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Honey use in burn management: potentials and limitations

Boukraâ L, Sulaiman SA

Forsch Komplementmed, 2010 Apr;17(2):74-80.
PMID: 20484914 DOI: 10.1159/000297213

Management of the burn wound still remains a matter of debate, and an ideal dressing for burn wounds has not yet been discovered. Naturally occurring substances such as honey have been found to be useful as a wound cover for burns. Unlike most conventional local chemotherapeutics, honey does not lead to the development of antibiotic-resistant bacteria, and it may be used continuously. Among the challenging problems of using honey for medical purposes are dosage, safety, and formulation. Many approaches have been suggested to overcome such problems. With the increased availability of licensed medical products containing honey, clinical use is expected to increase and further evidence will become available. Honey seems to have the potential to clear infection as well as to be an effective prophylactic agent that may contribute to reducing the risks of cross-infection. A better understanding of the therapeutic and chemical properties of honey is needed to optimise the use of this product in the clinical management of burns. Its use in professional care centres should be limited to those with certified healing activities. The potentials and limitations of using honey as burn dressing are discussed in this review.

Matched MeSH terms: Cross Infection/therapy; Wound Infection/therapy*
Fulltext Orthopaedic infections

Choon DSK

Med J Malaysia, 2004 Dec;59(5):571-2.
PMID: 15889556
Matched MeSH terms: Surgical Wound Infection/therapy*
Fulltext Approaches for Mitigating Microbial Biofilm-Related Drug Resistance: A Focus on Micro- and Nanotechnologies

Rao H, Choo S, Rajeswari Mahalingam SR, Adisuri DS, Madhavan P, Md Akim A, et al.

Molecules, 2021 Mar 26;26(7).
PMID: 33810292 DOI: 10.3390/molecules26071870

Biofilms play an essential role in chronic and healthcare-associated infections and are more resistant to antimicrobials compared to their planktonic counterparts due to their (1) physiological state, (2) cell density, (3) quorum sensing abilities, (4) presence of extracellular matrix, (5) upregulation of drug efflux pumps, (6) point mutation and overexpression of resistance genes, and (7) presence of persister cells. The genes involved and their implications in antimicrobial resistance are well defined for bacterial biofilms but are understudied in fungal biofilms. Potential therapeutics for biofilm mitigation that have been reported include (1) antimicrobial photodynamic therapy, (2) antimicrobial lock therapy, (3) antimicrobial peptides, (4) electrical methods, and (5) antimicrobial coatings. These approaches exhibit promising characteristics for addressing the impending crisis of antimicrobial resistance (AMR). Recently, advances in the micro- and nanotechnology field have propelled the development of novel biomaterials and approaches to combat biofilms either independently, in combination or as antimicrobial delivery systems. In this review, we will summarize the general principles of clinically important microbial biofilm formation with a focus on fungal biofilms. We will delve into the details of some novel micro- and nanotechnology approaches that have been developed to combat biofilms and the possibility of utilizing them in a clinical setting.

Matched MeSH terms: Cross Infection/therapy*
Fulltext Bacteriological study and its role in the management of open tibial fracture

Faisham WI, Nordin S, Aidura M

Med J Malaysia, 2001 Jun;56(2):201-6.
PMID: 11771081

Sixty percent of open fracture wounds are contaminated at the time of injury. Despite that, the necessity for sequential multiple cultures and sensitivity studies for open fractures and their interpretation are still controversial. Predebridement, intraoperative, postoperative swabs and swabs in established infection for culture and sensitivity study were taken in 33 open tibial fractures over a 6 months period. 39.3% of predebridement swabs grew bacteria with the majority yielding gram-positive organism. None of the patients developed infection with similar organisms. 24.2% of the postoperative swabs grew bacteria, of which 75% were gram-negative. 50% of the patients with positive postoperative swabs developed infection. Thus, the role of sequential multiple cultures and sensitivity studies are not helpful in management of open fracture.

Matched MeSH terms: Wound Infection/therapy*
Fulltext Cytokines in infection

Pang T

Med J Malaysia, 1993 Mar;48(1):9-11.
PMID: 8341179

Cytokines are central to the development of effective immunity against microbial pathogens and their beneficial effects in the control of a variety of infections of man and animals are well-documented. However, it appears that cytokines may also have detrimental effects in infections by actually enhancing microbial growth. These observations emphasise the fact that many successful pathogens possess mechanisms enabling them to evade the immune response and that caution needs to be exercised in using cytokines as therapeutic agents to control infections in various human diseases.

