prescribing systems, and improvements in discharge communication.6,13-16 Opioid analgesic stewardship interventions can reduce the dose, number of prescriptions, or number of days of opioid supply, and decrease the proportion of patients receiving chronic opioid therapy.17 However, more research is required to directly measure the effect of opioid analgesic stewardship programs on preventing adverse outcomes such as opioid addiction, overdose or mortality.17 Anticoagulation stewardship programs Anticoagulation stewardship programs aim to prevent adverse patient outcomes due to over- or under-anticoagulation. Venous thromboembolism is a common preventable cause of in-hospital death and accounts for an estimated 7% of all deaths in Australian hospitals.18 Interventions can include implementing anticoagulation or thromboprophylaxis guidelines, education for prescribers and patients to optimise the use of anticoagulants or reversal agents, and oversight of the management of heparin-induced thrombocytopaenia.6,19,20 One Australian program described a 33% reduction in hospital-acquired venous thromboembolism and a 20% reduction in anticoagulant-related bleeds after program implementation.6 Psychotropic stewardship programs Psychotropic stewardship programs are emerging and target inappropriate psychotropic prescribing and administration to reduce adverse effects and persistent use. This is particularly pertinent for older people and people with disabilities, for whom antipsychotics or benzodiazepines may be misused or overused as chemical restraints.21 Interventions include strategies to support the monitoring, review and deprescribing of psychotropic medicines, and reinforcing the non-pharmacological management of agitation in delirium.22,23 Transitions of care Care across a patient’s whole therapeutic journey is critical to their long-term benefit. While notable events may occur during episodes managed by hospitals or other institutions, patients’ needs rarely end before the responsibility for their care Full text free online at australianprescriber.tg.org.au 25 VOLUME 46 : NUMBER 2 : AUGUST 2023 Medicines stewardship ARTICLE Table Fundamental elements and principles of successful medicines stewardship programs 5-8 Fundamental elements of successful medicines stewardship Underlying principle Practical implications Multidisciplinary leadership team Stewardship programs are often administered by a dedicated stewardship lead or officer. However, support from a multidisciplinary leadership team is essential to provide a holistic system perspective that helps ensure the program achieves its intended aims and can be implemented sustainably. • Leadership team members should be chosen to represent the specialties and patient population that the specific stewardship program is trying to address, and reflect the expertise and skills required to support program functions. Medicines stewardship programs should be designed with the whole system of care in mind and should traverse transitions of care. Engagement of relevant organisational stakeholders and external partners is essential in understanding how to design or adapt a stewardship model for successful implementation within the local context. • Stakeholder mapping and analysis help identify key players who hold interest and influence over the program’s success and inform how the program is communicated and reported. Stewardship programs require a tailored communication strategy to provide timely, effective and appropriate information to support program functions. • Methods of communication are tailored to fit the specific purpose (e.g. to raise awareness, promote specific initiatives, issue program updates or provide feedback about successes and failures), as well as the intended audience. Stakeholder engagement Tailored communication strategy Proven methodologies in behavioural change and implementation science Successful stewardship programs adopt proven methodologies in behavioural change and implementation science to achieve clinical practice improvement. • Essential skills and knowledge for team members include clinical experience and expertise, clinical governance, medication safety and quality use of medicines principles, and accreditation processes. • The leadership team should ideally include core representation from the organisation’s executive, medical, nursing, pharmacy and consumer groups. • Stewardship program stakeholders may include clinicians, managers, administrative staff and consumers. Engagement of relevant external stakeholders is essential to ensure the continuity of stewardship changes and outcomes. • A communication strategy should leverage existing organisational structures and networks. Examples include: • using education strategies that are tailored to the target audience, incorporate competency standards, include evaluations of education activities and report feedback about successes and failures • developing clearly defined interventions that are trialled and optimised in one or a few selected settings, and then replicated systematically in other settings with local tailoring • selecting clinical champions to act as a knowledge and skill