What is the plan of care for an adult patient with a left arm laceration being treated with bacitracin (topical antibiotic ointment)?

Plan of Care for Left Arm Laceration with Bacitracin

Critical Recommendation: Do Not Use Bacitracin

Bacitracin should be avoided for routine wound care of simple lacerations due to inferior efficacy, high rates of allergic contact dermatitis, and risk of anaphylaxis—mupirocin 2% ointment applied three times daily for 5-7 days is the evidence-based first-line topical antibiotic if infection develops. 1, 2

Initial Wound Management

Immediate Wound Care Steps

• Irrigate the laceration thoroughly with warmed sterile water, saline, or dilute chlorhexidine (1:5000) to remove debris and reduce bacterial load 3
• Debride any devitalized tissue and remove foreign bodies to minimize infection risk
• Assess wound characteristics including depth, contamination level, and whether primary closure is appropriate
• Apply a greasy emollient such as 50% white soft paraffin with 50% liquid paraffin over the wound rather than bacitracin 3

Why Bacitracin Is Problematic

Bacitracin has emerged as a leading allergen with increasing rates of clinically relevant allergic contact dermatitis documented by the North American Contact Dermatitis Group 4

Key concerns include:

• Considerably less effective than mupirocin for treating skin infections caused by S. aureus and S. pyogenes 1
• High sensitization risk, particularly when used under occlusion (such as with adhesive bandages) 3
• Documented cases of near-fatal anaphylaxis following topical application to minor wounds 5
• Not recommended by the Infectious Diseases Society of America for impetigo or wound infections 1, 2

Appropriate Topical Antibiotic Use (If Needed)

When to Consider Topical Antibiotics

Topical antibiotics are indicated only if:

• Signs of infection develop (erythema, warmth, purulent drainage, increasing pain) 6
• High contamination risk exists (soil contamination, delayed presentation >3 hours) 3

First-Line Topical Agent

Mupirocin 2% ointment is the gold standard:

• Apply three times daily for 5-7 days 1, 2
• Clinical efficacy rates of 71-93% in controlled trials 1
• Effective against S. aureus (including MRSA) and S. pyogenes 2

Retapamulin 1% ointment is an alternative:

• Apply twice daily for 5 days if mupirocin unavailable 1, 2

Escalation to Systemic Antibiotics

Indications for Oral Antibiotics

Switch to systemic therapy if:

• No improvement after 48-72 hours of topical treatment 1, 2
• Systemic symptoms develop (fever, malaise, lymphadenopathy) 1, 2
• Extensive involvement with multiple lesions across large body surface areas 2

Oral Antibiotic Selection

For presumed MSSA:

• Dicloxacillin 250 mg four times daily for adults 1
• Cephalexin 250-500 mg four times daily as alternative 1

For suspected/confirmed MRSA:

• Clindamycin 300-450 mg three times daily for adults 1
• Trimethoprim-sulfamethoxazole 1-2 double-strength tablets twice daily as alternative 1

Wound Dressing Protocol

Appropriate Dressing Materials

• Apply nonadherent dressings such as Mepitel™ or Telfa™ to prevent trauma during dressing changes 3
• Use secondary foam dressing to collect exudate if needed 3
• Change dressings daily or when saturated 3
• Keep wound covered with clean, dry bandages 2

Critical Pitfall to Avoid

Never occlude wounds with adhesive bandages impregnated with bacitracin or benzalkonium chloride—this significantly increases sensitization risk 3

Infection Prevention Measures

Hygiene and Monitoring

• Maintain good hand hygiene with soap and water or alcohol-based gel, especially after touching the wound 2
• Avoid sharing personal items that contact the wound 2
• Monitor for infection signs including increased erythema, warmth, purulent drainage, or fever
• Take wound swabs for culture if infection develops to guide antibiotic selection 3

Antibiotic Stewardship

• Administer systemic antibiotics only if clinical signs of infection present—prophylactic antibiotics for simple lacerations lack clear evidence of benefit 3, 7
• Limit antibiotic duration to minimize resistance development and adverse effects 3

Common Pitfalls Summary

Avoid these errors:

• Using bacitracin routinely (high allergy risk, inferior efficacy) 1, 4
• Using penicillin alone (lacks adequate S. aureus coverage) 1, 2
• Using rifampin as monotherapy (ineffective for skin infections) 1, 2
• Prescribing prophylactic antibiotics for clean, simple lacerations without clear indication 7