Patient-Centered Approaches to Managing Wound Infection · PDF fileMs. Oliver, Mr. Robbin, Mr....
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Patient-Centered Approaches to Managing Wound Infection Grand Rounds Sponsored by North American Center for Continuing Medical Education, LLC, An HMP Communications Holdings Company Supported by an educational grant from KCI
Transcript of Patient-Centered Approaches to Managing Wound Infection · PDF fileMs. Oliver, Mr. Robbin, Mr....
Patient-Centered Approaches to Managing Wound Infection
Grand Rounds
Sponsored by North American Center for Continuing Medical Education, LLC, An HMP Communications Holdings Company
Supported by an educational grant from KCI
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To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Patient-Centered Approaches to Managing Wound Infection
Faculty
John C. Lantis, MD, FACSVice Chairman, Department of Surgery
Chief, Vascular and Endovascular SurgeryDirector, Surgical Clinical Research
St. Luke’s-Roosevelt HospitalProfessor of Clinical Surgery, Columbia University
New York, New York
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Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Intended LearnersTh is course is designed for surgeons, physicians, and allied health personnel who manage patients with wounds.
Learning ObjectivesAft er completing this activity, participants should be able to:
• Discuss the impact of biofi lms and bacteria on wound healing
• Review the current wound treatment practice for infected wounds
• Recognize the impact of diff erent topical wound treatment solutions on the infected wound
• Focus on the needs of the patient vs the needs of the healthcare provider
Activity OverviewTo be eligible for credit, participants must attend the full activity and complete the evaluation following the educational session. Participants who com-plete the evaluation online at www.naccme.com will immediately receive documentation of credit. Participants who submit a hard copy evaluation will receive documentation of credit within 8 weeks.
Th ere is no fee associated with this activity.
For questions regarding this activity, please call 609-371-1137.
Hardware/Software RequirementsTh e evaluation is accessible aft er the activity via a PC (Windows 2000/XP/Vista/7) or Mac (Mac OS 10.x or later) computer with current versions of the following browsers: Internet Explorer, Mozilla Firefox, Google Chrome, or Safari. A PDF reader is required for print publications. Please direct techni-cal questions to [email protected].
AccreditationIn support of improving patient care, North American Center for Continuing Medical Education, LLC (NACCME) is accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Creden-tialing Center (ANCC) to provide continuing education for the healthcare team.
CMENACCME designates this live activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity
Th e National Commission on Certifi cation of Physician Assistants accepts AMA PRA Category 1 Credit™ from organizations accredited by the ACCME.
CNETh is continuing nursing education activity awards 1.0 contact hour.
Provider approved by the California Board of Registered Nursing, Provider #13255 for 1.0 contact hour.
Nurse practitioners participating in this educational activity will earn an AMA PRA Category 1 Credit™ certifi cate of completion or ANCC contact hours through AANP’s reciprocity agreements.
CPMENorth American Center for Continuing Medical Education, LLC (NACCME) is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
Th is program is approved for 1.0 continuing education contact hour or 0.1 CEU.
Independent clinical reviewer: Alan Dardik, MD, PhD, Associate Professor, Yale University School of Medicine, Chief, Vascular Surgery, VA Con-necticut Healthcare Systems, West Haven, Connecticut
Nurse planner: Susie Seaman, NP, Sharp Rees-Stealy Wound Clinic, San Diego, California
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Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Planning CommitteeTh e planning committee comprises Alan Dardik, MD, PhD, John C. Lantis, MD, FACS, Susie Seaman, NP; and Tiff ney Oliver, Randy Robbin, John Savage, Jessica Steuerman, NACCME.
Financial Disclosures and Confl icts of InterestAccording to the disclosure policy of NACCME, faculty, editors, managers, and other individuals who are in a position to control content are required to disclose any relevant fi nancial relationships with relevant commercial companies related to this activity. All relevant confl icts of interest that are identi-fi ed are reviewed for potential confl icts of interest. If a confl ict is identifi ed, it is the responsibility of NACCME to initiate a mechanism to resolve the confl ict(s). Th e existence of these interests or relationships is not viewed as implying bias or decreasing the value of the presentation.
All educational materials are reviewed for fair balance, scientifi c objectivity of studies reported, and levels of evidence.