resource to peers and to provide motivation and advocacy to facilitate the adoption of stewardship interventions. Ongoing monitoring, evaluation and reporting Ongoing monitoring and reporting of defined measures or quality indicators are critical for evaluating the effectiveness of stewardship strategies and identifying opportunities for improvement. Medicines stewardship should evaluate clinical processes as well as consumer outcomes. A combination of measures should be used, such as: • structural measures – governance structures, drug formularies or guidelines • process measures – compliance with prescribing guidelines, or drug utilisation data • outcome measures – mortality, readmission rates, or patient experience reports • balancing measures – adverse events due to an intervention. transitions to another provider.24,25 Reducing harm from high-risk medicines and improving medication safety at transitions of care are flagship priorities of Australia’s response to the latest World Health Organization Global Patient Safety Challenge – Medication without harm.26 Hospital-based stewardship programs and prescribing decisions must include both communicating across transitions of care and facilitating ongoing care in the community. This requires communication with general 26 Full text free online at australianprescriber.tg.org.au practitioners, community pharmacists and community or aged-care nurses. Clear explanation of the intent and rationale for plans, tools and decisions initiated by stewardship programs helps ensure they can be properly understood and implemented by care providers and patients across transitions of care.27,28 Such communication must work within existing information systems. The linkage of electronic data sources will assist, but other technological solutions are often necessary. VOLUME 46 : NUMBER 2 : AUGUST 2023 ARTICLE When the communication of decisions initiated by hospital stewardship programs is not strategically planned and implemented, benefits from therapeutic decisions made in hospitals might be lost or unintended consequences might occur.29 Such consequences may become evident to care providers only after an irreversible impact (such as intracranial bleeding following the inappropriate continuation of anticoagulation) or may be hidden from care providers altogether (such as consumers substituting illicit opioids in the absence of licit opioid analgesics). Medication errors and adverse events are common following hospital discharge and involve medicines beyond those targeted by specific stewardship programs.28,30 Clinical handover of medication information is suboptimal,31 and few patients receive early post-discharge medication review despite guidelines and protocols supporting these.32 Improving transitions of care is a priority for medication safety policy, and applying medicines stewardship principles (Table) to transitions of care is recommended.32 Sustainability of medicines stewardship Medicines stewardship is a continual quality improvement process and therefore requires ongoing support and resources to be sustainable. Stewardship programs must be built into existing organisational clinical and medicines governance systems, with executive and clinical oversight and support. Embedding medicines stewardship programs into organisational safety and quality systems helps to ensure ongoing accountability for program objectives. These structures must include defined operational and reporting pathways, for example to medication safety committees, drug and therapeutics committees, medication advisory committees or executive administrators. This ensures that programs receive support from the institution to implement required interventions, are provided with sufficient resources and time to enact changes, and are accountable for achieving defined outcomes and managing potential risks. Embedding programs into safety and quality improvement frameworks and engaging frontline clinicians also help to ensure that stewardship is a part of routine care. The level of resources required depends on the aims and size of the individual program and health service, but may include: • a dedicated stewardship program lead, manager or officer to drive the program • clinical stewards (e.g. dedicated stewardship pharmacists) or clinical champions (e.g. designated nurse champions) to liaise with stakeholders, provide education, contribute to the development of guidelines and other resources, and implement interventions • allocating time and resources for clinicians to attend and contribute to specific meetings, and to develop complementary skills, such as implementation science and informatics capability. Medicines stewardship in community settings In community settings, individual healthcare providers are less likely to have the resources, staff or networks necessary to develop comprehensive practice guidelines, educational resources and health promotion tools to support medicines stewardship. This highlights the important role of independent services such as the Australian Commission on Safety and Quality in Health Care or the former NPS MedicineWise in developing evidence-based, consumer-centred