Effective Diagnosis of Local Wound Bed Infection. Julie Hewish Senior Tissue Viability Nurse Oxford Health NHS Foundation Trust

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1 Effective Diagnosis of Local Wound Bed Infection Julie Hewish Senior Tissue Viability Nurse Oxford Health NHS Foundation Trust

2 Localised Wound Bed Infection is the Result of imbalance between patient s immune system and the conditions within the wound (EWMA 2005)

3 The Germ is nothing. It is the terrain in which it is found that is everything. Pasteur 1880

4 Trust Guidelines Wound Infection is a clinical diagnosis Wound swabs are only indicated where systemic antibiotic therapy is required. Antibiotics should not be used in the absence of systemic/soft tissue infection.

5 All wound contain bacteria therefore the Challenge: recognising the signs of an increase in the numbers of bacteria the bioburden, which may lead to infection. Timely intervention

6 Bacterial Balance Routine wound management: Peri-wound cleansing Exudate management Presence of non-replicating micro-organisms Patient and Wound Bed currently stable.

7 Contamination

8 Routine wound management: Peri-wound cleansing Exudate management Debridement Consider topical antimicrobial dressing Presence of multiplying micro-organisms with no injury to the host Healing potentially compromised

9 Colonisation

10 Proactive approach to wound management: Debridement Use of antimicrobials Exudate management Antibiotic therapy Yes / No Micro-organisms are a burden Patient experience: Acute Increased pain Acute Increasing exudate levels

11 Local Wound Bed Infection

12 Consider: Increased wound discharge Unexpected pain Non or delayed healing Wound breakdown Bridging of epithelium Pocketing in the wound bed Unhealthy granulation tissue: bright red, often friable, bleeding brown Granulation tissue Abscess formation Malodour

13 Assessment and Management of patients with Infected wounds Assessment and Management of symptoms of infection Consider possible systemic treatments for wound infection Consider topical treatments for wound infection

14 LOCAL SIGNS & SYMPTOMS Wound Bed Exudate Levels Wound Bed Contamination Patient s immune system is maintaining bacteria at safe levels. Healing/patient not compromised Wound surface area has reduced in size by 40% at 6 weeks. Positive granulation/epithelialisation Normal exudate for patient / wound type Pain No change Erythema Erythema not usually present SYSTEMIC SIGNS & SYMPTOMS None MANAGEMENT Systemic Anttimicrobials (antibiotics) High Risk Patient No Wound Swabs for M, C & S No 2 Topical Antimicrobial dressing Other Actions Standard formulary dressing Treat / optimise co-existing morbidities Assess wound for critical colonisation/infection at every dressing change Debride sloughy/necrotic tissue 3

15 Wound Bed Colonisation Wound Bed Colonisation Multiplying bacteria has the ability to tip patient and wound defences Healing Compromised Healing has slowed / or stopped (non-progressing wound)). Sloughy/necrotic tissue may be present Wound Bed Increased exudate (sometmes mild odour) LOCAL SIGNS & SYMPTOMS Exudate Levels Pain Increased/changed pain Erythema not usually present Erythema None SYSTEMIC SIGNS & SYMPTOMS No MANAGEMEN T Systemic antibiotics Wound Swabs for M, C & S Antimicrobial dressing Other Actions Consider antibiotic in line with local prescribing protocols/guidelines No 1 st Line Honey-impregnated dressing 2 nd Iodine-based dressing Consider referral to Tissue Viability Treat / optimise co-existing morbidities Assess wound for infection at every dressing change

16 Local Wound Bed Infection Local Wound Bed Infection Patient s defences are overwhelmed Healing and patient compromised LOCAL SIGNS & SYMPTOMS Wound Bed Exudate levels Pain Healing has stopped or Wound has deteriorated / extended Malodour/Copious/purulent exudate Acute Pain/changed pain Erythema Local Wound Bed Infection Erythematous border <2cm Systemic Infection Erythematous border >2cm SYSTEMIC SIGNS & SYMPTOMS Abnormal /changed Odour Discoloured/friable Tissue pocketing Bridging /necrosis slough Pyrexia Tachycardia General malaise Raised WBC & CRP Soft Tissue Infection Systemic Antimicrobials (antibiotics) No Yes MANAGEMENT High Risk Patient Yes Wound Swabs for M, C & S No 2 Yes Antimicrobial dressing Other Actions 1 st Line Honey-impregnated dressing 2 nd Iodine-based dressing Refer to Tissue Viability if support needed Treat / optimise co-existing morbidities

17 Conclusion: Improve patient outcomes Need for early and accurate diagnosis of wound infection Indiscriminate use of antibiotics Increasing cost of antimicrobial dressings Careful, thorough assessment of the person with the infection Management of the symptoms of infection Reduce the risk of complications

18 Thank you for listening