Th e faculty has reported the following:
Dr. Lantis: Consultant—KCI, Smith & Nephew; Principle investigator—Smith & Nephew
Ms. Seaman: Consultant—Healthpoint Biotherapeutics; Scientifi c advisor—Molnlycke Health Care
Dr. Dardik disclosed no relevant fi nancial relationships with any commercial interests.
Ms. Oliver, Mr. Robbin, Mr. Savage, and Ms. Steuerman have disclosed no relevant fi nancial relationships with any commercial interests.
NACCME requires faculty to inform participants whenever off -label/unapproved uses of drugs and/or devices are discussed in their presentations.
Th e faculty has disclosed that no off -label/unapproved uses of drugs and/or devices will be discussed.
ADA StatementNorth American Center for Continuing Medical Education complies with the legal requirements of the Americans with Disabilities Act and the rules and regulations thereof. If any participant in this educational activity is in need of accommodations, please call 609-371-1137.
Privacy Policy NACCME protects the privacy of personal and other information regarding participants, educational partners, and joint sponsors. NACCME and our joint sponsors will not release personally identifi able information to a third party without the individual’s consent, except such information as is required for reporting purposes to the appropriate accrediting agency.
NACCME maintains physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal informa-tion.
Copyright © 2013 by North American Center for Continuing Medical Education, LLC. All rights reserved. No part of this accredited continuing educa-tion activity may be reproduced or transmitted in any form or by any means, electronic or mechanical, without fi rst obtaining permission from North American Center for Continuing Medical Education. Th e opinions expressed in this educational activity are those of the faculty and are not attributable to NACCME. Clinical judgment must guide each professional in weighing the benefi ts of treatment against the risk of toxicity. Dosages, indications, and methods of use for products referred to in this activity are not necessarily the same as indicated in the package insert for each product, may refl ect the clinical experience of the presenters, and may be derived from the professional literature or other clinical sources. Consult complete prescribing information before administering.
Grant Support
Supported by an educational grant from KCI
Patient-Centered Approaches to
Managing Wound Infection
Sponsored by North American Center for Continuing Medical Education, LLC, An HMP Communications Holdings Company
Supported by an educational grant from KCI
Course Chair
John C. Lantis, II, MDVice Chairman, Department of SurgeryChief of Vascular/Endovascular Surgery
St. Luke’s – Roosevelt HospitalClinical Professor of Surgery
Columbia UniversityNew York, New York
Learning Objectives
• Discuss the impact of biofilms and bacteria on wound healing
• Review the current wound treatment practice for infected wounds
• Recognize the impact of different topical wound treatment solutions on the infected wound
• Focus on the needs of the patient vs the needs of the healthcare provider
The Impact of Biofilms and Bacteriaon Wound Healing
Chronic vs Acute Wounds
• A chronic, nonhealing wound has been defined as a wound that fails to proceed through the orderly and timely series of events required to produce a durable structural, functional, and cosmetically acceptable closure
Lazarus GS, et al. Arch Dermatol. 1994;130(4):489-493.
Wound Etiology
• Mechanical/surgical
• Arterial
• Venous
• Neuropathic
• Malignancy
• Vasculitic
• Pressure
• Other
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Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
The Impact of Biofilms and Bacteriaon Wound Healing
Chronic vs Acute Wounds
• A chronic, nonhealing wound has been defined as a wound that fails to proceed through the orderly and timely series of events required to produce a durable structural, functional, and cosmetically acceptable closure
Lazarus GS, et al. Arch Dermatol. 1994;130(4):489-493.
Wound Etiology
• Mechanical/surgical
• Arterial
• Venous
• Neuropathic
• Malignancy
• Vasculitic
• Pressure
• Other
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Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Overview of Wounds
• The lifetime risk for development of DFUs in patients with type 2 diabetes is 15% to 25%
• 1% of all people in industrialized countries suffer from a leg ulcer
• The best estimates suggest that 2.5 million pressure ulcers are treated annually among hospitalized patients
DFUs = diabetic foot ulcers. Chow I, et al. Pharmacoeconomics. 2008;26(12):1019-1035. O’Meara S, et al. Cochrane Database SystRev. 2012;14:11:CD000265. Park-Lee E, et al. Pressure ulcers among nursing home residents: United States, 2004. NCHS data brief, no 14. Hyattsville, MD: National Center for Health Statistics. 2009.
