Use of corticosteroids and other immunosuppressant medications Inherited neutrophil deficits and/or immune deficient conditions

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1 Develped in cllabratin with the Wund Care Champins, Wund Care Specialists, Enterstmal Nurses, and Suth West Reginal Wund Care Prgram (SWRWCP) members frm Lng Term Care Hmes, Hspitals, and Suth West CCAC cntracted Cmmunity Nursing Agencies in the Suth West Lcal Health Integratin Netwrk. Title Guideline: The Assessment and Management f Bacterial Burden in Acute and Chrnic Wunds Backgrund As per the cncept f Preparing the Wund Bed, lcal factrs must be assessed and managed in rder t prmte timely and rderly clsure f wunds. This includes cnsideratin f increased bacterial burden and/r wund infectin and persistent inflammatin 1 Assessment f infectin needs t be f the whle persn, and specifically the persn s ability t resist infectin, as: Infectin = dse x virulence Hst resistance Whereas: Dse = the amunt f micrrganisms which is sufficient t cause infectin. It is generally accepted that rganisms in a quantity greater than 10 6 (the dse) will nt nly impair healing, but will prduce sufficient txins and prtelytic enzymes t harm living tissue 10 Virulence = the cmpetence f a nxius agent t prduce its effect. Different bacteria have different virulent prperties, s that a mre virulent species may have mre deleterius effects n the wund than the actual quantity f bacteria present Hst resistance = the ability f an individual t withstand the nxius influence. Systemic and lcal factrs can increase the risk f infectin: Systemic Factrs Lcal Factrs Malnutritin Edema Vascular disease and/r diabetes mellitus Use f crticsterids and ther immunsuppressant medicatins Inherited neutrphil deficits and/r immune deficient cnditins Prir surgery r raditherapy Alchlism Rheumatid arthritis Large wund area and/r depth High degree f wund chrnicity Anatmic lcatin, i.e. near anus Presence f freign bdies and/r necrtic tissue in the wund Mechanism f injury, i.e. trauma r perfrated viscus High degree f cntaminatin Reduced tissue perfusin Lng r cntaminated surgery All wunds cntain bacteria at levels ranging frm cntaminatin t systemic infectin (see Definitins f Bacterial Burden in Chrnic Wunds ). It is the interpretatin f the clinical signs f increased bacterial burden/infectin that directs treatment (if required) (see Biburden Assessment Tl and Interpretatin ). There is NO single scientific test t definitively diagnse infectin Infectin Guide Suth West Reginal Wund Care Prgram Last Updated March 17,

2 The rle f bifilms: Bifilms are cmmunities f bacteria/fungi that c-exist in a prtective matrix n the surface f sme chrnic wunds 5 The matrix prtects the bacteria/fungi living within it frm external threats, like tpical antimicrbials and wund cleansing and superficial debriding measures They are present in up 60% f chrnic wunds, and may be respnsible fr persistent inflammatin, which delays wund clsure 4 Sharp debridement fllwed immediately by the applicatin f a brad spectrum tpical antimicrbial (repeated as necessary) is the nly way t successfully remve and prevent bifilm recnstitutin Strategies t reduce risk f wund infectin: Adhere t hand washing prtcls befre and after dressing changes Remember that dressings supplies are fr single persn use nly, i.e. avid sharing dressings between peple Dressings pre-packaged fr single use are intended t be used in that manner, i.e. nt accessed and the remaining dressing fragments saved fr future use. NOTE: fr thse with ACUTE wunds receiving wund care, it is realized that in reality dressings are being accessed frm sterile, single use packaging, used, and that the remaining dressing fragments are being used in future dressing changes. Fr ACUTE wund care, this may be acceptable, if yur rganizatin s indicates in their plicies and if the fllwing criteria are met: The packaging is pened using aseptic technique The dressing is cut using sterile frceps and scissrs The remaining dressing pieces are placed int a sterile C+S cntainer, using aseptic technique, that has been labelled with the persn s name, the date, and the name f the dressing The remaining dressing pieces are accessed frm the C+S cntainer in the future using aseptic technique After tw weeks in the C+S cntainer, the cntainer and its remaining cntents are discarded Fr thse with CHRONIC wunds, althugh single use f prepackaged dressings is indicated by dressing manufacturers, it t is realized that in reality this may nt be happening, i.e. remaining dressing fragments are being saved fr future use. NOTE: fr thse with CHRONIC wunds receiving wund care, it may be apprpriate t re-use dressing fragments, if yur rganizatin s indicates in their plicies and if the fllwing criteria are met: The packaging is initially pened using aseptic Infectin Guide Suth West Reginal Wund Care Prgram Last Updated March 17,

