Criteria for Identifying Wound Infection — Revisited

Keith F. Cutting, MN, RN, Cert Ed; and Richard J. White, PhD

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.”


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