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Diagnosing Chronic Wound Infection: Efficacy and Cost Effective Dr. Luinio S. Tongson, FPCS, CWS, MSPH Wound Care Conference Singapore
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Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

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Page 1: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Diagnosing

Chronic Wound Infection:

Efficacy and Cost Effective

Dr. Luinio S. Tongson, FPCS, CWS, MSPH

Wound Care Conference

Singapore

Page 2: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Chronic Wound

• A wound in which the normal process of

healing has been disrupted.

• “Stuck" in the inflammatory or proliferative

phases of wound healing.

Enoch S.Harding K. Wound Bed Preparation: The Science

Behind the Removal of Barriers to Healing. Wounds. 2003;15(7)

Page 3: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Features of Chronic Wound

Clinical

• Presence of necrotic and unhealthy tissue

• Lack of adequate blood supply

• Absence of healthy granulation tissue

• Lack of reepithelization

• Recurrent wound breakdown due to

superficial bridging

Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner:

The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22

Page 4: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Microbiology

• High levels of bacterial content

• Presence of more than one bacterial strain

• Presence of multi-drug resistant

organisms

• Presence of biofilms

Features of Chronic Wound

Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner:

The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22

Page 5: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Introduction

• Poor clinical performance in diagnosing chronic

wound infection

– Soft tissue infection is the leading indication

for outpatient parenteral antibiotic therapy and

the third most common indication for oral

antibiotic use.1,2

• Sweden study - 60% of patients either were

actively receiving antibiotics or had been treated

with antibiotics in the previous 6 months.3

1. Nathwani D, Moitra S, Dunbar J, Crosby G, Peterkin G, Davey P. Skin and soft tissue infections: development of a

collaborative management plan between community and hospital care. Int J Clin Pract. 1998;52(7):456-60.

2. MacDonald T, Collins D, McGilchrist M, Stevens J, McKendrick A, McDevitt D, Davey P. The utilisation and economic

evaluation of antibiotics in primary care. J Antimicrob Chemother. 1995;35(1):191-204.

3. Tammelin A, Lindholm C, Hambraeus A. Chronic ulcers and antibiotic treatment. J Wound Care. 1998;7(9):435:7.

Page 6: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Introduction

• Clinical perplexity in the current North American

clinical practice guideline on management of

pressure ulcers.1

• Guideline recommends obtaining quantitative

bacterial cultures rather than swab cultures,

quantitative culture techniques are rarely utilized

in the management of most chronic wounds.2

1. Bergstrom N, Allman R, Alvarez O, Bennet M, Carlson C, Frantz R, et al. Clinical Practice Guideline Number

15: Treatment of Pressure Ulcers. Rockville, Md: US Department of Health Human Services. Public Health

Service. Agency for Health Care Policy and Research; 1994. AHCPR Publication 95-0652.

2. Thompson P, Smith D. What is infection? Am J Surg. 1994;167(suppl 1A):75-115.

Page 7: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Introduction

• Infection in chronic wounds may be quite

subtle.*

• Covert infections - out of bacterial balance

when the pathogens in question have

overcome the host immune response.

Dow G. Infection in chronic wounds. In: Krasner D, Rodeheaver G, Sibbald G (eds). Chronic

Wound Care: A Clinical Source Book for Healthcare Professionals, Third Edition. 2001:343-356.

Page 8: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Clinical Presentation

• Acute Wound Infection

or

• Severe

Chronic Wound Infection

• Advancing erythema

• Fever

• Warmth

• Edema / swelling

• Pain

• Purulence

“Classic” Signs & Symptoms

Page 9: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Clinical Presentation

• Critically Colonized

Bioburden

• Bacterial Burden

• Local

Wound Infection

• Delayed healing

• Change in color of wound bed

• Friable granulation tissue

• Absent or abnormal granulation tissue

• or abnormal odor

• serous drainage

• pain at wound site

Cutting & Harding (1994)

Gardner, Frantz & Doebbeling (2001)

“Secondary” Signs & Symptoms

Page 10: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Bacterial burden

Contaminated

woundColonised

Critical

colonization

Infection

Healing rate

Page 11: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Tissue biopsy culture

• Remove piece of

viable wound tissue

with a scalpel or

punch biopsy

instrument.