3 technique The dressing is cut using clean instruments The remaining dressing pieces are placed int a sterile C+S cntainer that has been labelled with the persn s name, the date, and the name f the dressing The remaining dressing pieces are accessed frm the C+S cntainer in the future using clean technique After tw weeks in the C+S cntainer, the cntainer and its remaining cntents are discarded Single use saline r sterile water bttles (110mL) are used in their entirety at each dressing change, i.e. they are nt recapped and used fr subsequent dressing changes, nr are they shared between peple Fr thse accessing larger cntainers f saline r sterile water, i.e. larger than 115mL, if accessed in a sterile manner, these bttles may be re-used fr the same persn fr a perid f 24 hurs, befre they are required t be discarded. The slutin must be dated and labelled with the persn s name when pened, and may be stred at rm temperature with the cap secured Assess and treat acute wunds, i.e. wunds that are less than fur weeks ld, using sterile (aseptic) technique. Thse with neutrphil deficits and/r immune deficiency and wh have chrnic wunds, may als benefit frm aseptic technique Assess and treat chrnic wunds, i.e. wunds that are greater than fur weeks ld, using clean technique Take nly the supplies needed fr the single dressing change t the persn s bedside r int the persn s hme, as such supplies cannt be returned t the dressing supply rm/shelf/cart, etc. and MUST BE DISCARDED fr infectin cntrl reasns If supplies are being stred in a persn s hme, they must be stred accrding t manufacturer s guidelines and in a lcatin that is inaccessible t children and pets Remve nn-viable tissue frm the wund surface, as apprpriate, as it prvides an pprtunity fr micrbial grwth 6 [see Guideline and Prcedures: Wund Debridement (excluding cnservative sharp debridement) and/r Guideline and Prcedure: Cnservative Sharp Wund Debridement (CSWD )] Optimize the misture balance f the wund bed (in healable wunds) 7, as dry wund beds may develp micrscpic cracks that may be prtals f entry fr bacteria Cnsider the use f tpical antimicrbials in high-risk individuals/wunds t prevent wund infectin 7, i.e.: Thse with a histry f delayed healing/infectin; Infectin Guide Suth West Reginal Wund Care Prgram Last Updated March 17,

4 Indicatins Guideline Thse with wunds in anatmical lcatins that increase the risk f cntaminatin, i.e. the sacrum; Wunds f 4+ weeks duratin at initial presentatin, that have n visible signs f healing r with signs f deteriratin; Thse with pathlgies r activities that may cmprmise immunity, i.e. thse with diabetes and prly cntrlled bld sugars, smking, alchl abuse, etc.; In areas f significantly cmprmised bld flw where healing is unlikely, and; T reduce dr that may be affecting quality f life. This guideline is intended t be used by frnt line registered health care prviders, t guide their assessment and management f wund bacterial burden/infectin in thse individuals presenting with a wund. NOTE: The assessment and management f a persn s wund fr bacterial burden/infectin is but ne part f the hlistic assessment and management f individuals admitted with/presenting with a wund. Assessment 1. Review the persn s medical recrds fr the fllwing infrmatin, as it may help yu t determine if the persn s wund is critically clnized, r has spreading r systemic infectin: a. Histry f stalled r slw wund clsure b. Histry f increasing exudate/dr c. Presence f lcalized edema d. Increase in wund related pain experience e. New wund breakdwn r satellite lesins f. Histry f lymphangitis, general malaise, fever, rigrs, chills, hyptensin, rgan failure 2. Review the persn s medical recrds fr the fllwing infrmatin: a. Healability status (see the Determining Healability Tl ) b. Infrmatin re the size, lcatin, and characteristics f the wund t be assessed/debrided/dressed, as this will help yu anticipate supplies needed c. Current wund infectin treatment and respnse d. Current wund care rders Planning 1. Expected utcmes: a. Infrmatin frm the persn s chart, the persn and/r their substitute decisin maker (SDM)/pwer f attrney fr persnal care (POA C), and yur assessment allws fr the determinatin f the level f bacterial burden present in/n the wund (as per the Biburden Assessment Tl ), and as such the selectin f the mst apprpriate interventins b. Infrmatin btained will allw fr the determinatin f Infectin Guide Suth West Reginal Wund Care Prgram Last Updated March 17,

