Criteria for Identifying Wound Infection — Revisited
- 0 Comments
- 22288 reads
This article first appeared in the British Journal of Community Nursing. 2004;9(3 Suppl);S6–S16.
T he accurate identification of wound infection is a challenge for any clinician involved in this area of care and can have a significant impact on patient morbidity. The more obvious infection signs, such as purulent discharge and spreading erythema, are generally recognized as diagnostic. However, these features are not always present in the early stages when diagnosis is important for treatment and the avoidance of complicating sequelae.
A number of subtle signs (clinical indicators) that herald the onset of infection have been proposed. Following a review of the available literature, Cutting and Harding1 attempted to collate the indicators of infection. The aim was to include all clinical indicators of acute and chronic wound infection that had been used by colleagues in the field and had been shown to be of value, either by being generated through research or through empirical findings. These collated criteria appear to have gained acceptance not only in the UK but also elsewhere.
In addition to the use of clinical criteria to assist in the identification of wound infection, strong opinion exists that quantitative bacteriology is of significance.2-4 However, reliance on this approach has been challenged by Bowler,5 who maintains that the types of organisms, their interactions with not only each other but with the wound environment, and the local conditions are relevant factors for consideration together with host resistance.
Cutting and Harding1 brought to the attention of many clinicians subtle criteria (see Table 1) that may not have previously been considered. For an explanation, the reader is referred to the original paper. These criteria provide a reminder or checklist and it is likely that many clinicians have put the criteria to the test in their own clinical practices. For any clinical tool to be of proven value it needs to be tested and there have been two validation studies challenging the 1994 criteria; these are Cutting6 and Gardner et al.7
Cutting6 tested the criteria by asking ward nurses to view patients’ wounds and to make a decision on the infection status of the wound by using their own criteria. These decisions were then compared with the researcher’s verdict, using the 1994 criteria, and a microbial assay of the wound taken via wound swab. A consultant microbiologist also took decisions on the infection status of the wound from results of the cultures. A total of 20 nurses took part in the study. Two nurses at a time viewed four wounds, so a total of 40 different patients’ wounds were seen which allowed 80 opportunities for separate decisions to be made. Although the types of wounds included in the study were not made explicit in the publication, all of the wounds were healing by secondary intention and did not include burns or leg ulcers. The findings in this study indicated that the criteria have a high degree of validity. Thirty-nine of the 40 decisions (97.5%) made by the researcher on the infected status of the wounds were corroborated by the wound swab culture.
Gardner et al7 examined the validity of the classic signs of infection (pain, erythema, edema, heat and purulence) and “… signs specific to secondary intention wounds (ie, serous exudate, delayed healing, discoloration of granulation tissue, friable granulation tissue, pocketing at the base of the wound, foul odor, and wound breakdown).” The wound types against which the criteria were tested were described in the study as “a mix of chronic wounds,” and subjects were enrolled who had a “nonarterial chronic wound.” These types of wounds are defined as “… wounds caused by prolonged pressure, venous insufficiency, peripheral neuropathy, surgical incision (healing by secondary intention) or trauma.”
1. Cutting KF, Harding KG. Criteria for identifying wound infection. J Wound Care. 1994;3(4):198–201.
2. Robson MC, Lea CE, Dalton JB, Heggers JP. Quantitative bacteriology and delayed wound closure. Surg Forum. 1968;19:501–502.
3. Robson MC, Heggers JP. Bacterial quantification of open wounds. Military Medicine. 1969;134:19–24.
4. Robson MC, Heggers JP. Delayed wound closure based on bacterial counts. J Surg Oncol. 1970;2:379–383.
5. Bowler PG. The 105 bacterial growth guideline: reassessing its clinical relevance in wound healing. Ostomy Wound Manage. 2003;49(1):44–53.
6. Cutting KF. The identification of infection in granulating wounds by registered nurses. J Clin Nurs. 1998;7(6):539–546.
7. Gardner SE, Frantz RA, Doebbeling BN. The validity of the clinical signs and symptoms used to identify localized chronic wound infection. Wound Repair Regen. 2001;9(3):78–186.
8. Marks J, Harding KG, Hughes LE, Ribeiro CD. Pilonidal sinus excision - healing by open granulation. Br J Surgery. 1985;72:637–640.