• Used in wound

microbiology research

Method of Diagnosing

Chronic Wound Infection

Page 12: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Deep tissue biopsy culture

• Reference standard for the diagnosis of infection

of chronic wounds

• Indicator of infection of chronic wounds:

– Microbial loads of greater than 105 of any

organism per gram of wound tissue

– Presence of any level of β-hemolytic

streptococcus

• Reddy M, et al. Does This Patient Have an Infection of a Chronic Wound? JAMA. 2012;307(6):605-611

• Schraibman IG. The significance of beta-haemolytic streptococci in chronic leg ulcers. Ann R Coll Surg

Engl. 1990;72(2):123-124 PubMed

Method of Diagnosing

Chronic Wound Infection

Page 13: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

• Tissue biopsy culture

– Assist with the recognition of

increased bacterial burden

– Not regularly undertaken

– Wounds can heal despite high bacterial

counts*.

Steer JA, Papini RP, Wilson AP, McGrouther DA, Parkhouse N. Quantitative microbiology in the management of burn

patients. II. Relationship between bacterial counts obtained by burn wound biopsy culture and surface alginate swab

culture, with clinical outcome following burn surgery and change of dressings. Burns 1996; 22(3): 177-81.

Method of Diagnosing

Chronic Wound Infection

Page 14: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

• Tissue biopsy culture

• Limitations:

– Skills

– Invasive

– Availability of laboratories

– Expenses

– Further tissue damage and delay of healing

when biopsies are taken

Bamberg R. Sullivan K. Conner-Kerr T. Diagnosis of Wound Infections: Current

Culturing Practices of US Wound Care Professionals. Wounds. 2002;14(9)

Method of Diagnosing

Chronic Wound Infection

Page 15: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Needle-aspiration

technique

• Sensitivity, specificity,

and accuracy of

quantitative needle-

aspiration unclear

• For focal collections

of tissue fluid or

abscess formations

Method of Diagnosing

Chronic Wound Infection

Page 16: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

• Wound swabbing is the most common

sampling method used throughout the UK

• Clinical value has been questioned

• Routine swabbing, such as at weekly

intervals or at the time of frequent dressing

changes, is neither helpful nor cost

effective *

Gilchrist B. Taking a wound swab. Nurs Times 2000; 96(4 Suppl): 2.

Method of Diagnosing

Chronic Wound Infection

Page 17: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Wound Swabbing

• Routine swabbing in

the absence of

clinical indicators of

infection is neither

helpful nor cost-

effective.

• Unnecessary cost to

both the NHS and

the patient.

Collier M (2004) Recognition and Management of Wound Infections.

Method of Diagnosing

Chronic Wound Infection

Page 18: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

C-reactive protein (CRP)

• Serum investigation

• Identify elevated white cell counts and

protein in serum

• Present in many acute inflammatory

conditions and with necrosis

• Not diagnostic of a chronic wound infection*

Krasner (Ed) D. Chronic Wound Care: a clinical source book for professionals.

Pennsylvania: Health Management Publications, 1990.

Method of Diagnosing

Chronic Wound Infection

Page 19: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Clinical manifestation + Culture

• Wound infection is initially identified by

the recognition of clinical signs + culture.

• Wound swabbing is not a tool that can be

used to diagnose in isolation.

• Assist in the appropriate antibiotic or

treatment options.

Pattern H. Identifying wound infection: Taking a swab. Wound Essential Vo 5. 2010

Method of Diagnosing

Chronic Wound Infection

Page 20: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

When Should a Chronic Wound

Be Cultured?

• A wound should be cultured after wound

infection has been clinically diagnosed.

• Clinical diagnosis of infection is essential before

culturing because 100% of wounds are

contaminated at the time of wounding.*

• Soon after the inoculation event, 100% of

wounds become colonized

Bowler P, Duerden B, Armstrong D. Wound microbiology and associated

approaches to wound management. Clin Microbiol Rev. 2001;14(2):244-269.

