Post on 11-Oct-2020
Infection/Wound & Dressings
Wendy McInnes ; Vascular Nurse Practitioner
The Lyell McEwin Hospital, Adelaide, South Australia
wendy.mcinnes@sa,gov.au 0447 051 036
WIFi – Foot Infection
Clinical Manifestation of Infection PEDIS Grade
Infection Severity
No local or systemic signs of infection 0 Uninfected
Infection present, as defined by the
presence of at least 2 of the following:
• Local swelling or induration
• Erythema > 0.5 to < 2 cm around the ulcer
• Local tenderness or pain
• Local warmth or purulent discharge (thick, opaque to white or sanguineous secretion)
1 Mild
Infection involving structures deeper than
skin and subcutaneous tissues (e.g. bone,
joint, tendon, muscle) or erythema > 2 cm
around ulcer margin and NO altered infection parameters (see below)
2 Moderate
Evidence of local infection with 2 or more of
the following altered parameters:
• Temperature >38° or <36°C
• Heart Rate >90 beats/min
• Respiratory rate >20 breaths/min or PaCO2
<32 mmHg • White cell count < 4 or > 12 x 109/L
3 Severe
Foot Infection: IDSA/PEDIS System of Infection Severity
Infection Local swelling or Induration
Purulent discharge
Odour
Friable tissue – bleeds easily
Abscess formation
Delayed Healing
Infection
Don’t always show signs of infection
Infection
Investigations Complete blood counts, HbA1c, liver function, serum creatinine
C-reactive protein, erythrocyte sedimentation rate (ESR) (markedly high markers are suggestive of osteomyelitis)
X ray for all patients with suspected non superficial Diabetic foot infection; particularly if ulcer present for over 2 weeks (assess deformity, bone destruction, soft tissue gas and foreign bodies)
MRI if abscess, OM or Charcot is suspected especially if ulcer is chronic, deep or overlying bony prominence
Bone scan or labelled white cell scan – if MRI is contraindicated/not possible
ABI/ Toe pressures
CT angiogram or MR angiogram – consider when ulcer doesn’t heal in 6 weeks despite optimal management OR urgent imaging and revascularisation if ankle pressure , 50 mmHg/ABI <0.5 Toe pressure <30mmHg
Deep tissue histology and microscopy, culture and sensitivities – punch biopsy or curette after cleaning/debridement – aspirate purelent secretions with sterile needle/syringe
Do not obtain repeat cultures unless evaluating non response or for infection control surveillance
Considerations
– Sepsis
– Perfusion
– Functionality / offloading
– Bone Involvement
– Age/Lifestyle
– Co-morbidities/ Risk factors
Infection
Infection – delayed closure
Infection Impiric Antibiotic Therapy – according to severity of infection (CALHN)
Likely pathogens - Methicillin sensitive Staphylococcus aureus & Beta-haemolytic streptococci
High Risk MRSA – add vancomycin
and seek ID advice
High Risk Psueodomonas spp.
Replace IV amoxicillin/clavulanic acid with
Piperacillin/tazobactam 4.5g IV 6hrly
Central Adelaide Local Health Network : Infectious Diseases 2017
Diabetic Foot Infection Assessment, Management & Treatment Guideline
Severity of Infection
(refer to Appendix
1
Table 3) for
classification
No Penicillin or Cephalosporin
Allergy
Penicillin Allergy (Delayed rash
which is NOT urticarial or
DRESS/SJS/TEN)
High Risk Penicillin / Cephalosporin
allergy (e.g. anaphylaxis, urticaria,
bronchospasm, angioedema,
DRESS/SJS/TEN)
For antibiotic allergies not listed above, consult ID for advice
Ulceration
(no infection) Antibiotics not recommended
Mild Infection Dicloxacillin 1 gram
PO QID*
If patient has received
antibiotic therapy in the past
month instead give
Amoxicillin/ Clavulanate
875/125mg PO BD* (for additional
Gram negative & anaerobic cover)
Cefalexin 1 gram PO QID*
Clindamycin 450 mg PO TDS
Moderate Infection
(if patient has
received antibiotic
therapy in past
month – treat as for
severe infection
below)
Flucloxacillin 2 gram IV
6-hourly*
PLUS
Metronidazole 400 mg
PO BD
Followed by:
Dicloxacillin 500mg
PO QID*
PLUS
Metronidazole 400 mg PO BD
Cefazolin
2 gram IV 8-hourly*
PLUS
Metronidazole
400 mg PO BD
Followed by:
Cefalexin 500mg PO QID*
PLUS
Metronidazole 400 mg PO BD
Clindamycin 450 mg PO TDS
Severe Infection
Amoxicillin / Clavulanic acid
1.2 g IV 8-hourly*♠
Cefepime 2 gram IV
8-hourly*#
PLUS Metronidazole 400mg PO BD
Clindamycin 900 mg IV
8-hourly (slow infusion)
