Infection and Bioburden in the Chronic Wound


These are notes from an inservice

  • 60% of infected wounds create a biofilm
  • Microbial flora of normal skin
    • Gram+ propionibacterium and corynebacterium
      • 28-51%
    • Gram- Betaproteobacteria
      • 19-40%
    • Gram+ cocci, staphylococcus and streptococcus
      • 12-24%
    • Anaerobes Bacteroides and prevotella
      • 2-14%
    • Pseudomonas and staphylococcus are potentially pathogenic
  • Delaying healing due to infection influenced by
    • host resistance
    • # organisms
    • type of organism
  • contamination
    • no tissue damage
    • no infection
    • no change with healing
  • colonization
    • multiplying
    • no tissue damage
    • no change with healing
  • localized infection
    • intervention
    • tissue damage
    • healing impaired
  • spreading infection
    • intervention
  • systemic infection
    • intervention
    • host compromise
  • increased risk
    • comorbidities
    • meds
    • psychosocial factors
    • large and deep
    • necrotic tissue
    • foreign body
    • prolonged duration
    • location
  • 75% chronic wounds have 1 of:
    • staphylococcus
    • corynebacterium
    • clostridiales
    • pseudomonas
  • biofilms present in 60% of chronic wounds
    • carbohydrate matrix
    • shields the microbe
    • prolongs inflammation
    • impairs granulation
    • impairs epithelialization
    • 24-48 hours to develop
    • sign and symptoms
      • erythema
      • pain
      • swelling
      • local heat
      • classics may not be present in chronic wounds
  • localized infection signs and symptoms
    • highly indicative
      • new, increased or altered pain
      • delayed healing
    • highly likely if 2 or more present
      • periwound edema
      • bleeding
      • friable granulation tissue
      • malodor
      • wound bed discoloration
      • increased or altered exudate
      • induration
      • pocketing
      • bridging
  • spreading infection signs and symptoms
    • new, increased or altered pain
    • delayed healing
    • highly likely if 2 or more present along with the localized signs and symptoms
      • erythema extended past wound edge
      • crepitus
      • warmth
      • induration
      • discolored periwound
      • lymphangitis
      • malaise
  • sepsis signs and symptoms
    • fever or decreased temp
    • increased pulse
    • increased respirations
    • WBC increase or decrease
    • severe = multi organ dysfunction
    • septic shock = low BP despite volume resuscitation
  • criteria for diagnosis in specific wounds
    • pressure ulcers
      • cellulitis
      • crepitus
    • venous leg
      • cellulitis
      • increased localized temp
    • arterial leg
      • cellulitis
      • pus
      • abscess
      • dry necrosis turning wet
    • diabetic foot
      • cellulitis
      • lymphangitis
      • purulent
      • abscess
      • phlegmon (diffuse spreading infection)
  • colonization
    • NERDS
      • nonhealing
      • exudate
      • red
      • debris
      • smell
  • infection
    • STONEES
      • size
      • temp
      • OS
      • new
      • edema
      • exudate
      • smell
  • any 3 of NERDS = topical treatment
  • any 3 of STONEES = systemic treatment
  • visual of biofilm
    • shiny, translucent, slimy
    • opaque, loosely attached patch
    • viscus, slimey or gel-like
    • bright green or pale yellow
    • removes easily and quickly reforms
  • 10 indicators of biofilms without visual symptoms
    • excessively moist
    • poor granulation
    • recurrent infection despite antibiotic treatment
    • negative culture despite signs and symptoms of infection
    • delayed wound healing despite addressing underlying comorbidities
  • wound culture if
    • signs and symptoms of spreading or systemic
    • not responding to antibiotic treament
  • can also check via aspiration or biopsy
  • wound swabbing
    • levine
      • cleanse with normal saline
      • blot dry
      • rotate swab
      • don’t swab eschar, pus or exudate
    • Z
      • cleanse with normal saline
      • blot dry
      • swab in zig zag fashion wound edge to wound edge with 10 points
  • consider diagnosis of pressure ulcer if
    • microbes greater then 105
    • + hemplytic streptococci
  • # types of microbes greater factor for not healing
  • treatment focus on
    • optimal host response
    • decrease microbe load
  • debridement
    • autolytic
    • enzymatic
    • mechanical
    • surgical or sharp
    • biologic
    • for diabetic, venous, arterial or pressure ucler
  • removal of biofilm essential
    • showering better then foot baths
    • irigation preferred
  • 4 main classes of antimicrobial dressings
    • silver alginate, hydrofibers, hydrogels
    • iodine impregnated
    • polyhexamethyl biguanide (PHMB)
    • honey
  • silver
    • strong
      • gram +/-
    • weak
      • fungi
      • virus
    • superficial or deep
    • increases healing
    • decreases odor
    • decreases pain
    • decreases exudate
    • risk
      • cytotoxic
      • can stain skin
    • management of biofilms
  • iodine
    • strong
      • gram +/-
      • fungi
      • endospore
    • moderate
      • virus
    • disadvantages
      • pain
      • sensitive skin
      • altered thyriod function
    • manages biofilms
  • PHMB
    • act by exudate
    • for small to moderate exudate
  • honey
    • antimicrobial
    • antiinflammitory
    • debridement
    • decreases odor
    • promotes moist enivronemnt
    • strong
      • gram+/-
      • fungi
    • low
      • virus
    • do not use if
      • allergic to bee stings
      • heavy bleeding
      • 3rd degree burns
    • monitor with diabetic patients
  • treatment critical colonization 2-4 weeks
  • eval every 1-2 weeks
  • discontinue treatment if resolved or not improving
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About piggie4299

I am Myself I am a Wife Blessed with love I am a Mother Endowed with divinity Through the power of creation I am a Daughter Brought into this world With unending hope And the promise of the future I am a Sister Made fierce and strong While forged with kindness Protector and protected Spiraling together forever I am a Nurse Holding out the hands of healing And offering the sick comfort And the dying love Knowing that through this All things are healed and made whole I am a Writer Creating myself and world Sharing the inner depths of humanity Bringing together the divine And the humble mortal I tell the story of the Goddess And am remembered forever

Posted on October 8, 2015, in Medical and tagged , , , , . Bookmark the permalink. Leave a comment.

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