5 whether r nt the wund is psitively respnding t bacterial burden/infectin management measures, i.e. the clinical signs f critical clnizatin, spreading infectin, and systemic infectin (see: Definitins f Bacterial Burden in Chrnic Wunds ) are disappearing/reslving c. Registered nursing staff, in cllabratin with the individual with the wund and/r their SDM/POA C, and ther invlved health care disciplines, are able t use the assessment infrmatin t initiate/mdify and implement an apprpriate persn-centered, interdisciplinary plan f care which cntains clear directins t staff and thers wh are prviding the persn with direct care 2. Explain the prcedure and its purpse t the persn and/r their SDM/POA C, and btain infrmed implied/verbal cnsent 3. Assess the need fr pre-prcedure pain medicatin remval f dressings, the dressing prcedure itself, and/r debridement may be painful. If required, the persn must be alltted enugh time t achieve the drug s peak effect BEFORE initiating the dressing change/debridement Implementatin 1. Prvide fr privacy and ensure the persn is in a cmfrtable psitin t facilitate assessment f the wund and fr the wund debridement/dressing prcedure 2. Wash yur hands and attend t the persn with yur assessment tls and anticipated debridement and/r wund dressing supplies 3. If the persn is in bed, raise the bed (if yu are s able t) t an apprpriate ergnmic psitin t allw fr the wund assessment and treatment while preventing self-injury 4. Ensure adequate lighting 5. Dn clean dispsable glves and additinal persnal prtective equipment (PPE), i.e. gwn, gggles, and/r mask as required if risk fr splash back r spray exists 6. Remve the existing wund dressing as per the manufacturer s instructins. Observe the dressing fr the appearance f the drainage f n the dressing. Assess fr dr 7. Dispse f the siled dressings in the prper receptacle and remve and dispse f yur siled glves 8. Apply new clean dispsable glves and cleanse the wund as rdered r as per the SWRWCP s Dressing Selectin and Cleansing Enabler HEALABLE WOUNDS r the SWRWCP s Dressing Selectin and Cleansing Enabler MAINTENANCE/NON-HEALABLE WOUNDS 9. Gently pat the wund bed dry (if required) and dry the surrunding skin with gauze 10. If indicated, and if yu have the knwledge, skill, judgment, and authrity, cnservatively sharp debride any necrtic tissue present Infectin Guide Suth West Reginal Wund Care Prgram Last Updated March 17,

6 and re-cleanse the wund as abve [see: Guideline and Prcedure: Cnservative Sharp Wund Debridement (CSWD) ] 11. Assess the wund using the NPUAP PUSH Tl 3.0 (see Prcedure: NPUAP PUSH Tl 3.0 ) 12. Observe fr clinical signs f increased bacterial burden/infectin using the Biburden Assessment Tl, determining the level f risk, i.e. clnized, critically clnized, spreading infectin, r systemic infectin, as nted n the Tl itself 13. Crss reference the bacterial burden risk level with the dcument Definitins f Bacterial Burden in Chrnic Wunds, as this will suggest apprpriate clinical interventins based n level f risk, i.e. Bacterial Burden Level Clinical Interventins Cntaminated Mnitr and risk reductin* Clnized Mnitr and risk reductin* Tpical antimicrbials Critical Clnizatin Effective debridement Tpical antimicrbials Spreading Infectin Effective debridement Systemic antibitics Tpical antimicrbials Effective debridement Systemic Infectin Systemic antibitics Rule ut ther infectin surces *Risk reductin suggestins can be fund in the Backgrund sectin f this dcument 14. If the use f tpical antimicrbials are indicated, see the fllwing resurces (fund n the Prgram s website: t infrm yur chice f antimicrbial(s). NOTE: antimicrbials shuld be trialed fr a day perid (a Tw Week Challenge ), and if the wund shws n imprvement, the persn and the wund shuld be re-evaluated, a wund swab shuld be cnsidered, and the persn shuld be assessed by their primary care prvider t determine if systemic antibitic treatment is warranted (see Criteria fr Interdisciplinary Referrals ). If after tw weeks the wund is prgressing twards clsure yet still exhibits signs f infectin, cntinue the use f the antimicrbial dressing fr anther tw weeks. If the persn has had an antimicrbial dressing n fr lnger than fur weeks, review the dressing regimen and cnsider a referral t Enterstmal (ET) Nurse r Wund Care Specialist (WCS) fr further discussin f the management plan (see Criteria fr Interdisciplinary Referrals ): a. Safest Tpical Antimicrbials fr Use in Wund Care b. Tpical Antimicrbials fr Selective Use in Wund Care c. Tpical Antimicrbials fr Cautinary Use in Wund Care NOTE: STOP using tpical antimicrbials when the signs f infectin reslve, when the wund starts t prgress twards clsure, and/r if the persn experiences an antimicrbial Infectin Guide Suth West Reginal Wund Care Prgram Last Updated March 17,

