Managing Wound Infection - St Luke's · PDF file · 2014-06-09Managing Wound Infection ... nursing/ medical care in a timely fashion. 5 Ensure that people who have or develop an....

Managing Wound Infection

Lorraine Grothier

Clinical Nurse Specialist Tissue Viability

The new name for Central Essex Community Service

UK Health and Social Care Act Compliance Criteria

• Ensure that patients presenting with an infection or who acquire an infection during their care are identified promptly and receive appropriate management and treatment to reduce the risk of transmission.

• Have adhered to appropriate policies and protocols for the prevention and control of HCAI.

The Code of Practice 4 Provide suitable accurate information on infections to

any person concerned with providing further support or nursing/ medical care in a timely fashion.

5 Ensure that people who have or develop an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of passing on the infection to other people.

6 Ensure that all staff and those employed to provide care in all settings are fully involved in the process of preventing and controlling infection.

9

Have and adhere to policies, designed for the individual’s care and provider organisations that will help to prevent and control infections.

Health and Social care Act. The Code of Practice 2008

Consequences of Failure to Identify Wound Infection

• Prolonged healing & risk of systemic complications.

• Detrimental impact on patients quality of life.

• Inappropriate selection of treatments.

• Increased risk of cross infection.

• Increased costs & length of inpatient stay.

Cost of Wound Infection

• Resistance to antibiotics leads to difficulty and prolonged treatment

• Zero tolerance to MRSA Bacteraemia incurring financial penalties

• Estimated cost of treating a surgical site Infection average £3200 per case (Coello et al, 2005)

• Risk of litigation

• Damaged reputation

Tissue Management

‘Monitoring the type of tissue in a wound has been the mainstay of wound assessment in clinical practice, recording the presence of necrosis, slough, granulation or epithelium.’

(Flanagan 2003)

Bacteria In Wounds - A Significant Barrier To Healing

• Bacteria create on-going inflammation, the wound is ‘stuck’ in the inflammatory phase.

• Bacteria adversely affect formation of new capillaries and granulation tissue.

• Bacteria adversely affect the epithelialisation of wounds.

Wound Infection Prolongs Healing

• By destroying cells and competing for available oxygen supplies.

• By releasing toxins that damage tissue causing necrosis and pus formation.

• By releasing toxins into the blood stream.

Signs And Symptoms • Abscess formation

• Local/general swelling/oedema

• Erythema(redness)

• Localised warmth or heat which may spread

• Purulent exudate (discharge)

• Serous exudate with concurrent inflammation

• Discolouration of tissues both within the wound and the wound margins

• Delayed healing

• General oedema

• Friable and/or bleeding granulation tissue

• Pocketing and or bridging at the wound base

• Abnormal odour

• New or altered pain

• Wound breakdown/dehiscence

• Deterioration in patients general health, lethargy, loss of appetite

Other Considerations

• Compromised vascular status

• Malnourished

• Medication/treatment

• Smoking

• Lifestyle choices

Assessment

• Holistic assessment of the patient is key.

Consider: – Underlying disease processes

– Cardiac output/respiratory function

– Nutrition

– Lifestyle

– Concordance

Critical Variables Affecting Wound Healing

• Amount of necrotic tissue

• Number of bacteria present

• Bacterial virulence/pathogenicity

• Host resistance/patients immune response

• As bacterial count rises, signs of infection increase.

Impact On The Patient

• Wound odour causes embarrassment and isolation.

• Patient’s mobility can be severely restricted

• Wounds may be painful

• Excessive exudate may leak, soaking into clothes and linen

Infection Continuum

Term Definition

Contamination Presence of non-multiplying bacteria in a wound

Colonisation Presence of multiplying bacteria in the wound but no immune

response.

Critical colonisation The immune system has been compromised and the patient is no

longer able to control the multiplying bacteria.

Infection The multiplying bacteria overwhelm the immune response,

resulting in clinical signs and symptoms.

Adapted from Kingsley 2001

Contaminated

• Contaminated

– Non-replicating microorganisms in the wound

– No cellular damage

– No host reaction normal healing

Colonised

• Colonised

– Replicating bacteria in the wound

– Many become more sloughy

– No host reaction

– Wound continues to heal

Contaminated/Colonised

• Likely signs

– Normal healing

– No odour

– Prink/red healthy granulating tissue

• Choice of dressing

– Dressing without silver depending on individual assessment

– Silver dressing if there is a risk of infection (careful consideration should be given for prophylactic use of silver).

Critical Colonisation

• Likely signs – Delayed healing

– Odour

– Increased exudate

– Absent, abnormal or discoloured granulation tissue

– Increased pain at wound site

Choice of dressing – absorbent silver dressing

Infected Replicating micro-organisms in the wound Local and systemic immune response

Likely signs

– Delayed healing

– Odour

– Excessive purulent exudate

– Pain at wound site

– Tenderness, warmth, redness of wound surrounding skin

– Fever

Wound Bed Preparation

• A healthy wound bed is a prerequisite to the use of modern wound care products.

• Wound bed preparation is dependent on management of microbial balance.

Reduced bacterial burden – Accelerates healing

– Improves clinical and cosmetic outcome

– Improves quality of life

Mode Of Action • Silver has antiseptic, antimicrobial and anti-

inflammatory properties.

