Wound infection clinical practice

Wound infectionclinical practiceDr. Marwan Jabr AlwazzehAssoc. Prof. of Medicine Consultant Internist/ Infectious DiseasesUniversity of Dammam

"Every operation in surgery is an experiment in bacteriology"

Berkely Moynihan 1920

DEFINITIONSContamination: the bacteria do not increase in number or cause clinical problemsColonization: the bacteria multiply, but wound tissues are not damagedInfection:Local infection: the bacteria multiply, healing is disrupted and wound tissues are damaged Spreading infection: the bacteria produce problems nearby Systemic infection.

DEFINITIONS*Localized infection may or may not be accompanied by the classical signs and symptoms of inflammation.Tow or more of the following:Temperature 38 C or 36 CHeart rate 90 beats/minRespirations 20/min or arterial Carbone dioxide tension (PaCO2) < 32 mm HgWhite blood cell count 12,000/mm3 or 4000/mm3 or >10% immature [band] forms

DEFINITIONSSystemic Inflammatory Response SyndromeDEFINITIONS

Host factorsDiabetes mellitusHypoxemiaHypothermiaLeukopenia Nicotine (tobacco smoking)

Immunosuppression MalnutritionPoor skin hygiene Obesity Steroid use Hospital stay

Classification of surgical wounds

Surgical woundsTypeExampleCleanHernia repairClean-contaminatedElective colectomyContaminatedEmergency colectomyDirtyPerforated appendicitis

Surgical site infections (SSIs)

SYMPTOMS AND SIGNS ACUTE WOUNDSLocalized infectionSpreading infectionClassical findings:new or increasing painErythemalocal warmthSwellingpurulent dischargeDelayed healingAbscessMalodourAs for localized infection PLUS:extension of erythemaLymphangitisCrepitus in soft tissuesWound breakdown/dehiscence

Postoperative fever5 WsWind (atelectasis/pneumonia) Water (UTI)Walk (DVT-PA)Wound (infection) Wonder (drug reaction)

SYMPTOMS AND SIGNS CHRONIC WOUNDSLocalized infectionSpreading infectionNew, increased or altered painDelayed healingPeriwound oedemaBleeding or easily damaged granulation tissueDistinctive malodour or change in odourWound bed discolorationIncreased or altered/purulent exudateIndurationPocketingBridgingAs for localized infection PLUS:Wound breakdownErythema extending from wound edgeCrepitus, warmth, induration or discolorationspreading into periwound areaLymphangitisMalaise or other non-specific deterioration in patients general condition

Localized infection-Bridging

INVESTIGATIONSAcute wounds with signs of infectionChronic wounds with signs of spreading or systemic infectionInfected chronic wounds that have not responded to or are deteriorating despite appropriate antimicrobial treatmentAs required by local surveillance protocols for drug resistant micro-organisms

The best technique for swabbing wounds has not been identified and validated. In general, sampling should take place after wound cleansing (and, if appropriate, debridement), and should concentrate on areas of the wound of greatest clinical concernINVESTIGATIONS

EFFECTIVE MANAGEMENT OF WOUND INFECTIONGENERAL MEASURESManage any systemic symptoms, such as painPyrexiaProvide patient and carer educationOptimize patient cooperation with management planEnsure psychosocial support

EFFECTIVE MANAGEMENT OF WOUND INFECTION OPTIMIZE HOST RESPONSEOptimize management of comorbidities (optimize glycaemic control in diabetic patients, enhance tissue perfusion/oxygenation)Minimize or eliminate risk factors for infection where feasibleOptimize nutritional status and hydrationSeek and treat other sites of infection (urinary tract infection)

EFFECTIVE MANAGEMENT OF WOUND INFECTION REDUCE BACTERIAL LOADPrevent further wound contamination or crosscontaminationFacilitate wound drainage as appropriateOptimize wound bed (debridement, increase frequency of dressing change as appropriate, cleanse wound at each dressing change, manage excess exudate, manage malodour)topical antisepticAntimicrobial therapy /systemic antibiotic(s)

EFFECTIVE MANAGEMENT OF WOUND INFECTIONThe ideal agent for and method of cleansing infected wounds have not yet been identified.There is a role for judicious irrigation with an antiseptic solution (at body temperature) to assist with reduction of wound bacterial load.

Antiseptics

Using of topical antibioticsThe use of topical antibiotics in the management of infected wounds should generally be avoided to minimize the risk of allergy and the emergence of bacterial resistance.Topical antibiotics should only be used in infected wounds under very specific circumstances by experienced clinicians.

Using of systemic antibioticsIndications for systemic antibioticsProphylaxis where risk of wound infection is high (e.g. contaminated colonic surgery or dirty traumatic wounds)Spreading or systemic wound infectionWhen culture results reveal b-haemolytic streptococci, even in the absence of signs of infection

Using systemic antibioticsReview antibiotic regimenThere is no improvement of systemic or local signs and symptoms, re-evaluate the patient and the wound;Consider microbiological analysis and changing antibiotic regimenIf the patient has an antibiotic-related adverse event; discontinue causative antibioticDiscontinue/review systemic antibioticsAt the end of the prescribed course (according to type of infection, wound type, patient comorbidities and local prescribing policy)

We cannot live without bacteria!