7 related adverse event 15. Antimicrbial dressings shuld be selected based n their ability regarding: a. Absrbency and ability t be used with highly exudating r lw exudating wunds b. Cnfrmability t the wund surface i.e. the mre that the dressing matches the cnturs f the wund surface and directly cntacts it, the better the antimicrbial effect c. Management f dr and/r pain d. Activity against the specific bacteria in the wund e. Sufficient levels f the agent t achieve bacterial kill as ppsed t bacterial inhibitin (and within what length f time) f. Cyttxicity, i.e. are the cmpnents f the dressing likely t damage healthy living cells g. Allergenicity h. What the persn can tlerate i. The cst f the dressing vs the frequency f dressing changes 16. If debridement is indicated see Guideline and Prcedures: Wund Debridement (excluding cnservative sharp debridement), Guideline and Prcedure: Cnservative Sharp Wund Debridement (CSWD), and/r cnsider a referral t a general surgen r ther such prfessinal skilled in sharp debridement (and wh has the authrity t perfrm such a prcedure), i.e. see Criteria fr Interdisciplinary Referrals NOTE: aggressive debridement f slugh and the underlying tissue may disrupt the bacterial burden and suppress bifilm regrwth 8. Debridement shuld be fllwed by wund cleansing (see #19) and applicatin f an antimicrbial dressing that is apprpriate fr the clinical indicatins (i.e. exudate and dr management), as well as safe fr and acceptable fr the persn with the wund. See: a. Safest Tpical Antimicrbials fr Use in Wund Care b. Tpical Antimicrbials fr Selective Use in Wund Care c. Tpical Antimicrbials fr Cautinary Use in Wund Care 17. If systemic antibitics are indicated, refer the persn t their primary care prvider fr assessment and cnsideratin f systemic antibitics (see Criteria fr Interdisciplinary Referrals ). Systemic antibitics shuld be used in additin t debridement and the use f tpical antimicrbials (see #19 and #20). Prescribing prfessinals must take int cnsideratin the fllwing when chsing an antibitic 10 : a. The mst likely r cnfirmed antibitic susceptibilities f the suspected r knwn pathgen(s). NOTE: in wunds less than 4 weeks ld, the mst cmmn pathgens are gram +. In wunds greater than 4 weeks ld, the mst Infectin Guide Suth West Reginal Wund Care Prgram Last Updated March 17,

8 cmmn pathgens are gram +, gram and anaerbes. If empirical treatment is necessary, start with an apprpriate brad-spectrum antibitic and when susceptibilities becme available, if the wund is nt respnding t the afrementined treatment, cnsider switching t a narrwer-spectrum agent(s) b. The persn with the wund, i.e. allergies, ptential interactins with current medicatins, cmrbidities, ability/willingness t cmply with treatment c. Guidelines fr the treatment f infectin in specific wund types, i.e. diabetic ft ulcers d. Severity f the infectin (NOTE: IV antibitics are usually reserved fr serius r life-threatening infectins) e. Availability, cst and safety 18. Wund swab cultures ften tell yu what micrbes are present n the surface f the wund, which may nt be the same as thse causing infectin deeper in the wund, ften making the results incnclusive. It is apprpriate t swab a wund (using the Levine Technique, see Prcedure: Wund Swabbing Using the Levine Technique ) 10 : a. When yu have an acute wund with clinical signs f infectin b. When yu have a chrnic wund with signs f spreading r systemic infectin c. When yu have a chrnic wund that has nt respnded t r is deterirating despite antimicrbial treatment d. As required by lcal surveillance prtcls 19. Fr thse with spreading and systemic infectin, it is imprtant t ptimize the hst respnse s that their immune system may best fight the infectin, i.e. ptimize the management f cmrbidities, minimize risk factrs fr infectin, ptimize nutritin and hydratin, and treat ther surces f infectin 20. Once yu have prvided wund care, remve yur glves and ther PPE and dispse f them and f any siled supplies in the apprpriate receptacle 21. Dispse f any used sharps in a sharps cntainer 22. Clean reusable equipment/surfaces tuched during the prcedure with sap and water r detergent wipes and dry thrughly t prevent crss infectin, returning reusable equipment t the apprpriate places 23. Wash yur hands 24. Assist the persn t a cmfrtable psitin if required, and assess fr any cncerns 25. Lwer the persn s bed t an apprpriate height (if applicable), and ensure the persn s safety, i.e. apply side rails, persnal alarms, restraints, etc. as per the persn s care plan/medical rders 26. Discuss yur findings f the assessment and yur thughts re the presence/absence f signs f infectin with the persn and/r their Infectin Guide Suth West Reginal Wund Care Prgram Last Updated March 17,