• Silver ions (Ag+) are bound to the cell wall - blocks transport in and out of the cell.

• Silver ions (Ag+) interact with DNA and inhibits cell division – stops formation of colonies

• Silver ions (Ag+) interact with enzymes and proteins important for respiration – the bacteria will starve

• Leads to the cell leaking and breakdown of the membrane

(Lansdown, 2002).

Characteristics Of A Silver Dressing

• Delivers silver in a sustained therapeutic manner.

• Combines antimicrobial effect with capacity to absorb exudate and control odour.

• Provides a moist wound healing environment.

• Easy to use and comfortable

• Cost effective (White 2002)

Acticoat Silver

• Acticoat is a nanocrystalline silver-coated dressing that provides a rapid and sustained release of silver ions within the dressing and to the wound bed for 3–7 days, depending on the characteristics of the wound and the type of Acticoat dressing selected (Thomas, 2004)

Silver Sulphadiazine • Cream or ointment containing silver-antibiotic

compound

• Short acting and requires regular (min daily) application

• Messy to apply and can cause maceration to periwound

• Should not be compared with silver-containing dressings due to difference in ingredients

Misconceptions About Silver

• ‘Silver does not improve healing rates’ – The aim of treatment is to reduce wound bioburden, treat

local infection and prevent systemic spread.

• ‘Silver dressings cause effects such as Argyria’ – Silver dressings may at times cause staining/discolouration

which is harmless and temporary. True systemic argyria is usually related to oral ingestion of silver solutions

Misconceptions About Silver

• ‘Silver dressings are toxic to wounds and delay healing’ – In vitro studies found some toxicity to keratinocytes and

fibroblasts and delay in epithelialisation

• ‘Bacteria become resistant to silver’ – Prevalence of resistance is unknown but appears to be

rare. Silver has been used in low concentration for a very long time. Silver has multiple actions on the cell unlike antibiotics

Misconceptions About Silver

• ‘Silver dressings could make bacteria resistant to antibiotics’ – Theoretically possible but no evidence exists to suggest

cross-resistance. The main cause of antibiotic resistance is overuse/misuse of antibiotics

• ‘Silver dressings shouldn’t be used in children’ – Silver dressings should be used with caution in children

and for limited periods. Some reports of increased blood silver levels in children with burns and epidermolysis bullosa

Misconceptions About Silver

• ‘Silver dressings are bad for the environment’ – Suggestions that silver released into the environment may

be harmful. Used worldwide in a range of technologies although it’s impact is not clear. A producer of silver dressings use 0.0008% of global silver consumption which is considered very small

• ‘Silver dressings are too expensive’ – Cost effectiveness may include direct and indirect costs

which may be difficult to measure i.e. reduced quality of life and productivity of individuals at work or in the home.

Two week Challenge

• Use silver dressing for two week then evaluate for clinical effectiveness

• Improvement but continuing signs of infection – continue with regular review

• Improvement in the wound, no clinical signs and symptoms of infection – discontinue

• If no improvement after 4 weeks – discontinue and review, discuss with MDT

Prophylactic Use

• Silver dressings may have a role in preventing infection in high risk wounds –

• Pressure ulcers close to the anus, burns, exposed bone, Immunocompromised, poor circulation and diabetes

• Medical device entry sites i.e. tracheostomy and orthopaedic pins.

• Use in this way is still being defined and evaluated

Considerations For Practice

• What suggests the wound is infected?

• What would your management plan be?

• What impact would this have on the wound ?

• What possible impact would this have on the patient?

• What is the potential impact on resources?

• How would you evaluate and measure if your intervention has been effective?

Case study 1

• 24 year old first time mother

• Episiotomy – post incision strep A infection

• Treatment: – Excision and drainage – Antimicrobial cavity dressing – Systemic antibiotics – Analgesia Outcome: Pain controlled Healed within 3 weeks.

Case Study 2

• 56 year old lady. Leg ulcers 3 years duration.

• Multiple infections and treatment with antibiotics.

Treatment:

– Systemic antibiotics – Absorbent silver dressings – Compression therapy

Outcome: Tolerated compression Pain controlled Ulcers progressed to healing

Case Study 3 • 70 year old man with

longstanding history of leg ulceration extending to the foot

• Uncontrolled pain

• Multiple infections

Treatment:

– Absorbent silver dressing

– Combined with systemic antibiotic treatment

– Debridement of devitalised tissue

– Address underlying disease Outcome: Pain controlled,

modified compression therapy, progressed to healing

Case study 4

• 82 year old gentleman • History of diabetes • Great toe amputated • Subsequent wound

infection • Treatment:

– Absorbent antimicrobial – Systemic antibiotics – Urgent referral to vascular

surgeon. Outcome: Below knee amputation.

In Summary

• Managing wound bacteria is a vital factor for wound healing

• Ensure that a knowledgeable health professional assesses and plans care for the patient

• Clearly identify a treatment plan and be able to rationalise decisions.

• Ensure the care plan is evaluated at regular intervals, any intervention should be evaluated after two weeks for signs of improvement/deterioration

• Communicate with the patient/ family/carers and all health professionals involved in the patients care

Thank you for listening

[email protected]

Ref: www.woundsinternational.com