programs to steward the quality use of medicines. Conclusion Medicines stewardship is a proven approach to improving the quality use of medicines. Successful stewardship programs use strategic health design to support actions that benefit individual patients and the broader population. The programs work best when their design considers key elements (Table) and they receive sustained support. Considering how decisions or actions are implemented and communicated across the transition of care is critical to delivering real benefits to patients. Further research is needed to measure the impact of emerging stewardship models in Australian health care. Conflicts of interest: David Liew is a member of the Drug Utilisation Subcommittee of the Pharmaceutical Benefits Advisory Committee. REFERENCES 1. 2. Brinkerhoff DW, Cross HE, Sharma S, Williamson T. Stewardship and health systems strengthening: an overview. Public Adm Dev 2019;39:4-10. https://doi.org/10.1002/ pad.1846 Veillard JHM, Brown AD, Barış E, Permanand G, Klazinga NS. Health system stewardship of National Health Ministries in the WHO European region: concepts, functions and assessment framework. Health Policy 2011;103:191-9. https://doi.org/10.1016/j.healthpol.2011.09.002 3. 4. World Health Organization, Travis P, Egger D, Davies P, Mechbal A. Towards better stewardship: concepts and critical issues. Geneva: World Health Organization; 2002. https://apps.who.int/iris/handle/10665/339291 [cited 2023 Jul 1] Zavaleta KW, Philpot LM, Cunningham JL, Gazelka HM, Geyer HL, Rismeyer HL, et al. Why we still prescribe so many opioids: a qualitative study on barriers and facilitators to prescribing guideline implementation. J Opioid Manag 2021;17:115-24. https://doi.org/10.5055/jom.2021.0622 Full text free online at australianprescriber.tg.org.au 27 VOLUME 46 : NUMBER 2 : AUGUST 2023 ARTICLE Medicines stewardship 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. Australian Commission on Safety and Quality in Health Care. Antimicrobial stewardship in Australian health care. Sydney: ACSQHC; 2022. https://www.safetyandquality.gov.au/ publications-and-resources/resource-library/antimicrobialstewardship-australian-health-care [cited 2023 Jul 1] Bui T, Bortz H, Cairns KA, Graudins LV, Corallo CE, Konstantatos A, et al. AAA stewardship: managing high-risk medications with dedicated antimicrobial, anticoagulation and analgesic stewardship programs. J Pharm Pract Res 2021;51:342-7. https://doi.org/10.1002/jppr.1716 Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2019. https://www.cdc.gov/antibiotic-use/core-elements/ hospital.html [cited 2023 Jul 1] Uritsky TJ, Busch ME, Chae SG, Genord C. Opioid stewardship: building on antibiotic stewardship principles. J Pain Palliat Care Pharmacother 2020;34:181-3. https://doi.org/10.1080/15360288.2020.1765066 Australian Commission on Safety and Quality in Health Care. National safety and quality health service standards. 2nd ed. – version 2. Sydney: ACSQHC;2021. https://www.safetyandquality.gov.au/publications-andresources/resource-library/national-safety-and-qualityhealth-service-standards-second-edition [cited 2023 Jul 1] Khumra S, Mahony AA, Bergen PJ, Elliott RA. Evaluation of intravenous to oral antimicrobial switch at a hospital with a tightly regulated antimicrobial stewardship program. Br J Clin Pharmacol 2021;87:3354-8. https://doi.org/10.1111/ bcp.14734 Allen ML, Leslie K, Parker AV, Kim CC, Brooks SL, Braat S, et al. Post-surgical opioid stewardship programs across Australia and New Zealand: current situation and future directions. Anaesth Intensive Care 2019;47:548–52. https://doi.org/10.1177/0310057x19880904 Australian Commission on Safety and Quality in Health Care. Opioid analgesic stewardship in acute pain clinical care standard – acute care edition. Sydney: ACSQHC; 2022. https://www.safetyandquality.gov.au/publications-andresources/resource-library/opioid-analgesic-stewardshipacute-pain-clinical-care-standard-2022 [cited 2023 Jul 1] Gondora N, Versteeg SG, Carter C, Bishop LD, Sproule B, Turcotte D, et al. The role of pharmacists in opioid stewardship: a scoping review. Res Social Adm Pharm 2022;18:2714-47. https://doi.org/10.1016/j.sapharm.2021.06.018 Tran T, Taylor SE, Hardidge A, Findakly D, Aminian P, Elliott RA. Impact of pharmacists assisting with prescribing and undertaking medication review on oxycodone prescribing and supply for patients discharged from surgical wards. J Clin Pharm Ther 2017;42:567-72. https://doi.org/10.1111/ jcpt.12540 Stevens J, Trimboli A, Samios P, Steele N, Welch S, Thompson P, et al. A sustainable method to reduce postoperative oxycodone discharge prescribing in a metropolitan tertiary referral hospital. Anaesthesia 2019;74:292-9. https://doi.org/10.1111/anae.14570 Schwartz GD, Harding AM, Donaldson SR, Greene SL. Modifying emergency department electronic prescribing for outpatient opioid analgesia. Emerg Med Australas 2019;31:417-22. https://doi.org/10.1111/1742-6723.13192 Shoemaker-Hunt SJ, Wyant BE. The effect of opioid stewardship interventions on key outcomes: a systematic review. J Patient Saf 2020;16(Suppl):S36–41. http://dx.doi.org/10.1097/PTS.0000000000000710 Australian