Practice development Innovations


allowing for longer intervals between dressing changes.


Expert Commentary David Leaper, Visiting Professor, Cardiff University


No accepted method currently exists for accurately predicting the risk of infection developing in a chronic wound. In order to address this gap, the Wounds At Risk (WAR) score was devised through a consensus group of European interdisciplinary hygienists/microbiologists, surgeons, dermatologists, wound healing and infection prevention clinicians[1]


. The objective was to aid early decision making in the use of


antimicrobials, specifically the topical antiseptic polyhexanide, to prevent progression to local or systemic infection.


The WAR score is flawed by not having been derived from logistic regression data


analysis or Bayesian probability, for example, which may have given more reliable scores. However, such internationally sourced accurate data has never been collected and made available for statistical analysis — hence the decision by the group to devise a score based on the weighting of infection risk based on best current evidence and collective experience.


The WAR score considers the quantity and virulence of the pathogenic bioburden


in a chronic wound together with the patient's immune competence. The microbiological continuum of contamination-colonisation-critical colonisation- local and systemic infection is also discussed, acknowledging that the diagnosis of infection is essentially clinical. The quantitative microbiological assessment of colonisation/infection is also considered and the difficulties of using a guide value of 105


INFECTION Another major challenge is the management of infected leg ulcers. Emerging evidence in relation to the presence of biofilms[3]


has currently led


to revision of the treatment strategy for infected wounds in the author's clinic. Here, a wound swab is taken from


every new patient and the presence of bacteria (including Methicillin-resistant Staphylococcus Aureus [MRSA]) and fungi is monitored as well as C-reactive protein (CRP) levels in the blood. The team is also currently considering introducing the WAR (Wounds At Risk) score[4]


in order to detect wounds at


risk of infection at an early stage (See Expert Commentary, left). When a wound is infected the clinic's


/g of tissue is highlighted. The drawbacks of microbiological sampling are, of


course, legion and many microbiologists will not respond to requests to process a swab without consultation as they are aware that providing sensitivities to bacteria, which may be related to irrelevant transients or contaminants, often leads to inappropriate antibiotic therapy.


Wounds at risk are classified as being in two groups — those with endogenous


factors (the patient's immune competence) and those with exogenous factors (the quantity and pathogenicity of organisms and their susceptibility to antimicrobials). Points are allocated in the WAR score in three categories of at-risk wounds: n Class 1 (allocation of one point): based on the presence of metabolic diseases such as diabetes, cancer and its therapy, contamination and poor personal hygiene, long hospital stays, age, wound size and duration


n Class 2 (two points): severe immune defects, such as AIDS, and contaminated traumatic wounds


n Class 3 (three points): large burns, presence of foreign material, or extensive heavily contaminated wounds.


1. Dissemond J, Assadian O, Gerber V, Kingsley A, Kramer A, Leaper DJ, Mosti G, Piatkowski de Grzymala A, Riepe G, Risse A, Romanelli M, Strohal R, Traber J,


Vasel-Biergans A, Wild T, Eberlein T. Classification of wounds at risk and their antimicrobial


treatment with polyhexanide: a practice-oriented expert


recommendation. Skin Pharm Physiol 2011; 24: 245–55.


After all the risk factor points are added (and there may be more than one point scored in each class) the risk score is derived. When the WAR score is greater than 3, the use of topical antiseptics is indicated. However, no detailed advice is proffered on the use and timing of antibiotics.


References In conclusion, the WAR score is a clinical guide


for the early, and justified, use of topical antiseptics, specifically polyhexanide, in chronic wounds. There are no indications for debridement, nor any recognition of biofilm presence, which might require added intervention to optimise the value of topical antiseptics.


When diagnostics are available to detect the


presence of biofilm or critical colonisation, WAR may become more helpful. However, there has been no validation of the use of the WAR score so far. The weightings have been derived from expert consensus opinion, rather than statistically derived data, and the


score does needs a clinical study to prove its worth. However, WAR scores can already be used for classification and audit in wound care.


protocol requires daily debridement for a period of 3–5 days. This is either performed surgically or with the aid of an ultrasound device (ie Sonoca, Söring). Following debridement, a hydrophobic


bacteria-binding dressing pad is used to cover the wound (Cutimed® Sorbact®, BSN Medical). Bacteria-binding dressings are used because they contain no active antiseptics, which can be absorbed by the wound and become harmful over time. This means that these dressings can be


used for an extended period and are suitable for younger patients[5]


. Similarly, there is no


evidence of allergic reaction or bacterial resistance with these dressings.


CONCLUSION To ensure that patients receive optimum treatment, expertise in treating chronic wounds is needed across all hospital departments. The author's clinic now boasts 10 qualified


wound experts who meet on a quarterly basis to exchange new information and serve as the conduit in their departments for ensuring that wound care best practice is disseminated around the hospital.


AUTHOR DETAILS Astrid Probst is a wound care specialist nurse in Klinikum am Steinenberg Hospital, Germany.


19 Wounds International Vol 3 | Issue 1 | ©Wounds International 2012


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