Page 21: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

A six-page, 34-item questionnaire titled

"Wound Culture Survey"

• types of wounds seen in

clinical practice;

• whether wounds are

cultured

• types of wound

specimens collected and

average number per

wound

• factors that prompt a

culture

• specific swab culture and

biopsy techniques used

• specific lab tests

• most common organisms

isolated from wounds

• routine approaches used

in wound diagnosis

• most common treatment

• demographic and

professional information

Bamberg R. etc. Diagnosis of Wound Infections: Current Culturing

Practices of US Wound Care Professionals; Wounds. 2002;14(9)

Page 22: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Type of wounds cared for by

respondents

No. (%)* of Respondents by Frequency Category

Wound Type Frequently or Very Frequently Occasionally Never or Almost Never

Venous insufficiency 277 (80.3) 50 (14.5) 15 (4.3)

Pressure 273 (79.1) 63 (18.3) 7 (2.0)

Arterial insufficiency 181 (52.5) 135 (39.1) 27 (7.8)

Surgical 176 (51.0) 128 (37.1) 37 (10.7)

Neuropathic (diabetic) 166 (48.1) 65 (18.8) 12 (3.5)

Inflammatory 110 (31.9) 159 (46.1) 62 (18.0)

Abscess 108 (31.3) 168 (48.7) 58 (16.8)

Trauma 102 (29.6) 157 (45.5) 76 (22.0)

Neuropathic (nondiabetic) 73 (21.2) 166 (48.1) 87 (25.2)

Burn 39 (11.3) 139 (40.3) 156 (45.2)

Sickle 5 (1.4) 75 (21.7) 253 (73.3)

Fasciitis and/or necrotizing** 4 (1.2) 7 (2.0) - - - -

Pyoderma** 2 (0.6) 7 (2.0) - - - -

Melanoma** 2 (0.6) - - - - - - - -

Cancer** 1 (0.3) 8 (2.3) - - - -

Frost bite** 1 (0.3) - - - - - - - -

Osteomyelitis (refractory)** 1 (0.3) - - - - - - - -

Skin or wound graft** 1 (0.3) 3 (0.9) - - - -

Calciphylaxis** - - - - 1 (0.3) - - - -

Lymphatic** - - - - 1 (0.3) - - - -

Bamberg R. etc. Diagnosis of Wound Infections: Current Culturing

Practices of US Wound Care Professionals; Wounds. 2002;14(9)

Page 23: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Specimen collection:

When, why, and by whomWhen wounds are routinely cultured %*

Before treatment is begun 12.4

After treatment failure 20.2

Varies depending on wound situation 64.7

Only when 3 clinical signs of infection are present 1.0

Did not answer 1.7

Why wounds are routinely cultured %*

To plan a treatment regimen 48.0

For diagnosis of the wound 9.5

For both diagnosis and design of a treatment plan 41.2

Did not answer 1.3

Who makes the final decision to culture %*

Physician or Podiatrist 80.7

Nurse Practitioner or Physician Assistant 7.5

Registered Nurse (RN) 3.6

Wound Care Specialist 2.9

Enterostomal RN 2.6

Physical Therapist 1.6

Did not answer 1.1

Bamberg R. etc. Diagnosis of Wound Infections: Current Culturing

Practices of US Wound Care Professionals; Wounds. 2002;14(9)

Page 24: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Specimen collection:

Type, number, and wound siteType of wound specimens routinely collected %*

Swab only 53.9

Swab and/or biopsy depending on nature of the wound 41.8

Biopsy only 4.3

Number of specimens routinely collected per wound Mean

Swabs 1.8

Biopsies 1.7

Site preparation before wound specimen is collected %*

Saline cleansing 81.7

No preparation 10.1

Aseptic cleansing 8.8

Debridement 4.6

Water and mild soap cleansing 3.9

Irrigation 0.6

Bamberg R. etc. Diagnosis of Wound Infections: Current Culturing

Practices of US Wound Care Professionals; Wounds. 2002;14(9)

Page 25: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Specimen collection:

Techniques and lab tests orderedSwab Specimens* % Biopsy Specimens* %

Collection technique

routinely used:

10-point diagonal 56.7 Punch 54.2

1-point rotation 38.2 Scalpel 33.8

Swab of whole surface 1.4 Surgical scissors 8.5

Levine technique 1.0 Varies 3.5

2-3 point touch 0.3

Varies 2.4

Area of wound from

which

specimens are

routinely collected:**

(Not asked relative to swabs) Most clinically

suspicious area 61.3

Margins 40.8

Center 30.3

Deepest area 2.8

Lab tests ordered:*** Aerobic culture 100.0 Aerobic culture 100.0

Anaerobic culture 54.6 Anaerobic culture 74.6

Gram stain 47.8 Gram stain 58.5

Fungal culture 22.9 Fungal culture 40.8

Viral culture 0.3 Viral culture 11.3

Mycobacteria culture

(i.e., acid fast bacillus) 0.3

Mycobacteria culture

(i.e., acid fast bacillus) 4.2

Bamberg R. etc. Diagnosis of Wound Infections: Current Culturing

Practices of US Wound Care Professionals; Wounds. 2002;14(9)