Commission on Safety and Quality in Health Care. Venous thromboembolism prevention clinical care standard. Sydney: ACSQHC; 2020. https://www.safetyandquality.gov.au/publications-andresources/resource-library/venous-thromboembolismprevention-clinical-care-standard-2020 [cited 2023 Jul 1] Wychowski MK, Ruscio CI, Kouides PA, Sham RL. The scope and value of an anticoagulation stewardship program at a community teaching hospital. J Thromb Thrombolysis 2017;43:380-6. https://doi.org/10.1007/s11239-016-1455-z FURTHER READING Council of Australian Therapeutic Advisory Groups. Getting it right: guiding principles for medicines stewardship programs. CATAG; 2022. https://catag.org.au/resource/medicinesstewardship [cited 2023 Jul 1] 28 Full text free online at australianprescriber.tg.org.au 20. Dane KE, Streiff MB, Lindsley J, Montana MP, Shanbhag S. The development and impact of hemostatic stewardship programs. Hematol Oncol Clin North Am 2019;33:887-901. https://doi.org/10.1016/j.hoc.2019.05.010 21. Australian Commission of Safety and Quality in Health Care. Joint statement on the inappropriate use of psychotropic medicines to manage the behaviours of people with disability and older people. Sydney: ACSQHC; 2022. https://www.safetyandquality.gov.au/about-us/latestnews/media-releases/joint-statement-inappropriate-usepsychotropic-medicines-manage-behaviours-peopledisability-and-older-people [cited 2023 Jul 1] 22. Pellicano OA, Tong E, Yip G, Monk L, Loh X, Ananda‑Rajah M, et al. Geriatric psychotropic stewardship team to de-escalate inappropriate psychotropic medications in general medicine inpatients: an evaluation. Australas J Ageing 2018;37:E37-41. https://doi.org/10.1111/ajag.12501 23. Brown D, Norris M, Gandell D, Jaunkalns R, Contreras J, Liu BA. Antipsychotic stewardship for older patients in acute care: promoting appropriate prescribing. Innov Aging 2017;1(Suppl 1):705. https://doi.org/10.1093/geroni/igx004.2526 24. Dobbin M, Liew DF. Real-time prescription monitoring: helping people at risk of harm. Aust Prescr 2020;43:164-7. https://doi.org/10.18773/austprescr.2020.050 25. Wheeler AJ, Scahill S, Hopcroft D, Stapleton H. Reducing medication errors at transitions of care is everyone’s business. Aust Prescr 2018;41:73-7. https://doi.org/10.18773/ austprescr.2018.021 26. Australian Commission on Safety and Quality in Health Care (ACSQHC). Medication without harm – WHO Global Patient Safety Challenge. Australia’s response. Sydney: ACSQHC; 2020. https://www.safetyandquality.gov.au/publicationsand-resources/resource-library/medication-without-harmwho-global-patient-safety-challenge-australias-response [cited 2023 Jul 1] 27. Manias E, Bucknall T, Hutchinson A, Botti M, Allen J. Improving documentation at transitions of care for complex patients. Sydney: ACSQHC; 2017. https://www.safetyandquality.gov.au/publications-andresources/resource-library/improving-documentationtransitions-care-complex-patients [cited 2023 Jul 1] 28. Australian Commission on Safety and Quality in Health Care. Safety issues at transitions of care: consultation report on pain points relating to clinical information systems. Sydney: ACSQHC; 2017. https://www.safetyandquality.gov.au/ publications-and-resources/resource-library/safety-issuestransitions-care-consultation-report-pain-points-relatingclinical-information-systems [cited 2023 Jul 1] 29. Liew D, Joules E, Booth J, Garrett K, Frauman A. Evidence to inform the inclusion of Schedule 4 prescription medications on a real-time prescription monitoring system. Melbourne: Austin Health; 2017. https://www.health.vic.gov.au/publications/report-literaturereview-for-real-time-prescription-monitoring [cited 2023 Jul 1] 30. Alqenae FA, Steinke D, Keers RN. Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: a systematic review. Drug Saf 2020;43:517-37. https://doi.org/10.1007/ s40264-020-00918-3 31. Wembridge P, Rashed S. Discharge summary medication list accuracy across five metropolitan hospitals: a retrospective medical record audit. Aust Health Rev 2022;46:338-45. https://doi.org/10.1071/ah22012 32. Angley M, Criddle D, Rigby D, Elliott RA, Phillips K, Penm J, et al. Hospital-initiated post-discharge medication reviews in Australia: expert opinion on the barriers and enablers to implementation. J Pharm Pract Res 2022;52:446-53. https://doi.org/10.1002/jppr.1832 VOLUME 46 : NUMBER 2 : AUGUST 2023 ARTICLE An update on wound management SUMMARY Wound management involves an understanding of the aetiology and pathophysiology of a wound, the healing process and how best to manage both. Acute wounds can occur suddenly, such as burns and skin tears. Chronic wounds fail to progress through the normal stages of healing and can include ulcers, pressure injuries and infected wounds. Dressings and bandages provide the optimal environment for the healing of all wound types. It is important for healthcare practitioners to understand the key differences in their properties, uses and precautions. Selecting the ideal dressing or bandage can minimise the healing duration, reduce the bioburden, and improve a patient’s quality of life. Introduction The prevalence of wounds continues to increase because of the