Best Practice And

International Consensus:
Infection Control in the
Management Of Wound
Care
{ WOCARE CENTER
Outline :
 Bacground
 Defenition and wound
continum.
 Signs and symptoms
wound infection (acute
and crhonic)
 Management Infection
 Sampling Techniques.
 Antimicrobial therapy
IWCC DOC
Background
 Infections occur when
microorganisms overcome the host
natural immune system and
subsequent invasion and
dissemination of microorganisms in
viable tissue provoke a series of local
and systemic host responses. With
acute and chronic wound infections,
mixed populations of both aerobic
and anaerobic microorganisms are
commonly found (Association for the
Advancement of Wound Care, 2008).
 Biofilms are reported to be a
major factor contributing to multiple
chronic inflammatory diseases and
60% founded on crhonic wound
(Philips at all 2010). IWCC DOC
 Defenition
The presence of bacteria in a wound may
result in:

Contamination – the bacteria do not
increase in number or cause clinical
problems

Colonisation – the bacteria multiply,
but wound tissues are not damaged.
 Critical colonization
The inability of the wound to maintain a
balance between altered bioburden and an
effective immune system, denoted by an
unexplained delay in healing but not
necessarily deterioration in the wound or
other overt signs of clinical infection. Adapted
from White, Cutting and Kingsley 2006.
 infection – the bacteria multiply,
healing is disrupted and wound tissues
are damaged (local infection).; Bacteria
may produce problems nearby (spreading
infection) or cause systemic illness
Biofilem
A surface-associated microbial
community that is composed
of various phenotypes and
commonly various genotypes,
which encases it self in a 3-
dimensional matrix of
extracellular polymeric
substances (EPS)
(e.g. polysaccharides,
nucleic acids and
proteins) and demonstrates
increased resistance to cellular
and chemical attack.
IWCC DOC
 FORMATION PROCESS
BIOFILEM
CONTAMINATED
INFECTION

Critical
colonized

colonized

KCI [Link]™. (2012). Bioburden lifecycle.

 Wound Continum

Critical
CONTAMINATIO COLONITATIO
N N colonizatio INFECTION
n
 Contamination – the bacteria
do not increase in number or cause
clinical problems

Wound Continum
IWCC DOC
Colonization

Bacteria that have adhered to superficial tissue, have

begun to form colonies without generating a

host immune response and are not considered to be
associated with a delay in healing.

Colonization

IWCC DOC
Critical
colonization
The inability of the wound to maintain a balance between altered
bioburden and an effective immune system,
denoted by an unexplained delay in healing but not necessarily
deterioration in the wound or other overt signs of clinical
infection. Adapted from White, Cutting and Kingsley 2006.

Critical colonization

IWCC DOC
Infection
The bacteria multiply, healing is disrupted and wound
tissues are damaged (local infection).;
Bacteria may produce problems nearby (spreading

infection) or cause systemic illness

Infection
IWCC DOC
APPLICATION TO PRACTICE

high
Intervention is usually required only when the patient is at a
risk of wound infection or when the interaction
between the bacteria in a wound and the host’s
defences impairs healing, causes further damage, and
results in localised, spreading or systemic infection

APPLICATION TO PRACTICE

IWCC DOC
DIAGNOSIS
 The diagnosis of wound
infection is made mainly on
clinical grounds.
 Incorporation of assessment
for wound infection into
routine wound practice will
aid early detection and
subsequent treatment.
RISK OF INFECTION
Acute wounds : Chronic wounds:
- Contaminated surgery. - Necrotic tissue or foreign
- Long operative procedure. body.
- Prolonged duration.
- Trauma with delayed
- Large in size and/or deep.
treatment.
- Anatomically situated near a
- Necrotic tissue or foreign
site of potential
body. contamination, eg anal area.