Matched MeSH terms: Infection/therapy*
Perforated appendicitis--the Malaysian experience

Lee CM, Teoh MK

J R Coll Surg Edinb, 1990 Apr;35(2):83-7.
PMID: 2355382

Perforated appendicitis, with its increased complication rate, today still poses a formidable problem in the Kuala Lumpur General Hospital. Out of 1694 emergency operations performed by our unit in 1987, there were 927 appendicectomies. A retrospective study of these cases showed 126 cases of perforated appendicitis, which were then subjected to detailed analysis. We have a diagnostic accuracy of 81% and perforation rate of 18%. In addition, it is interesting to note the racial differences in the relationship of diagnostic accuracy to perforation rate. Perforation is associated with an increased wound infection rate. Transperitoneal drainage in perforated appendicitis did not lead to a lower incidence of wound infection or improve postoperative performance. Distinguishing between perforated and non-perforated appendicitis may be difficult. Perforation could occur while awaiting operation. We recommend the early administration of systemic antibiotics should appendicectomy be delayed and the cautious use of drains in cases of perforated appendicitis.

Matched MeSH terms: Surgical Wound Infection/therapy
Fulltext Sterilisation of Lucilia cuprina Wiedemann maggots used in therapy of intractable wounds

Mohd Masri S, Nazni WA, Lee HL, T Rogayah TA, Subramaniam S

Trop Biomed, 2005 Dec;22(2):185-9.
PMID: 16883286 MyJurnal

Three new techniques of sterilising maggots of Lucilia cuprina for the purpose of debriding intractable wounds were studied. These techniques were utilisation of ultra-violet C (UVC) and maggot sterilisation with disinfectants. The status of sterility was checked on nutrient agar and blood agar and confirmed with staining. The indicators for the effectiveness of the methods were sterility and survival rate of the eggs or larvae. Egg sterilisation with UVC had the lowest hatching rate (16+/-0.00%) while egg sterilisation with disinfectants showed high hatching rate (36.67+/-4.41%) but low maggot survival rate (31.67+/-1.67%). Sterilisation of the maggots was the most suitable, since the survival rate was the highest (88.67+/-0.88%). Complete sterility was achieved in all cases, except that Proteus mirabilis was consistently found. However, the presence of this microorganism was considered beneficial.

Matched MeSH terms: Wound Infection/therapy*
The effects of honey compared to silver sulfadiazine for the treatment of burns: A systematic review of randomized controlled trials

Aziz Z, Abdul Rasool Hassan B

Burns, 2017 Feb;43(1):50-57.
PMID: 27576926 DOI: 10.1016/j.burns.2016.07.004

Evidence from animal studies and trials suggests that honey may accelerate wound healing. The objective of this review was to assess the effects of honey compared with silver dressings on the healing of burn wounds. Relevant databases for randomized controlled trials (RCTs) of honey compared with silver sulfadiazine (SSD) were searched. The quality of the selected trials was assessed using the Cochrane Risk of Bias Assessment Tool. The primary endpoints considered were wound healing time and the number of infected wounds rendered sterile. Nine RCTs met the inclusion criteria. Based on moderate quality evidence there was a statistically significant difference between the two groups, favoring honey in healing time (MD -5.76days, 95% CI -8.14 to -3.39) and the proportions of infected wounds rendered sterile (RR 2.59; 95% CI 1.58-2.88). The available evidence suggests that honey dressings promote better wound healing than silver sulfadiazine for burns.

Matched MeSH terms: Wound Infection/therapy*
Fulltext Diagnosis and management of Guillain-Barré syndrome in ten steps

Leonhard SE, Mandarakas MR, Gondim FAA, Bateman K, Ferreira MLB, Cornblath DR, et al.