9 References SDM/POA C and implement referrals and further interventins as indicated 27. Share yur wund assessment and interventin implementatin findings/utcmes with the interdisciplinary members f the persn s wund care team 28. Cmplete/update and implement an apprpriate, persn-centered, interdisciplinary plan f care, based n yur hlistic assessment and interventins, and as per yur rganizatin s plicy Evaluatin 1. Unexpected utcmes: a. The persn reprts prly managed pain assciated with this prcedure b. There is an increase in clinical signs f wund infectin, despite implementatin f apprpriate interventins 2. Re-assess the wund using the NPUAP PUSH Tl 3.0 at a minimum f weekly t ensure yur bacterial balance interventins were effective, and t determine if cnsideratin f ther/additinal frms f infectin management interventins are necessary 1. Sibbald RG, Orsted HL, Cutts PM, et al. Best practice recmmendatins fr preparing the wund bed: Update Wund Care Canada. 2006;4(1): Cutting KF, Harding KG. Criteria fr identifying wund infectin. Jurnal f Wund Care. 1994;3: Caput GM, Jshi N, Weitekamp MR. Ft infectins in patients with diabetes. Am Fam Phys. 1997;56: James GA, Swgger E, Wlctt R, et al. Bifilms in chrnic wunds. Wund repair Regeneratin. 2008;16(1): Wlctt RD, Rhads DD. A study f bifilm-based wund management in subjects with critical limb ischemia. J Wund Care. 2008;17(4): Penhallw K. A review f studies that examine the impact f infectin n the nrmal wund-healing prcess. J Wund Care. 2005;14(3): Wunds UK Best Practice Statement. The use f tpical antimicrbial agents in wund management (3 rd edn). Lndn: Wunds UK, Accessed at: 8. Schultz G. Understanding bifilm-based wund care: What yu need t knw. Wunds Internatinal webcast Accessed at 9. Wrld Unin f Wund Healing Sciety Principles f Best Practice Cnsensus. Wund Infectin in Clinical Practice. Lndn: WUWHS, Accessed at: _31.pdf 10. W KY, Sibbald RG. A crss-sectinal validatin study f using NERDS and STONEES t assess bacterial burden. Ostmy Wund Infectin Guide Suth West Reginal Wund Care Prgram Last Updated March 17,

10 Related Tls (NOTE: these tls and their instructins can be fund n the SWRWCP s website: swrwundcareprgram.ca) Management. 2009;55(8): Definitins f Bacterial Burden in Chrnic Wunds Biburden Assessment Tl and Interpretatin Determining Healability Tl SWRWCP s Dressing Selectin and Cleansing Enabler HEALABLE WOUNDS SWRWCP s Dressing Selectin and Cleansing Enabler MAINTENANCE/NON-HEALABLE WOUNDS Guideline and Prcedure: Cnservative Sharp Wund Debridement (CSWD) NPUAP PUSH Tl 3.0 Prcedure: NPUAP PUSH Tl 3.0 Safest Tpical Antimicrbials fr Use in Wund Care Tpical Antimicrbials fr Selective Use in Wund Care Tpical Antimicrbials fr Cautinary Use in Wund Care Guideline and Prcedures: Wund Debridement (excluding cnservative sharp debridement) Criteria fr Interdisciplinary Referrals Prcedure: Wund Swabbing Using the Levine Technique Infectin Guide Suth West Reginal Wund Care Prgram Last Updated March 17,