Page 26: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Significant differences in wound care

practices between practitioners

Wound Care Practices

Work in an OWC*

(n = 132)

Do Not Work in an

OWC (n = 214)

Work time spent in wound care

(mean)**

73.5% 58.0%

Wounds treated without ever

culturing (mean)**

65.7% 72.5%

Culture at least some

wounds***

94.7% 82.5%

Reported non-physician makes

final decision to culture

wound***

18.2% 15.2%

Collect both swab and biopsy

specimens depending on

nature

of wound***

46.2% 31.5%

Use lab culture reports as a

factor in wound diagnosis***

74.2% 68.1%

Bamberg R. etc. Diagnosis of Wound Infections: Current Culturing

Practices of US Wound Care Professionals; Wounds. 2002;14(9)

Page 27: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Results

• Indicate that wound care clinicians are

relying heavily on clinical characteristics

for the diagnosis of wound infection.

– Clinical characteristics (98 %)

– Patient-reported symptoms (88%)

– Wound culturing (70%)

Bamberg R. etc. Diagnosis of Wound Infections: Current Culturing

Practices of US Wound Care Professionals; Wounds. 2002;14(9)

Page 28: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Results

• 79 % of the wounds with positive clinical

signs for infection have positive cultures.

• Supports the practice of using physical

signs as a quick screen to determine

which wounds should be cultured.

Bamberg R. etc. Diagnosis of Wound Infections: Current Culturing

Practices of US Wound Care Professionals; Wounds. 2002;14(9)

Page 29: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Results

• 21% of wound patients with potential

wound infections may go undiagnosed if

clinical signs and symptoms alone are

utilized in diagnosis.

– Immunocompromised patients may not exhibit

typical signs and symptoms

Bamberg R. etc. Diagnosis of Wound Infections: Current Culturing

Practices of US Wound Care Professionals; Wounds. 2002;14(9)

Page 30: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Results

• Situations with False positive wound

infection

• Unrelieved pressure

• Allergies to dressing components

• Have chronic inflammation*

Bamberg R. etc. Diagnosis of Wound Infections: Current Culturing Practices of

US Wound Care Professionals; Wounds. 2002;14(9)

* van Rijswijk L. Wound assessment and documentation. In: Krasner DL, Rodeheaver

GT, Sibbald RG (eds). Chronic Wound Care: A Clinical Source Book for Healthcare

Professionals, Third Edition. Wayne, PA: HMP Communications, 2001

Page 31: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Cultures of wound exudates or swabs

performed with the Z-technique

• Neither predicted nor excluded wound

infection. (CI including 1.0 for positive or negative

results.)

From: Does This Patient Have an Infection of a

Chronic Wound? JAMA. 2012;307(6):605-611.

doi:10.1001/jama.2012.98

Gardner SE, Hillis SL, Frantz RA. Clinical signs of infection in diabetic foot

ulcers with high microbial load. Biol Res Nurs. 2009;11(2):119-128

Page 32: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

• Inflammatory marker IL-6 in wound fluid

did not predict the presence or absence of

wound infection.

From: Does This Patient Have an Infection of a

Chronic Wound? JAMA. 2012;307(6):605-611.

doi:10.1001/jama.2012.98

Ambrosch A, Lobmann R, Pott A, Preissler J. Interleukin-6 concentrations in

wound fluids rather than serological markers are useful in assessing bacterial

triggers of ulcer inflammation. Int Wound J. 2008;5(1):99-106

Page 33: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

From: Does This Patient Have an Infection of a

Chronic Wound? JAMA. 2012;307(6):605-611.

doi:10.1001/jama.2012.98

Comparisons With Non-reference Standards

• Semiquantitative swab cultures were as

predictive as quantitative swab cultures

• Superficial drainage fluid swab cultures were as

predictive as deep wound swab cultures

obtained after debridement,1

• ↑ white blood cell count or ↑ ESR - as predictive

as clinical features.2

1. Ratliff CR, Rodeheaver GT. Correlation of semi-quantitative swab cultures to quantitative

swab cultures from chronic wounds. Wounds. 2002;14(9):329-333

2. Uzun G, Solmazgul E, Curuksulu H, et al. Procalcitonin as a diagnostic aid in diabetic

foot infections. Tohoku J Exp Med. 2007;213(4):305-312 Pubmed

Page 34: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

From: Does This Patient Have an Infection of a

Chronic Wound? JAMA. 2012;307(6):605-611.