ageing population, rising incidence of diabetes and respiratory diseases, and poor nutrition. The skill of identifying and treating wounds grows with our understanding and knowledge of the processes of wound repair and healing. There are many types of wound treatments available. This often causes confusion and the misuse of products. On any given day in Australia, around 500,000 people have an unhealed wound, and the annual financial impact is more than $3 billion. These costs are both direct, in terms of wound treatment, and indirect such as the impact on the ability to work. Cost savings can be achieved by appropriate wound management.1-3 Over the last 50 years, the emphasis has been on developing a range of wound dressings with properties of absorption, hydration and antimicrobial activity. Wound care has seen a shift from simple dressings to devices and products that incorporate pharmaceutically active ingredients.4 Current and future treatments include biologicals, topical immunosuppressants, growth factors and various types of tissue matrices. Assessment The ageing process affects most structures of the skin. The skin loses hair follicles, sebaceous glands that supply natural moisture to the skin, receptors (including those for touch, pressure, pain and temperature), blood supply and sweat glands. As a result, the skin becomes thinner, more brittle, avascular and more prone to injury.5 Comorbidities and various intrinsic and extrinsic factors significantly affect wound healing (see Box 1).6 © 2023 Therapeutic Guidelines Ltd Assessing the patient and wound is critical to facilitate an accurate diagnosis and thus an appropriate management strategy. The main issues to consider are the wound type, wound position, wound shape, level and type of exudate, presence of any comorbidities, drugs being used, nutritional state and known investigations. Geoffrey Sussman Associate professor, Faculty of Medicine, Nursing and Health Sciences, Monash University Keywords bandages, dressings, wound care, wound pathophysiology Aust Prescr 2023;46:29–35 https://doi.org/10.18773/ austprescr.2023.006 There are several tools that can be used as part of the assessment including the TIME and MEASURE frameworks (see Box 2).7,8,9 These allow clinicians to consider a wide range of factors relating to the wound and patient.8,9 General principles The management of any wound involves addressing the cause of the wound and the use of dressings or bandages. Wound dressings can be divided into two broad groups – inert/passive and interactive/bioactive. Inert dressings fulfil very few of the properties of an ideal dressing and can be subclassified into absorbent and non-absorbent. They include gauze, lint, nonadherent dressings and tulle dressings. They have limited (if any) use as primary dressings (which are Box 1 Factors that affect wound healing Intrinsic factors Extrinsic factors • health status • mechanical stress • immune function • debris • age • temperature • extremes of body mass • drying or maceration • diabetes • infection • nutritional status • chemical stress • other factors (e.g. smoking, drugs) This article is peer-reviewed 29 VOLUME 46 : NUMBER 2 : AUGUST 2023 ARTICLE An update on wound management Box 2 Assessment tools TIME framework 7 • Tissue • Infection • Moisture balance • wound Edge MEASURE framework 8 • Measure (length, width, depth and area) • Exudate (quantity and quality) • Appearance (wound bed, including tissue type and amount) • Suffering (pain type and level) • Undermining (presence or absence) • Re-evaluate (monitoring of all parameters regularly) • Edge (condition of edge and surrounding skin) applied directly on the wound), but some are useful as secondary dressings (which are used on top of primary dressings). Interactive dressings alter the wound environment and interact with the wound surface to optimise healing. Interactive dressings can be absorbent, non-absorbent or moisturising. They include films, hydrocolloids, foams, hydrogels and hydroactive dressings. They have the properties of protection, absorption, hydration, antimicrobial action and tissue modulation. When instructing a patient or their family or carers on the use of dressings, remember to keep it simple to increase the likelihood that a product will be used correctly. Acute wounds Acute wounds occur suddenly and can include burns, lacerations, grazes and skin tears.10 Burns The main aims of burn management are to prevent infection, reduce pain and provide an ideal woundhealing environment. It is important to identify the type, depth and area of a burn.11,12 Many burn injuries are superficial. They involve pain, discomfort and disruption to a patient’s routine activities of daily living. Most superficial burns involve only the top layer of the skin. These burns do not form blisters and generally heal in 3–6 days without scarring. The superficial burns requiring specialist care are typically in patients who are immunosuppressed. The essential management of a superficial burn involves the immediate application of cold running tap water for 20–30 minutes, but not ice, as temperatures 30 Full text free online at australianprescriber.tg.org.au