Nat Rev Neurol, 2019 Nov;15(11):671-683.
PMID: 31541214 DOI: 10.1038/s41582-019-0250-9

Guillain-Barré syndrome (GBS) is a rare, but potentially fatal, immune-mediated disease of the peripheral nerves and nerve roots that is usually triggered by infections. The incidence of GBS can therefore increase during outbreaks of infectious diseases, as was seen during the Zika virus epidemics in 2013 in French Polynesia and 2015 in Latin America. Diagnosis and management of GBS can be complicated as its clinical presentation and disease course are heterogeneous, and no international clinical guidelines are currently available. To support clinicians, especially in the context of an outbreak, we have developed a globally applicable guideline for the diagnosis and management of GBS. The guideline is based on current literature and expert consensus, and has a ten-step structure to facilitate its use in clinical practice. We first provide an introduction to the diagnostic criteria, clinical variants and differential diagnoses of GBS. The ten steps then cover early recognition and diagnosis of GBS, admission to the intensive care unit, treatment indication and selection, monitoring and treatment of disease progression, prediction of clinical course and outcome, and management of complications and sequelae.

Matched MeSH terms: Zika Virus Infection/therapy
Fulltext "Postpartum morbidity--what we can do"

Zainur RZ, Loh KY

Med J Malaysia, 2006 Dec;61(5):651-6.
PMID: 17623974

Postpartum is a crucial period for a mother. During this period a mother is going through the physiological process of uterine involution and at the same time adapting to her new role in the family. Many postpartum complications occur during this period. Among the important obstetric morbidities are postpartum hemorrhage, pregnancy related hypertension, pulmonary embolism and puerperal sepsis. Common surgical complications are wound breakdown, breast abscess and urinary fecal incontinence. Medical conditions such as anemia, headache, backache, constipation and sexual problems may also be present. Unrecognized postpartum disorders can lead to physical discomfort, psychological distress and a poor quality of life for the mothers. Providing quality postnatal care including earlier identification of the problems (correction) and proper intervention will help the mother to achieve full recovery and restore her functional status back to the pre-pregnancy state sooner.

Matched MeSH terms: Puerperal Infection/therapy
Diabetic Hand Infection: An Emerging Challenge

Bahar Moni AS, Hoque M, Mollah RA, Ivy RS, Mujib I

J Hand Surg Asian Pac Vol, 2019 Sep;24(3):317-322.
PMID: 31438802 DOI: 10.1142/S2424835519500401

Background: Hand infection in diabetics is an often ignored but challenging condition. If not addressed effectively, it may result in long term disability, contracture, amputation and even death. Methods: From August 2014 to December 2015, a study was done in our centre, where 49 diabetic hand infection cases were analyzed in two groups, superficial and deep hand infection. Results: Mean age of the patients was 51.63 years. There were 21 superficial infections and 28 deep infections. Cause of infection was unknown or spontaneous in 16 cases, traumatic laceration or crush in 14 patients, following minor prick in 10 cases. Most of the cases were the results of neglected minor wound. Forty-one patients were insulin dependent. Five cases were diagnosed as diabetic at the time of treatment. Four patients were treated conservatively and 45 (92%) cases required operation in the form of incision, drainage and debridement. In 16 (35%) cases, wound was left open and was healed by secondary intention following regular dressing. In five patients, wound was closed secondarily. Partial thickness skin graft was applied in 15 cases. Seven patients were treated with flap coverage. Partial digital or ray amputation were done in 16 cases. All fingers except thumb were amputated in one case and amputation from wrist was done in another patient. Wound swabs were taken, and antibiotics were changed or continued accordingly. But reports of 26 cases were available. No growth was found in four cases, monomicrobial infection was found in 15 patients and polymicrobial in seven cases. Infection resolved with healing in 47 cases. Two patients died during treatment from sepsis, both were insulin dependent, had associated renal failure and from deep infection group. One patient developed severe mental disorder. Conclusions: For diabetic hand infection, early diagnosis and prompt treatment with appropriate antibiotics and emergency surgery with extensile incision is crucial. Primary amputation of the part could be life and limb saving.

Matched MeSH terms: Wound Infection/therapy*
Fulltext Low-molecular-weight heparin and mortality in acutely ill medical patients

Kakkar AK, Cimminiello C, Goldhaber SZ, Parakh R, Wang C, Bergmann JF, et al.