doi:10.1001/jama.2012.98

• Comparisons With Non-reference Standards

• Absence of the laboratory marker C-reactive

protein was as predictive as clinical features in

ruling out infection.*

Uzun G, Solmazgul E, Curuksulu H, et al. Procalcitonin as a diagnostic aid in

diabetic foot infections. Tohoku J Exp Med. 2007;213(4):305-312 Pubmed

Page 35: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

From: Does This Patient Have an Infection of a

Chronic Wound? JAMA. 2012;307(6):605-611.

doi:10.1001/jama.2012.98

• Comparisons With Non-reference Standards

• Handheld infrared thermometer to assess

periwound skin temperature may be of use in

diagnosing infection of chronic wounds but

needs further study.

Page 36: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Quantitative swab conducted with Levine

technique

• Helpful in predicting wound infection (positive LR, 6.3; 95% CI, 2.5-15).

• Negative swab culture result makes

wound infection less likely

(LR, 0.47; 95% CI, 0.31-0.73).

From: Does This Patient Have an Infection of a

Chronic Wound? JAMA. 2012;307(6):605-611.

doi:10.1001/jama.2012.98

Gardner SE, Hillis SL, Frantz RA. Clinical signs of infection in diabetic foot

ulcers with high microbial load. Biol Res Nurs. 2009;11(2):119-128

Page 37: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

• Increasing pain and wound breakdown

have been shown to be particularly good

predictors of infection in the chronic

wound.

Gardner SE, Frantz RA, Troia C, et al. A tool to assess clinical signs and symptoms of localized

infection in chronic wounds: Development and reliability. Ost/Wound Manag 2001;47:40–7

Clinical Manifestation of

Chronic Wound Infection

Page 38: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

• Several intrinsic limitations to diagnosing a

wound infection and establishing a

treatment paradigm via clinical signs and

symptoms alone.

• Constantly evolving number of

microorganisms with antibiotic resistance.

Bamberg R. Sullivan K. Conner-Kerr T. Diagnosis of Wound Infections: Current

Culturing Practices of US Wound Care Professionals. Wounds. 2002;14(9)

Clinical Manifestation of

Chronic Wound Infection

Page 39: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

• Clinical signs and symptoms may be a

cost-effective method

– Does not inform the appropriate

chemotherapeutic approach to treatment

broad-spectrum chemotherapeutic agents

may be initiated that facilitate the

development of antibiotic resistance.

Bamberg R. Sullivan K. Conner-Kerr T. Diagnosis of Wound Infections: Current

Culturing Practices of US Wound Care Professionals. Wounds. 2002;14(9)

Clinical Manifestation of

Chronic Wound Infection

Page 40: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Best Practice Recommendations for

Preparing the Wound Bed: Update 2006

• Diagnosis of infection is based on clinical

criteria, with bacterial swabs or deep

cultures, laboratory and radiological tests

• All wounds contain bacteria

• Increased bacterial burden in pressure

ulcers delay healing in patients with

chronic ulceration *.

Sibbald. Volume 4, Number 1, 2 0 0 6 Wound Care Canada 15

Volume 4, Number 1, 2 0 0 6 Wound Care Canada 15

* Heggers JP. Defining infection in chronic wounds: Does it

matter? J Wound Care. 1998;7:389-392.

Page 41: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Best Practice Recommendations for

Preparing the Wound Bed: Update 2006

Sibbald. Volume 4, Number 1, 2 0 0 6 Wound Care Canada 15

Volume 4, Number 1, 2 0 0 6 Wound Care Canada 15

Clinical Signs and Symptoms of Wound Infection

Critically Colonized Deep Wound Infection Systemic Infection

Non-healing Pain Fever

Bright red granulation Swelling, induration Rigors

Friable and exuberant

granulation

Erythema Chills

New areas of

breakdown or necrosis

of the wound surface

Increased temperature

Wound breakdown

Hypotension

Multiple organ failure

Increased exudate

Maybe translucent or

clear before becoming

purulent

Increased sized or

satellite areas

Undermining

Foul odor Probing to bone

Page 42: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Clinical Manifestation of

Chronic Wound Infection

• Serous exudate may be increased in a

chronic wound with increasing bacterial

burden before purulence is noted. Chronic

wounds some healing within four weeks to

progress to healing by week 12

• > 12 weeks - ↑ bacterial burden or

infection

Keast DH, Bowering K, Evans W, et al. Measure: A proposed assessment framework for developing

best practice recommendations for wound assessment. Wound Repair Regen. 2004;12:S1-S17

Page 43: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Date of download: 5/21/2012Copyright © 2012 American Medical

Association. All rights reserved.