IWCC DOC
 SIGNS AND SYMPTOMS
ACUTE WOUNDS (eg. surgical or traumatic wounds, or burns)

Localised infection: Spreading infection

 Classical signs and symptoms: :
– new or increasing pain
As for localised
– erythema
– local warmth
infection PLUS:
– swelling ■ Further extension
– purulent discharge of erythema
 Pyrexia – in surgical wounds, ■ Lymphangitis.
typically five to seven days
post-surgery ■ Crepitus in soft
■ Delayed (or stalled) healing tissues
. ■ Wound
■ Abscess breakdown/dehisc
■ Malodour
ence.
 SIGNS AND SYMPTOMS (CHRONIC WOUNDS eg diabetic
foot ulcers, venous leg ulcers, arterial leg/foot ulcers or pressure ulcers)

Spreading infection:
Localised infection :  As for localised infection PLUS:
 New, increased or altered pain
 Wound breakdown.
 Delayed (or stalled) healing
 Erythema extending from wound
 Periwound oedema
edge
 Bleeding or friable (easily  Crepitus, warmth, induration or

damaged) granulation tissue. discoloration spreading into

 Distinctive malodour or change periwound area
 Lymphangitis .
in odour
 Wound bed discoloration  Malaise or other non-specific

 Increased or altered/purulent deterioration in patient’s general

exudate condition
 Induration Individually highly indicative of infection.
 Pocketing Infection is also highly likely in the presence of
 Bridging
two or more of the other signs
listed
 SYSTEMIC INFECTION CATEGORY (acute and Cronic
wound)
Sepsis :
Documented infection with pyrexia or
hypothermia, tachycardia,
tachypnoea, raised or depressed
white blood cell count

Severe sepsis ;
Sepsis and multiple organ IWCC DOC
dysfunction

Septic shock :
Sepsis and hypotension despite
adequate volume resuscitation.

Death
INVESTIGATIONS
Initial assessment may
indicate the need for
 Microbiology :
microbiological In practice, the use of
analysis, blood tests or microbiological
imaging investigations to analysis to guide
confirm the diagnosis,
management will be
detect complications
heavily influenced by local
such as osteomyelitis, availability of microbiology
and guide management. services. Even where
readily accessible,
microbiological tests
should not be
performed routinely.

IWCC DOC
 INVESTIGATIONS

Indications for wound

specimen collection for
microbiological analysis :

 Acute wounds with signs of

infection.
 Chronic wounds with signs of
spreading or systemic
infection.
 Infected chronic wounds that
have not responded to or
are deteriorating despite
appropriate antimicrobial
treatment As required by local
surveillance protocols for drug
resistant micro-organisms IWCC DOC
Sampling techniques.

 Levine technique;
A swab is rotated over a 1  Needle Aspiration
cm2 area of the wound
and Wound Biopsy
with sufficient pressure to
express fluid from within
the wound tissue.

But may mislead by Accurate

detecting surface information about
colonising microorganisms type and quantity
rather than more deeply of pathogenic bacteria.
sited pathogens.
APPLICATION TO PRACTICE

 Assessment of wounds for

infection incorporates a full
evaluation of the patient
and should consider how
immune status, comorbidities,
wound aetiology/status and
other factors will affect the
risk, severity and likely signs
of infection.
 The diagnosis of wound
infection is based mainly on
judgement –
clinical
appropriate
investigations
(eg microbiology of wound
samples) can support and
guide management
MANAGEMENT

 Effective management of
wound infection often
requires a
multidisciplinary
approach and may
involve specialist referral, It
aims to readjust the interaction
between the patient and the
infecting micro-organism(s) in
favour of the patient by:
■ Optimising host
response
■ Reducing the number
of micro-organisms.
EFFECTIVE MANAGEMENT OF
WOUND INFECTION
OPTIMISE HOST RESPONSE :
- Hyperglicemic control
- Minimise or eliminate risk factors for
infection where feasible.
- Optimise nutritional status and
hydration
- Seek and treat other sites of
infection, eg urinary tract infection. IWCC DOC
REDUCE BACTERIAL LOAD: TISSUE INFLAMATIO
MANAGEMEN
TIME management. T
N CONTROL

GENERAL MEASURES :
- Manage any systemic symptoms TIME
- Education and ensure
psychososial support. MOISTURE EPITELIAL
BALANCE EDGE
REDUCING
Effective hygieneBACTERIAL
and LOAD
preventative
measures :
 Infection control
procedures should be
followed to prevent
further contamination of
the wound and cross
contamination. Good
hygiene practice
includes paying particular
attention to thorough
hand
cleansing/disinfection
and suitable protective
working clothes,
 Wound drainage and
debridement
 Pus, necrotic tissue and slough
CSWD :
are growth media for micro- CONSERVATIVE
SHARP WOUND
organisms. Drainage of pus and DEBRIDMENT MECHANICAL :
excess exudate can be aided by HYDROPRESSURE

the use as
appropriate
AUTOLYSIS
of: absorbent DEBRIDMEN
T
dressings; wound/ostomy BIOLOGICAL
: MAGGOT
drainage appliances; surgical
intervention; insertion of drains;
or topical negative pressure
therapy. Necrotic tissue and
slough should be removed by NECROTI
debridement. In general, rapid C WOUND
methods of debridement,
Cleansing infected wounds