PLUS
Ciprofloxacin*# 400mg IV
12-hourly OR Ciprofloxacin*# 750 mg PO BD
Once systemically improved, switch to oral therapy according sensitivity results (seek advice from ID)
Infection
Antimicrobial Stewardship
Oral antibiotics
IV antibiotics
May require long term antibiotics
PICC /24 hr infusion
Antimicrobials
Wound Ulcer Classifications Wagner
– ulcer depth, gangrene, loss of perfusion
– 6 grades
– does not take into account infection& ischaemia
University of Texas
– Two part score, grade & stage
WIFi –
– Wound, Ischaemia, Foot infection
World Union of Wound Healing Societies 2016 “Local Management of Diabetic Foot Ulcers – A position Document” Wounds International
WIFi – Wound Grading Classification
Grade Ulcer Gangrene
0 None No
1 - Small shallow ulcer, no bone exposure
unless limited to distal phalanx
- Minor tissue loss, salvageable with 1-2 digital amputations
No
2 - Deeper with bone exposure not
involving heel /shallow heel ulcer,
without calcaneal involvement
- Major tissue loss, salvageable with > 3 digital amputations/standard TMA
Digits only
3 - Extensive deep ulcer involving forefoot
and/or midfoot/ deep full thickness
heel +/- calcaneal involvement
- Extensive tissue loss, salvageable only
with complex foot reconstruction/non-
traditional proximal TMA/flap coverage
or complex wound management needed for soft tissue defect
Extensive/Heal
Wound Grading Classification
*TMA, Trans-metatarsal amputation
The Wound T: tissue viability Location
I: infection / inflammation Pain
M: moisture imbalance Odour
E: edge of wound Education
Debridement
Reduce Bioburden and biofilm reformation
Reduce Callous
PERFUSION ? Promote eschar
IS IT SAFE????
Wound Management Moisture Balance
Low Exudate
May require increased moisture if perfusion ok
May require slough removal
Consider gel (PHMB/ Superoxidized )
High exudate
Slough & high levels of exudate
Maceration
Excoriation
Wound Management
Dry Necrotic Tissue
Keep Dry – can paint with betadine
Prevent Infection (always cover even in shower)
Low adherent dressing or gauze between toes
Keep covered so as not to induce infection – demarcated areas can allow bacteria in
Oedema Management
Risk of skin damage from adhesives
Venous insufficiency, cardiac, renal issues
Consider compression if perfusion intact
Cleansing Normal saline or sterile water
Antiseptic Solutions
– Povidone Iodine (promotes eschar – dry gangrene)
– PHMB (surfactant lifts debri)
– Super-oxidised solutions – (disrupts biofim & planktonic bacteria)
International Wound Infection Institute 2016 “Wound Infection in Clinical Practice International consensus update 2016
Note – antimicrobial effect on biofilm increases with exposure time – washes/soaks for smaller time periods may not see the same effects as studies reporting 24 hour exposure time
Edwards-Jones, V 2017 “Wound Biofilms: What makes them stick? Wound Essentials, Vol 12, No.1
Bjarnsholt T, Eberlein T, Malone M, &Schultz G 2017 Management of Biofilm Made Easy” Wounds International, May 2017
Wound Management
NO EVIDENCE
Absorb excess exudate
Maintain moist environment
Protect surrounding skin
Barrier to bacterial contamination
Cost effective
Not require frequent changes
Gas and water vapour permeable – no films
Comfortable
Not too bulky – added pressure - footwear
Dry Moist Exuding Heavily Exuding
Hydrogels Films Foams/Absorbent pads Extra Absorbent Pads
Gel sheets Hydrocolloids Absorbent Films Hydrofibre
Non adherent nets/dressings Alginates Negative Pressure
Wound
Hydration/
Debridement
Moisture
Retentive
Exudate
Management
Infected
Heavily Colonised Antimicrobials
Silver
Iodine based dressings
Disinfectant Solutions/Gels
Never debride legs
or feet if decreased
blood supply
Protect the Skin Odour
Control Offload Pressure
First Aid Kit
Povidone Iodine
– Betadine (promote gangrene)
– Inadine (decrease bacterial load)
Gel - consider PHMB or Super-oxidized Solution
Absorbent – reflect exudate level
– Foam – expensive option
– Absorbent pads (cheap option) – some better than others
– Calcium Alginates (stop bleeding)
– Fibre dressings (+/- silver)
Non adherent contact layers (some much more expensive than others
Primary/secondary dressing (not films)
Tubular compression – oedema reduction if perfusion ok