below 5 oC may deepen burns. This is followed by the use of silver dressings or amorphous or sheet hydrogels.13 The use of topical silver-containing treatments has shifted from creams to metallic silver dressings. The use of a topical silver cream on a mucous surface will result in the formation of a mucilaginous slime on the surface of the tissue, which is cytotoxic and slows healing. Deep burns, on the other hand, are associated with scarring, functional defects, psychological problems, costs to the community and contractures. Deep burns involve damage to the dermis and subcutis. It is essential to assess the cause of and extent of damage associated with deep burns. Management involves infection prevention, debridement and grafting. Skin tears As a result of skin ageing and the epidermal layer separating more easily from the dermis with age, skin tears are common in older people. The main cause is trauma from manual handling (e.g. transferring a patient from a bed to a chair, removing adhesive tapes, falls, and collisions with bed rails and wheelchair foot plates). If possible, align the skin back in place, secure with adhesive skin strips, such as Steri-Strips, and cover with a silicone foam dressing. If there is a loss of the epidermis, cover the area of loss with a silicone tulle before the application of a silicone foam dressing. In addition to treatment, it is essential to identify the risk of recurrence and introduce a plan for prevention. The use of an effective moisturiser twice a day can reduce the risk of skin tears significantly.14,15 Chronic wounds A chronic wound is described as an acute wound that has not healed after six weeks. Chronic wounds fail to progress through the normal stages of healing and can include venous leg ulcers, pressure injuries, diabetic foot ulcers, neoplasia, and atypical wounds such as vasculitis.10 If you are treating a chronic wound and observe no improvement after four weeks of management, it is then essential to reassess and consider a biopsy or referral to a specialist wound clinic. It is important to note that a non-healing wound can become neoplastic. Venous ulcers Venous leg ulcers are the most common ulcers. The cause is valve incompetence, with consequent venous hypertension forcing fluid into tissues, producing hypoxia at the periphery. The initial wound is often traumatic, with poor healing due to the presence of hypoxic tissue. The main features include VOLUME 46 : NUMBER 2 : AUGUST 2023 ARTICLE oedema, staining due to haemosiderin deposition, lipodermatosclerosis, presentation in the lower third of the leg, an often-painless presentation, an irregular shape and the potential for copious exudate. It is important to perform a vascular assessment to identify a clear venous pathology and check the arterial system to ensure that compression is safe. Other aspects of the wound can be addressed with specific dressings placed under the compression (see Table 1).4,10,16-18 If a venous pathology is confirmed, apply graduated compression bandages or stockings to the ulcers (see Table 2). There are different grades of stockings available to provide different pressures. The minimum coverage should be from the toes to the knee, with a compression pressure of 30–40 mmHg at the ankles.18 Arterial ulcers Arterial ulcers result from reduced arterial blood flow. The features include claudication, pain at rest, a reduction in the ankle brachial index score, weak or absent pedal pulses and sluggish or poor capillary refill. The wounds are regular in outline with a punched-out appearance, and the ulcer site is usually at or below the ankles. The acute management of arterial ulcers usually involves improving blood flow through angioplasty, stenting or bypass grafting and, if necessary, the amputation of a digit or limb. Pain management is often necessary.16 Diabetic foot ulcers Diabetic wounds can be classified as either neuropathic, ischaemic or neuroischaemic. Neuropathic wounds are painless and thus often unnoticed, occur over bony prominences or areas of pressure, and will heal with a sufficient blood supply. Ischaemic wounds are painful and not necessarily in areas of pressure. A poor blood supply negatively affects healing. Neuroischaemic wounds involve the loss of both sensation and arterial blood supply. Optimising glycaemic control is critical for management. The main management issues are ensuring that the circulation is adequate, that any infection is controlled and that pressure is removed. It is essential to involve a multidisciplinary team including an orthotics specialist and podiatrist in the management of diabetic foot ulcers. Treatment will often involve antimicrobial dressings and pressure off-loading. Pressure off-loading refers to reducing or removing weight placed on the feet, which is achieved using felt devices and specialised footwear that are provided by podiatrists. There is a new treatment containing sucrose octasulfate with strong evidence for its use.19,20 Management should involve regular review and examination of the patient. It should also involve education of the patient, their family or carers and healthcare providers, as well as appropriate