 Infected wounds should

be cleansed at each
dressing change.
Cleansing by irrigation
should use sufficient
pressure to effectively
remove debris and
micro-organisms
without damaging the
wound or driving micro-
organisms into wound
IWCC DOC
tissues.
Antimicrobial therapy
Antiseptics are applied
topically and are non-
selective agents that inhibit
multiplication of or kill
micro-organisms. They may
also have toxic effects on
human cells. Development of
resistance to antiseptics is
unusual.
Antibiotics act selectively
against bacteria and can be
administered topically (not
usually recommended) or
systemically. Development of
resistance to antibiotics is an
increasing problem. IWCC DOC
 Antiseptics generally have a
broad spectrum of
antibacterial activity. Their
 Clinician familiarity
action at multiple sites within  Availability, cost and
microbial cells reduces the reimbursement issues
likelihood of bacteria  Ease of use and
developing mechanisms to implications for
avoid their effects and so may pattern of care
explain their relatively low  Efficacy and safety.
levels of bacterial resistance.
Factors influencing the choice
of antiseptic for an infected
USING
wound include:

ANTISEPTICS
 Using antiseptics in wound
infection
Review regimen
Indications for ■ If the wound deteriorates or
the patient experiences
antiseptics : symptoms suggestive of
 To prevent wound infection or spreading or systemic
recurrence of infection in infection
patients at greatly increased ■ If a chronic wound with
risk. localised infection shows no
 To treat: improvement after 10–
– localised wound infection 14 days of antiseptic
– spreading wound infection therapy alone – re-evaluate
– wound infection accompanied the patient and the wound;
send samples for
by systemic symptoms.
microbiological analysis;
in combination with consider whether there are
systemic antibiotics any indications for systemic
antibiotic treatment.
 Discontinue
antiseptics
 When the signs of
infection resolve
 When the wound

starts to heal
 If the patient

experiences an
antiseptic-related
adverse event.
IWCC DOC
Using systemic antibiotics in wound
infection
Review antibiotic regimen
Indications for ■ If there is no improvement of
systemic or local signs and
systemic antibiotics : symptoms, re-evaluate the patient
Prophylaxis where risk of and the wound; consider
wound infection is high, eg microbiological analysis and
contaminated colonic changing antibiotic regimen
surgery or ‘dirty’ traumatic ■ If the patient has an antibiotic-
wounds related adverse event; discontinue
causative antibiotic.
 Spreading or systemic
Discontinue/review systemic
wound infection antibiotics
 When culture results reveal ■ At the end of the prescribed
b-haemolytic streptococci, course (according to type of
even in the absence of infection, wound type, patient
signs of infection comorbidities and local prescribing
policy)
CONCLUSION

Hollister wound care. (2014). Wound Bioburden Continuum.

Availabel at [Link]
  Clinicians should understand infection
process and wound continum.
 Clinicians should carefully consider the
potential risks and benefits of using an
antiseptic.
 Clinicians are also strongly advised to
consult research evidence.
 Multidiscipline appropriate in wound
infection management

CONCLUSION
  Best Practice Statement (2011) The use of
topical antiseptics/antimicrobials in wound
management. 2nd edition. Wounds UK. Available
at: [Link]
content_9969.pdf.
 European Wound Management Association
(EWMA) (2004) Position document: management
of wound infection. MEP Ltd, London.
 European Wound Management Association
(EWMA) (2004) Position document: identifying
criteria for wound infection. MEP Ltd, London.
 PRINCIPLES OF BEST PRACTICE (A World Union
of Wound Healing Societies’ Initiative), 2008

References
CASE STUDY
Healing ; 1 Month, 20 days.

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Healing; 13 Days

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Healing; 2 month

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Healing Progress; 2 month

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Healing Progres; 2-3 Month
Healing; 2 Month

IWCC DOC
THANKYOU....