N Engl J Med, 2011 Dec 29;365(26):2463-72.
PMID: 22204723 DOI: 10.1056/NEJMoa1111288

BACKGROUND: Although thromboprophylaxis reduces the incidence of venous thromboembolism in acutely ill medical patients, an associated reduction in the rate of death from any cause has not been shown.
METHODS: We conducted a double-blind, placebo-controlled, randomized trial to assess the effect of subcutaneous enoxaparin (40 mg daily) as compared with placebo--both administered for 10±4 days in patients who were wearing elastic stockings with graduated compression--on the rate of death from any cause among hospitalized, acutely ill medical patients at participating sites in China, India, Korea, Malaysia, Mexico, the Philippines, and Tunisia. Inclusion criteria were an age of at least 40 years and hospitalization for acute decompensated heart failure, severe systemic infection with at least one risk factor for venous thromboembolism, or active cancer. The primary efficacy outcome was the rate of death from any cause at 30 days after randomization. The primary safety outcome was the rate of major bleeding during and up to 48 hours after the treatment period.
RESULTS: A total of 8307 patients were randomly assigned to receive enoxaparin plus elastic stockings with graduated compression (4171 patients) or placebo plus elastic stockings with graduated compression (4136 patients) and were included in the intention-to-treat population. The rate of death from any cause at day 30 was 4.9% in the enoxaparin group as compared with 4.8% in the placebo group (risk ratio, 1.0; 95% confidence interval [CI], 0.8 to 1.2; P=0.83). The rate of major bleeding was 0.4% in the enoxaparin group and 0.3% in the placebo group (risk ratio, 1.4; 95% CI, 0.7 to 3.1; P=0.35).
CONCLUSIONS: The use of enoxaparin plus elastic stockings with graduated compression, as compared with elastic stockings with graduated compression alone, was not associated with a reduction in the rate of death from any cause among hospitalized, acutely ill medical patients. (Funded by Sanofi; LIFENOX ClinicalTrials.gov number, NCT00622648.).
Note: Malaysia is a study site: participating investigators: Yaw Chong Hwa (WT Ma), Najihah I, SH How, Abdul Razak AM, Law WC (ST Tie), Bharathan T, Monniaty M, Aris Chandran, Ngau Yen Yew, Aziah AM, Irene Wong, CK Chuah, Rosemi S, KK Sia, Jeyaindran S, CY Leong

Matched MeSH terms: Infection/therapy
Fulltext Use of gentamicin impregnated POP discs for antibiotic pouch dressing

Lau CP, Chee EK, Thirumal M

Med J Malaysia, 2006 Dec;61 Suppl B:32-6.
PMID: 17600990

Antibiotic pouch technique is commonly used due to the high local antibiotic concentration and moist environment for wound healing. We used locally made gentamicin impregnated Plaster of Paris discs in treating wounds with exposed deep structures like tendons and bones. Out of 22 patients treated with this method, 19 completed treatment. Granulation tissue formed quickly and effectively covered the exposed structures. All wounds either healed by secondary intention or became suitable for split skin grafting. Gentamicin impregnated Plaster of Paris disc pouch dressing is safe, cost saving, and effective for management of deep open wounds.

Matched MeSH terms: Wound Infection/therapy*
Fulltext Neonatal septic arthritis

Halder D, Quah BS, Malik AS, Choo KE

Southeast Asian J. Trop. Med. Public Health, 1996 Sep;27(3):600-5.
PMID: 9185277

Neonatal septic arthritis has always been considered as separate from its counterpart in older children. The condition is uncommon but serious. Affected neonates usually survive, but with permanent skeletal deformities. Ten cases of neonatal septic arthritis were diagnosed between January 1989 and December 1993 in the neonatal intensive care units of two referral hospitals in the state of Kelantan, Malaysia. All except one neonate was born prematurely. The mean age of presentation was 15.6 days. Joint swelling (10/10), increased warmth (7/10) and erythema of the overlying skin (7/10) were the common presenting signs. Vague constitutional symptoms preceded the definitive signs of septic arthritis in all cases. The total white cell counts were raised with shift to the left. The knee (60%) was not commonly affected, followed by the hip (13%) and ankle (13%). Three neonates had multiple joint involvement. Coexistence of arthritis with osteomyelitis was observed in seven neonates. The commonest organism isolated was methicillin resistant Staphylococcus aureus (9/10). Needle aspiration was performed in nine neonates and one had incision with drainage. Follow up data was available for five neonates and two of these had skeletal morbidity. Early diagnosis by frequent examination of the joints, prompt treatment and control of nosocomial infection are important for management.