footwear and the treatment of non-ulcerative pathology.19,21,22 These include changes in the skin and nails, such as plantar erythema, xerosis (dry skin), fungal toe infections and dystrophic nails. The ongoing risk of foot ulcers includes the impact of sensory loss, which can be assessed by daily inspections of the feet for blisters, fissures, bleeding or lesions such as tinea between the toes. Treatment of dry skin and lesions, and the removal of calluses caused by autonomic neuropathy are important. Pressure injuries Pressure injuries are a frequent problem for patients in hospital and residential aged-care facilities. When pressure of more than 30 mmHg is applied over bony prominences, this physically closes off small vessels, resulting in hypoxic tissue and ischaemic injury. Pressure injuries may also be caused by friction or shear forces. It is important to identify patients at risk using screening tools, such as the Norton or Braden scales, and to manage risk factors. Skin damage in the sacral region can also be caused by incontinence-associated dermatitis, but this is not classified as a pressure injury. The main management strategy involves off-loading, dressings, improving nutrition if necessary, and the use of pressure-reducing surfaces on beds and chairs.23-27 Wound infection Infection is a major factor in delaying wound healing. However, most chronic wounds have bacteria present on the surface, but they are not necessarily infected. Tissue biopsy is the most accurate method of identifying an infection. Do not swab chronic wounds routinely, as this often leads to unnecessary antibiotic use and does not address the underlying problem. However, if a swab is to be used, the Levine method is preferred, described as follows. The wound should be cleaned with water or saline, not an antimicrobial solution. Following this, identify 1–2 cm of clean wound tissue. Rotate the applicator for five seconds while applying sufficient pressure to produce fluid from the wound tissue. Do not obtain a specimen from exudate, eschar or necrotic material. Infected chronic wounds are more often due to the presence of anaerobes. For localised wound infections, use topical antimicrobials (e.g. polyhexamethylene biguanide (PHMB), octenidine dihydrochloride, chlorhexidine, povidone-iodine). For systemic or spreading infections, systemic antimicrobials are required in combination with Full text free online at australianprescriber.tg.org.au 31 VOLUME 46 : NUMBER 2 : AUGUST 2023 An update on wound management ARTICLE Table 1 Wound dressings 4,10,16-18 Product Classification Properties Uses Precautions Protects new tissue growth Low- to high-exuding wounds Atraumatic to surrounding skin Primary dressing over superficial low-exuding wounds No longer used due to shedding of fibres and being open weave Tulles Paraffin gauze (e.g. Jelonet) Conformable to wound bed Provides a protective layer Nonparaffin (e.g. Cuticerin, Adaptic, Atrauman) Silicone (e.g. Mepitel) May dry out if left in place for too long Contact layer is soft silicone Wounds in patients with fragile skin Consider allergies to soft silicone adhesives Basic (e.g. Melolin, Cutilin) Cotton wool with plastic surface Very low absorption Primary dressing over superficial low-exuding wounds Will not cope with moderate or high levels of exudate High absorption (e.g. Mesorb, Vliwasorb, Zetuvit) Polymers Moderate- to high-exuding wounds Highly absorbent Secondary dressing over exuding wounds Do not use on dry or low-exuding wounds Polyurethane film Primary dressing over superficial low-exuding wounds Do not use on patients with fragile or compromised surrounding skin Secondary dressing over alginate or hydrogel primary dressing Do not use on moderate- to highexuding wounds Clean, low- to moderate-exuding wounds Do not use on dry or necrotic wounds or high-exuding wounds Non-adherent dressings Film dressings (e.g. Opsite, Tegaderm) Moisture control Breathable bacterial barrier Transparent (allows for visualisation of the wound) Hydrocolloid dressings (e.g. DuoDERM, Comfeel) Absorb low to moderate levels of fluid May encourage overgranulation Promote autolytic debridement May cause maceration Do not use on diabetic wounds Foam dressings Standard (e.g. Lyofoam Max, Allevyn) Fluid absorption Moderate- to high-exuding wounds Moisture control Low- to non-adherent products available for patients with fragile skin Conformable to wound bed Thermal insulation Do not use on dry or necrotic wounds or those with minimal exudate Cushioning Soft silicone (e.g. Mepilex, Allevyn Life) Non-adherent Wounds in patients with fragile skin Pressure prevention Consider allergies to soft silicone adhesives Hydroactive dressings Foam like (e.g. Biatain, Tielle) Fluid absorption Moderate- to high-exuding wounds Moisture control Products available for cavity wounds Conformable to wound bed Low-adherent products available for patients with fragile skin Similar but not the same as foam dressings Alginate dressings (e.g. Kaltostat, Algisite M) Fluid absorption Moderate- to high-exuding wounds Promote autolytic debridement Products in the form of ropes available for cavity wounds Moisture control Conformable