Not all wounds will respond to topical antimicrobial dressings. In such cases bacterial culture results will assist in the selection of appropriate treatment. Bacterial culture results will also allow identification of patients with resistant strains of bacteria within the wound which will inform their subsequent management17


.


In locally infected wounds antimicrobial dressings should be considered. When there are no longer signs of local infection or spreading infection, the antimicrobial dressing should be discontinued. If the wound continues to show signs of infection, a systemic antibiotic should be considered9


. Clinical problem


A patient with a known venous ulcer that initially responded to compression bandaging with simple non-adherent dressings developed increasing exudate, wound pain and wound odour. The removed dressing was stained green indicating possible pseudomonas colonisation. The dependent periwound skin shows signs of maceration and the granulation tissue, which had been healthy, developed a coating of slough and appeared dark and friable. There was no evidence of systemic infection or cellulitis.


Action plan n n Take wound swab. Swab confirmed pseudomonas and mixed flora


Clean wound and periwound skin, removing as much necrotic tissue and wound debris/slough as possible


n n n


Select appropriate barrier product to protect the periwound skin Consider if antimicrobial dressing is appropriate at this stage — Yes


Consider wound requirement and area to be treated — select product with high absorbency and high levels of available antimicrobial agent such as a silver/foam or silver/alginate combination. Dressing should be known to function under compression. In this case, ACTICOAT® Absorbent (Smith & Nephew) was chosen because of its absorbency and its ability to maintain sufficient levels of silver18


n


Continue compression therapy, but increase dressing change frequency until exudate leakage is controlled


n


Continue ‘maintenance’ debridement and wound cleansing at each dressing change


n


Monitor closely for signs of spreading infection and cellulitis and review bacterial swab results. If wound continues to deteriorate add systemic therapy based on sensitivity results


n


Set treatment goals and review date, planning to discontinue antimicrobial dressing after 14–21 days. In this case, antimicrobial dressings were continued for 21 days (six dressing changes), at which stage the patient returned to a simple foam dressing under compression and weekly dressing changes.


Figure 3 Venous ulcer after one week of treatment with antimicrobial dressing. Patient reported less pain, odour and exudate had reduced, there was less periwound maceration and the wound bed had improved


S.4


Figure 2 Venous ulcer before treatment with antimicrobial dressing


In patients with conditions that put them at high risk of infection, such as poor vascularity, or in which the immune system is compromised, experienced clinicians may consider the use of systemic antibiotics since these conditions may mask the signs of infection14


.


Blood cultures should be taken of wounds which are assessed as having spreading and/or systemic infection to identify the offending organism and to assess for differential diagnosis1


. The


patient should be treated with broad- spectrum antibiotics which may be given intravenously. Topical antimicrobial dressings should also be used to help reduce wound bioburden locally.


Optimise the patient’s immune response Measures which will optimise the patient’s ability to fight infection will enhance their healing potential, e.g. improved nutritional intake and hydration. Systemic factors that may have contributed to the development of the wound and/or infection, should also be addressed. For example, glycaemic control in patients with diabetes should be optimised1


.


In addition to the use of antimicrobial dressings, it is important to ensure that all other factors that can contribute to wound infection are addressed as far as possible as part of the patient’s overall package of care14


.


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