Wound infection clinical practice

1. Wound infectionclinical practice Dr. MarwanJabrAlwazzeh Assoc. Prof. of Medicine Consultant Internist/ Infectious Diseases University of Dammam

2. "Every operation in surgery is an experiment in bacteriology"Berkely Moynihan 1920

3. DEFINITIONS • Contamination: the bacteria do not increase in number or cause clinical problems • Colonization: the bacteria multiply, but wound tissues are not damaged • Infection: • Local infection: the bacteria multiply, healing is disrupted and wound tissues are damaged • Spreading infection: the bacteria produce problems nearby • Systemic infection.

4. DEFINITIONS *Localized infection may or may not be accompanied by the classical signs and symptoms of inflammation.

5. DEFINITIONS Systemic Inflammatory Response Syndrome • Tow or more of the following: • Temperature ≥38 °C or ≤36 °C • Heart rate ≥90 beats/min • Respirations ≥20/min or arterial Carbone dioxide tension (PaCO2) < 32 mm Hg • White blood cell count ≥12,000/mm3 or ≤4000/mm3 or >10% immature [band] forms

6. DEFINITIONS

8. Host factors • Diabetes mellitus • Hypoxemia • Hypothermia • Leukopenia • Nicotine (tobacco smoking) • Immunosuppression • Malnutrition • Poor skin hygiene • Obesity • Steroid use • Hospital stay

9. Classification of surgical wounds

10. Surgical wounds

11. Surgical site infections (SSIs)

12. SYMPTOMS AND SIGNS ACUTE WOUNDS Localized infection Spreading infection • Classical findings: • new or increasing pain • Erythema • local warmth • Swelling • purulent discharge • Delayed healing • Abscess • Malodour As for localized infection PLUS: • extension of erythema • Lymphangitis • Crepitus in soft tissues • Wound breakdown/dehiscence

13. Postoperative fever5 Ws • Wind (atelectasis/pneumonia) • Water (UTI) • Walk (DVT-PA) • Wound (infection) • Wonder (drug reaction)

14. SYMPTOMS AND SIGNS CHRONIC WOUNDS Localized infection Spreading infection • New, increased or altered pain • Delayed healing • Periwoundoedema • Bleeding or easily damaged granulation tissue • Distinctive malodour or change in odour • Wound bed discoloration • Increased or altered/purulent exudate • Induration • Pocketing • Bridging As for localized infection PLUS: • Wound breakdown • Erythema extending from wound edge • Crepitus, warmth, induration or discoloration • spreading into periwound area • Lymphangitis • Malaise or other non-specific deterioration in patient’s general condition

15. Localized infection-Bridging

16. INVESTIGATIONS • 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

17. INVESTIGATIONS • 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 concern

18. EFFECTIVE MANAGEMENT OF WOUND INFECTIONGENERAL MEASURES • Manage any systemic symptoms, such as • pain • Pyrexia • Provide patient and carer education • Optimize patient cooperation with management plan • Ensure psychosocial support

19. EFFECTIVE MANAGEMENT OF WOUND INFECTION OPTIMIZE HOST RESPONSE • Optimize management of comorbidities (optimize glycaemic control in diabetic patients, enhance tissue perfusion/oxygenation) • Minimize or eliminate risk factors for infection where feasible • Optimize nutritional status and hydration • Seek and treat other sites of infection (urinary tract infection)

20. EFFECTIVE MANAGEMENT OF WOUND INFECTIONREDUCE BACTERIAL LOAD • Prevent further wound contamination or crosscontamination • Facilitate wound drainage as appropriate • Optimize wound bed (debridement, increase frequency of dressing change as appropriate, cleanse wound at each dressing change, manage excess exudate, manage malodour) • topical antiseptic • Antimicrobial therapy /systemic antibiotic(s)

21. EFFECTIVE MANAGEMENT OF WOUND INFECTION • The 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.

22. Antiseptics

23. Using of topical antibiotics • The 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.

24. Using of systemic antibiotics • Indications for systemic antibiotics • Prophylaxis where risk of wound infection is high (e.g. contaminated colonic surgery or ‘dirty’ traumatic wounds) • Spreading or systemic wound infection • When culture results reveal b-haemolytic streptococci, even in the absence of signs of infection

25. Using systemic antibiotics • Review antibiotic regimen • There is no improvement of systemic or local signs and symptoms, re-evaluate the patient and the wound; • Consider microbiological analysis and changing antibiotic regimen • If the patient has an antibiotic-related adverse event; discontinue causative antibiotic • Discontinue/review systemic antibiotics • At the end of the prescribed course (according to type of infection, wound type, patient comorbidities and local prescribing policy)

27. We cannot live without bacteria!