to wound bed Some products are haemostatic Products available with silver for antimicrobial activity Do not use on dry or necrotic wounds or those with minimal exudate Do not use on dry or necrotic wounds Use with caution on friable tissue (may cause bleeding) Do not pack cavity wounds tightly Continued over page 32 Full text free online at australianprescriber.tg.org.au VOLUME 46 : NUMBER 2 : AUGUST 2023 ARTICLE Table 1 Wound dressings 4,10,16-18 (continued) Product Classification Properties Uses Precautions Sterile amorphous (e.g. Intrasite, Purilon) Rehydrate wound bed Dry and low- to moderate-exuding wounds and superficial burns Preserved amorphous (e.g. Solugel, Solosite) Promote autolytic debridement Do not use on high-exuding wounds or where anaerobic infection is suspected Sheet (e.g. Hydrotac Transparent) Provide pain relief Hydrogel dressings Moisture control Cooling Products available with antimicrobials May cause maceration Antimicrobial dressings Effective against bacteria, mycobacteria, fungi, protozoans, spores and viruses – no evidence of resistance to iodine Critically colonised wounds or wounds with clinical signs of infection Polyethylene glycol iodine (e.g. Inadine) Debrider Diabetic wounds Silver (e.g. Acticoat, Mepilex Ag, Aquacel Ag, Biatain Ag) Effective against a broad range of bacteria, fungi and viruses Iodine Cadexomer iodine (e.g. Iodosorb) Polyhexamethylene biguanide (PHMB) (e.g. Prontosan) Low- to high-exuding wounds Consider sensitivity to iodine Short-term use recommended (e.g. 3 months) to minimise risk of systemic absorption Some products stimulate wound healing Newer non-toxic products Effective against a broad range of bacteria, fungi and viruses Dialkylcarbamoyl chloride (DACC) (e.g. Sorbact) Critically colonised wounds or wounds with clinical signs of infection Some products may cause discolouration Low- to high-exuding wounds Consider sensitivity to silver Products available with foam and alginates or carboxymethylcellulose for increased absorption Discontinue after 2 weeks if no improvement and re-evaluate Sloughy, low- to moderate-exuding wounds Do not use on clean, granulating wounds Critically colonised wounds or wounds with clinical signs of infection Hypochlorous acid (e.g. Microdacyn) Enzymatic alginate gel (e.g. Flaminal) Miscellaneous dressings Sucrose octasulfate (e.g. UrgoStart) Controls wound protease levels Stimulates wound healing topical antimicrobial therapies; the choice of systemic antimicrobial should be based on identification of the causative organism and its susceptibilities.28 Biofilms have been described as an aggregate microorganism with unique characteristics and enhanced tolerance to treatment and the host defences. Wound biofilms are associated with impaired wound healing and signs and symptoms of chronic inflammation. Systemic antimicrobials in general do not penetrate biofilms and management involves debridement and the use of products such as cadexomer iodine.28 Clean wounds that are not progressing despite correction of underlying causes, exclusion of infection and optimal wound care Do not use on dry wounds or those with leathery eschar The bioburden refers to the number of microorganisms in a wound, the pathogenicity of which is influenced by the microorganisms present (i.e. the species and strain), their growth and their potential virulence mechanisms.2 The major roles for antimicrobial dressings in wound management are to reduce the bioburden in acute and chronic wounds that are infected or are prevented from healing by microorganisms, and to act as an antimicrobial barrier for acute and chronic wounds at high risk of infection or reinfection.28,29 Types of antimicrobial dressings are listed in Table 1. Full text free online at australianprescriber.tg.org.au 33 VOLUME 46 : NUMBER 2 : AUGUST 2023 ARTICLE An update on wound management Wound dressings Dressings provide the best environment for wound healing in combination with the management of the cause of the wound and factors impacting healing. Table 1 lists the different dressings that are available. The general rules for dressings are as follows: • allow 2–3 cm of dressing greater than the size of the wound • place a third of the dressing above and two-thirds below the wound • remove dressing when strikethrough occurs • remove dressing with care in older patients • do not pre-moisten alginate dressings • no single dressing will meet all the requirements. Bandages use for dressing retention. Light cohesive or tubular bandages are the most appropriate and cost effective for dressing retention. Resources The Wounds Australia website has guidelines on Prevention and Management of Venous Leg Ulcers, Prevention and Treatment of Pressure Ulcers Injuries, Aseptic Technique in Wound Dressing Procedure, Atypical Wounds - Best Clinical Practices and Challenges, and Wound Infection in Clinical Practice: Principles of Best Practice. The Department of Veterans’ Affairs website has a wound care module with a wound identification and product selection chart available to download. Conclusion There are three main roles for a bandage: keeping a dressing in place, supporting an injured joint and