Matched MeSH terms: Cross Infection/therapy
Six-year study on peripheral venous catheter-associated BSI rates in 262 ICUs in eight countries of South-East Asia: International Nosocomial Infection Control Consortium findings

Rosenthal VD, Bat-Erdene I, Gupta D, Rajhans P, Myatra SN, Muralidharan S, et al.

J Vasc Access, 2021 Jan;22(1):34-41.
PMID: 32406328 DOI: 10.1177/1129729820917259

BACKGROUND: Short-term peripheral venous catheter-associated bloodstream infection rates have not been systematically studied in Asian countries, and data on peripheral venous catheter-associated bloodstream infections incidence by number of short-term peripheral venous catheter days are not available.
METHODS: Prospective, surveillance study on peripheral venous catheter-associated bloodstream infections conducted from 1 September 2013 to 31 May 2019 in 262 intensive care units, members of the International Nosocomial Infection Control Consortium, from 78 hospitals in 32 cities of 8 countries in the South-East Asia Region: China, India, Malaysia, Mongolia, Nepal, Philippines, Thailand, and Vietnam. For this research, we applied definition and criteria of the CDC NHSN, methodology of the INICC, and software named INICC Surveillance Online System.
RESULTS: We followed 83,295 intensive care unit patients for 369,371 bed-days and 376,492 peripheral venous catheter-days. We identified 999 peripheral venous catheter-associated bloodstream infections, amounting to a rate of 2.65/1000 peripheral venous catheter-days. Mortality in patients with peripheral venous catheter but without peripheral venous catheter-associated bloodstream infections was 4.53% and 12.21% in patients with peripheral venous catheter-associated bloodstream infections. The mean length of stay in patients with peripheral venous catheter but without peripheral venous catheter-associated bloodstream infections was 4.40 days and 7.11 days in patients with peripheral venous catheter and peripheral venous catheter-associated bloodstream infections. The microorganism profile showed 67.1% were Gram-negative bacteria: Escherichia coli (22.9%), Klebsiella spp (10.7%), Pseudomonas aeruginosa (5.3%), Enterobacter spp. (4.5%), and others (23.7%). The predominant Gram-positive bacteria were Staphylococcus aureus (11.4%).
CONCLUSIONS: Infection prevention programs must be implemented to reduce the incidence of peripheral venous catheter-associated bloodstream infections.

Matched MeSH terms: Cross Infection/therapy
Fulltext Flaccid paralysis in an infant associated with a dirty wound and application of honey

Joseph CJ, Khoo TB, Lee KY

BMJ Case Rep, 2017 Jan 06;2017.
PMID: 28062435 DOI: 10.1136/bcr-2016-218044

An infant, who was born preterm at 36 weeks, presented with fever and ulcer at umbilical region which progressed to necrotising fasciitis of anterior abdominal wall. He was treated with intravenous penicillin, intravenous cloxacillin and local application of medicated honey. Subsequently, he required wound debridement. Postoperatively, he required prolonged invasive ventilation due to poor respiratory effort which was associated with hypotonia and areflexia. Nerve conduction study revealed absent responses. The diagnosis of infant botulism was made based on the clinical presentation, nerve conduction study and his clinical progress. Botulinum immunoglobulin was not available. He was treated with intravenous immunoglobulin and oral pyridostigmine. He was successfully extubated after 37 days, and currently the patient is doing well.

Matched MeSH terms: Wound Infection/therapy
Microcurrent as an adjunct therapy to accelerate chronic wound healing and reduce patient pain

Nair HKR

J Wound Care, 2018 05 02;27(5):296-306.
PMID: 29738296 DOI: 10.12968/jowc.2018.27.5.296

