Practice development


Table 1: Bacterial burden in chronic wounds Term


Clinical interpretation


Contaminated Bacteria on surface only. No signs or symptoms


Colonised


Localised infection (also called critical coloni- sation or occult Infection)


Bacteria attached to surface, starting to form colonies, minimally invasive. No local tissue damage


Bacteria more deeply invasive. Local wound bed involved. Healing com- promised in healable wounds. Subtle signs of infection may be present


including: n Friable bright red granulation tissue


n Increased or altered exudate n Increased odour n Increased pain n Localised oedema


Spreading infection


Bacteria now involve the surrounding tissues. In addition to the subtle signs described above classic signs of infec- tion such as pain redness, heat and swelling may be present. Other signs and symptoms include:


n Wound breakdown with satellite lesions


References


1. Principles of best practice: Wound infection in clinical practice: An


international consensus. London: MEP Ltd, 2008; Available at: www. www.woundsinternational.com (accessed on 22 August, 2012).


2. Vowden P, Cooper RA. An integrated approach to managing


wound infection. In EWMA Position Document: Management of Wound Infection 2006; MEP, London.


3. Hurlow J, Bowler PG. Potential implications of biofilm in chronic


wounds: a case series. J Wound Care 2012; 31(3):109–19.


4. Gurjala AN, Geringer MR, Seth


AK, et al. Development of a novel, highly quantitative in vivo model for the study of biofilm-impaired cutaneous wound healing. Wound Rep Regen 2011; 19(3): 400–10.


5. Wolcott RD, Kennedy JP, Dowd SE. Regular debridement is the main


tool for maintaining a health wound bed in most chronic wounds. J Wound Care 2009; 18(2): 54–56.


Systemic infection


n Induration and redness extending well beyond the wound borders


n Lymphangitis n General malaise


Classic signs of sepsis including pyrexia or hypothermia, tachycardia, tachypnoea, elevated or depressed white cell counts and in more severe cases multi-organ system failure


clinical. The assessment should include evaluation of host factors, the surrounding skin and the characteristics of the wound itself. Wound swabs, while helpful in directing treatment, do not in themselves diagnose infection. While there are no validated tools to assess for wound infection, a bioburden simple checklist based on the international consensus document may be helpful in deciding on the level of bacterial burden in a chronic wound[1,8,9,10]


. At each assessment, the


clinician checks the appropriate boxes if the signs or symptoms are present and leaves them blank if they are absent. (See Tables 2 and 3for the checklist and its interpretation.)


24 Wounds International Vol 3 | Issue 3 | ©Wounds International 2012


Intervention required as for spreading infection. Other sources of infection need to be ruled out. Systemic and topical measures required


TECHNIQUES FOR DISRUPTING INFECTION Clinical interventions are described for various levels of bacterial burden in wounds [Table 1]. Localised wound bioburden is managed through good cleansing, effective debridement and judicious use of antimicrobial dressings. For more deeply invasive infections or sepsis, systemic antibiotics are also required in addition to local measures. Recently, discussion has focused on disrupting biofilms. To date, the most effective intervention appears to be the ‘clean and cover’ approach, using effective debridement followed by application of an


Intervention required as for localised infection plus systemic antibiotics


Clinical intervention


Monitoring and risk reduction


Monitoring and risk reduction


Intervention required. Often can be managed with local measures such as topical antimicrobials or antimicro- bial dressings in addition to effective debridement


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