From: Does This Patient Have an Infection of a Chronic

Wound? JAMA. 2012;307(6):605-611. doi:10.1001/jama.2012.98

Page 44: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Recommendation

• Need to educate professionals

– Use a combination approach

– Screening for wound infection by assessing

for clinical signs and symptoms + culture

Definitive diagnosis of wound infection +

establishing a treatment plan.

Bamberg R. etc. Diagnosis of Wound Infections: Current Culturing

Practices of US Wound Care Professionals; Wounds. 2002;14(9)

Page 45: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Confirming a diagnosis of

wound infection

• After careful assessment,

it is apparent that the wound is infected,

it is important to confirm this and identify the

causative organism(s) and possible

sensitivities to antibiotics.

Page 46: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Diagnosis of wound infection

• Increasing pain

• Friable granulation tissue

• Foul odour

• Wound breakdown

** Gardner SE, Frantz RA, Troia C, et al. A tool to assess clinical signs and symptoms of localized

infection in chronic wounds: Development and reliability. Ostomy/Wound Management. 2001;47:40-47.

Clinical Manifestation of

Chronic Wound Infection

Page 47: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Clinical Manifestation of

Chronic Wound Infection

Symptoms with high positive predictive value:

• Increasing pain (1.0)

• Edema (0.93)

• Wound breakdown (0.89)

• Delayed healing (0.87)

• Friable granulation (0.8)

• Purulent exudate (0.78)

• Serous exudate (0.74)

* Gardner SE, Frantz RA, Doebbeling BN. The validity of the clinical signs and symptoms used

to identify localized chronic wound infection. Wound Repair Regen. 2001;9:178-186.

Page 48: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

When to swab?

• Local heat

• Redness/erythema

• Pain or tenderness

• Oedema

• Inflammation

• Increased exudate

• Cellulitis

• Abscess/pus

• Purulent discharge

• Malodour

• Delayed healing– (Beldon, 2001)

• Discoloration of wound bed

• Friable granulation tissue

that bleeds easily

• Pocketing/ bridging at the

base of the wound

• Wound breakdown/

enlargement – (Cutting and Harding, 1994).

Pattern H. Identifying wound infection: Taking a swab. Wound Essential Vo 5. 2010

Page 49: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Other clinical signs:

• Signs of a systemic infection such as pyrexia,

raised white cell count, CRP and/or ESR

• Elderly or immunosuppressed

– Other symptoms: drowsiness, loss of appetite,

nausea, restlessness and confusion

• Screening programme for Methicillin Resistant

Staphylococcus Aureus (MRSA).

Pattern H. Identifying wound infection: Taking a swab. Wound Essential Vo 5. 2010

When to swab?

Page 50: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

• Inflammation in isolation is not a reliable

indication for taking a swab or treating a

wound for infection» (Ferguson, 2005)

When to swab?

Page 51: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

How to swab?

Page 52: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

• Using an effective technique to take a

swab is paramount.

• Incorrect culture swabs technique

– False negative result due to poor technique,

– False positive - only colonising bacteria is

captured but with no clinical indication.

Pattern H. Identifying wound infection: Taking a swab. Wound Essential Vo 5. 2010

How to swab?

Page 53: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Z-stroke swab

• Swab rotated

between the fingers

as the wound is

swabbed from margin

to margin in a 10-

point, zigzag fashion.

• Large portion of the

wound surface is

sampled reflect

surface

Method of Swabbing

Page 54: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Levine technique

• Rotating a swab over

a square centimeter

of tissue for five

seconds with enough

pressure to extract

fluid from the tissue

• Most accurately

reflects wound 'tissue'

bioburden

Method of Swabbing

Gardner S, et al. Diagnostic Validity of Semiquantitative

Swab Culture. Wounds. 2007;19(2):31-38.

Page 55: Dr Tongson - Diagnosing Chronic Wound Infection Efficacy and Cost Effective

Diagnosing Chronic Wound Infection:

Cost Effective and Efficacy:

Clinical manifestation + Culture

Conclusion:

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Questions, Comments and Suggestions