9. Leaper DJ. Defining infection: Editorial. J Wound Care. 1998;7(8):373.
10. Boulton AJM, Bowker JH. (1985) The diabetic foot. In: Olefsky JM, Serwin R, eds. Diabetes Mellitus: Management and Complications. New York, NY: Churchill Livingstone;1985.
11. Armstrong DG, Lavery LA, Saraya M, Ashry H. Leukocytosis is a poor indicator of acute osteomyelitis of the foot in diabetes mellitus. J Foot Ankle Surgery. 1996;35(4):280–283.
12. International Working Group on the Diabetic Foot. International Diabetes Federation, Amsterdam, Netherlands;2003.
13. Armstrong D G, Lipsky BA. Diabetic foot infections: stepwise medical and surgical management. Int Wound J. 2004;1:2:123–132.
14. Heggers JP. Defining infection in chronic wounds: does it matter? J Wound Care. 1998;7(8):389–392.
15. Cooper RA. The contribution of microbial virulence to wound infection. In: White RJ, ed. The Silver Book. Dinton, Salisbury, UK: Quay Books;2003.
16. Bowler PG, Davies BJ, Jones SA. Microbial involvement in chronic wound malodour. J Wound Care. 1999;8(5):216–218.
17. Bliss M. Aetiology of pressure sores. Reviews in Clinical Gerontology. 1993;3:379–397.
18. Sibbald RG, Orsted H, Schultz GS, Coutts P, Keast D. Preparing the wound bed 2003: focus on infection and inflammation. Ostomy Wound Manage. 2003;49(11):24–51.
19. Reddy M, Keast D, Fowler E, Sibbald GS. Pain in pressure ulcers. Ostomy Wound Manage. 2003;49(4 Suppl):S30–S35.
20. Ayliff GAJ, Brightwell KM, Collins BJ, et al. Surveys of hospital infection in the Birmingham region. J Hygiene (Cambridge). 1977;79:299–314.
21. Vowden P, Vowden K. Investigations in the management of lower limb ulceration. Trends in Wound Care. Dinton, Wilts: Quay Books;2002:55–65.
22. Edmonds ME, Foster AVM. Managing the Diabetic Foot. Oxford, UK: Blackwell Science Ltd;2000.
23. Lamke LO, Nilsson CE. The evaporative water loss from burns and water vapour permeability of grafts and artificial membranes used in treatment of burns. Burns. 1997;3:159–165.
24. Davis E. Education, microbiology and chronic wounds. J Wound Care. 1998;7(6):272–274.
25. Sibbald RG, Williamson D, Orsted HL et al. Preparing the wound bed: debridement, bacterial balance and moisture balance. Ostomy Wound Manage. 2000;46(11):14–35.
26. Kingsley A. A proactive approach to wound infection. Nurs Stand. 2001;15(30):50–58.
27. White RJ. The wound infection continuum. In: White RJ, ed. Trends in Wound Care. Vol 2. Dinton, Salisbury, UK: Quay Books;2003.
28. Fumal I, Braham C, Paquet P, Pierard-Franchimont C, Pierard GE. The beneficial toxicity paradox of antimicrobials in leg ulcer healing impaired by a polymicrobial flora: a proof-of-concept study. Dermatology. 2002;204(Suppl 1):70–74.
29. Wall IB, Davies CE, Hill KE et al. Potential role of anaerobic cocci in impaired human wound healing. Wound Rep Regen. 2002;10(6):346–353.
30. Stephens, P, Wall IB, Wilson MJ. Cutaneous biology: anaerobic cocci populating the deep tissues of chronic wounds impair cellular wound healing responses in vitro. Br J Dermatol. 2003;148:456–466.
31. Edwards R, Harding KG. Bacteria and wound healing. Current Opinion Infect Dis. 2004;17:2:91–96.
32. Cutting KF. Wound healing, bacteria and topical therapies. EWMA Journal. 2003;3(1):17–19.
33. Wilson AP, Weavill C, Burridge J, Kelsey MC. The use of the wound scoring method 'ASEPSIS' in postoperative wound surveillance. J Hosp Infect. 1990;16(4):297–309.
34. Schultz G S, Sibbald R G, Falanga V, et al. Wound bed preparation: a systematic approach to management. Wound Rep Regen. 2003;11(2 suppl):S1–S28.
35. Jones J, Hunter D. Consensus methods for medical and health services research. Brit Med J. 1995;311(7001):376–380.