OBJECTIVE: The primary aim is to assess the efficacy of microcurrent, a form of electrical stimulation, as an adjunct therapy in accelerating healing in chronic wounds by reducing wound size and pain level. The secondary aim is to assess the qualitative changes in these parameters: inflammatory symptoms, vasodilation, sleep quality, gait and frequency of bowel movement.
METHOD: Eligible patients with chronic wounds were enrolled between March and June 2016, from the Wound Care Unit, Hospital Kuala Lumpur in this consecutive case series. Standard wound care was performed with microcurrent as an adjunct therapy. Each patient was treated with an anti-inflammatory frequency, followed by a vasodilation frequency, while having their wounds cleansed during each dressing change. Patients were loaned a home-microcurrent device to treat themselves three times daily using a tissue repair frequency for four weeks.
RESULTS: A total of 100 patients with chronic wounds, such as diabetic foot ulcers, venous leg ulcers, and pressure ulcers, were recruited. During the four-week treatment period, all patients had a reduction in wound size, with 16 having complete wound closure. All 89 of the 100 patients who complained of pain, associated with their wound, experienced reduced pain scores, with 11 being pain-free at the end of the four-week period. There was significant reduction (p<0.001) in both mean pain score and mean wound area during the treatment period, as well as improvements in other parameters, such as reduction in inflammatory symptoms (leg swelling, foot stiffness), increased vasodilation (skin discolouration, leg heaviness, early morning erection, sensation), improvement in sleep quality, gait, and frequency of bowel movement. No adverse events were reported.
CONCLUSION: The results of this study show there was significant reduction in wound area and pain score during the treatment period. The ease of use of microcurrent devices would advocate its use in accelerating wound healing.

Matched MeSH terms: Surgical Wound Infection/therapy*
Fulltext Outcomes of infected grade IIIB open tibial fractures

Yusof NM, Halim AS

Singapore Med J, 2012 Sep;53(9):591-4.
PMID: 23023900

Infection following grade IIIB open tibial fracture is common. The primary aim of managing this condition is to achieve control of infection before the bone reconstruction procedure is performed. The outcomes for such patients have not been evaluated in the literature. This study was conducted to examine the outcome of a multi-stage procedure for the treatment of infected grade IIIB open tibial fractures.

Matched MeSH terms: Wound Infection/therapy
Acceleration of cutaneous wound healing by Lucilia sericata maggots in diabetic Wistar rats

Borkataki S, Katoch R, Goswami P, Bhat A, Chakraborty D

Trop Biomed, 2021 Mar 01;38(1):86-93.
PMID: 33797529 DOI: 10.47665/tb.38.1.015

The study was aimed to evaluate the effectiveness of maggot therapy in healing of cutaneous infected wound in streptozotocin (STZ) induced diabetic Wistar rat. For live maggots, the sterilized eggs of Lucilia sericata were obtained from colonies established in laboratory. Diabetes model was established in 48 male Wister rat by intra-peritoneal injection of STZ at the dose of 60 mg/kg body-weight. Cutaneous wounds exposed with mixed colonies of bacteria like Staphylococcus aureus, E. coli and Pseudomonas aeruginosa were prepared in all rat. The animals equally divided in 4 groups with 12 rats each being presented as treatment group of control, antibiotic, maggot and maggot with antibiotic in combination. All treatments were done once and hold for 24 hours. Wound kinetics and bacterial bio burden were measured at weekly interval to till complete healing. Significant reduction in wound area with maximum contraction was found (>95%) in maggot treated group when compared to antibiotic treated (79%) and control (72%). In maggot as well as maggot and antibiotic in combination group showed early elimination of bacterial bio-burden 7.88±0.03log CFU/ml to 1.12±0.65log CFU/ml and 7.86±0.04) log CFU/ml to 1.54±0.52log CFU/ml respectively in three weeks of time. Early healing indication was also experienced on histomorphological examination of wounded tissue of maggot treated groups by early and better epithelialization, collagenation and neovascularization with complete healing of wound in three weeks in comparison to antibiotic and control respectively. However, the present study did not show any difference in healing of wound with use of maggot alone or in antibiotic combination. Live maggot of Lucilia sericata effectively lower bacterial bioburden and and accelerate healing of infected cutaneous wound in diabetic conditions.

Matched MeSH terms: Wound Infection/therapy*
Fulltext Successful laparoscopic management of combined traumatic diaphragmatic rupture and abdominal wall hernia: a case report

Siow SL, Wong CM, Hardin M, Sohail M

J Med Case Rep, 2016 Jan 18;10:11.
PMID: 26781191 DOI: 10.1186/s13256-015-0780-8

Traumatic diaphragmatic rupture and traumatic abdominal wall hernia are two well-described but rare clinical entities associated with blunt thoracoabdominal injuries. To the best of our knowledge, the combination of these two clinical entities as a result of a motor vehicle accident has not been previously reported.

Matched MeSH terms: Surgical Wound Infection/therapy

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