Biochemical Differences
Healing Wounds• High cell mitosis
• Low inflammatory cytokines
• Low proteases (MMPs)
• Increased growth factors
• Cells capable of rapid response
• Synergistic relationship with bacteria
Chronic Ulcers• Low cell mitosis
• High inflammatory cytokines
• High proteases (MMPs)
• Decreased response to growth factors
• Senescent cells
• Hostile relationship with bioburden
MMPs = matrix metalloproteinases.
Senescent Cells in Chronic Wounds
• Metabolically active, but nonproliferative or proliferating at greatly reduced rates
• Unresponsive or sluggishly responsive to chemical and physical stimuli
• Decreased migration rates
• Decreased production of matrix proteins and growth factors
The Items to Deal with…
• Necrotic burden– MMPs: breakdown extracellular matrix, growth factors
– Harbor resident bacteria
• Edema– Uncontrolled inflammation
• Poorly vascularized wound bed– Senescent cells that do not respond to stimuli
• Bacterial burden (bioburden)– Generate oxygen-free radicals and serine proteases
• Wound exudate– Overexpressed MMPs
Bioburden
• Critical colonization– Replicating bacteria in
the wound bed
• Infection stimulates– Prostaglandin E2 and
thromboxane
– Thrombosis and vasoconstriction
– Wound hypoxia
• Absence of classical signs of infection; bacteria that– Alter their phenotype and immune expression
– Development of “immune tolerance”
– Evade detection
Bioburden (continued)
• Not the presence of bacteria, but their interaction with the host that impairs wound healing
• Up to 30% of wounds that are critically colonized have no signs other than delayed healing
Schultz GS, et al. Wound Rep Regen. 2003;11(Suppl 1):S1-S28. Cutting KF, et al. J Wound Care. 1994;3(4):198-201. Gilchrist B. Finding bacteria in wounds: are you being misled? Presented at: European Wound Management Association Conference Proceedings, Pisa, Italy; May 22-24, 2003.
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Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
The Items to Deal with…
• Necrotic burden– MMPs: breakdown extracellular matrix, growth factors
– Harbor resident bacteria
• Edema– Uncontrolled inflammation
• Poorly vascularized wound bed– Senescent cells that do not respond to stimuli
• Bacterial burden (bioburden)– Generate oxygen-free radicals and serine proteases
• Wound exudate– Overexpressed MMPs
Bioburden
• Critical colonization– Replicating bacteria in
the wound bed
• Infection stimulates– Prostaglandin E2 and
thromboxane
– Thrombosis and vasoconstriction
– Wound hypoxia
• Absence of classical signs of infection; bacteria that– Alter their phenotype and immune expression
– Development of “immune tolerance”
– Evade detection
Bioburden (continued)
• Not the presence of bacteria, but their interaction with the host that impairs wound healing
• Up to 30% of wounds that are critically colonized have no signs other than delayed healing
Schultz GS, et al. Wound Rep Regen. 2003;11(Suppl 1):S1-S28. Cutting KF, et al. J Wound Care. 1994;3(4):198-201. Gilchrist B. Finding bacteria in wounds: are you being misled? Presented at: European Wound Management Association Conference Proceedings, Pisa, Italy; May 22-24, 2003.
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Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Bioburden (continued)
• Contamination– Presence of nonreplicating microorganisms in the wound
• Colonization– Replicating microorganisms
– Adhere to the wound surface
– Do not cause cellular damage
– Staphylococcus epidermidis, Corynebacterium
– Actually may be commensal organisms
• Critical colonization• Infection
– Replicating organisms within a wound that stimulates a host response
– Erythema, warmth, swelling, pain, and loss of function
Infection
• Replicating organisms within a wound that stimulates a host response with; erythema, warmth, swelling, pain, loss of function; ± leukocytosis
• Initiate parenteral antibiotics– Course determined by tissue infected
– Perfusion
• Ideally planktonic bacteria culture focused antibiotics OR based on known local epidemiology
• May also be influenced by “bad actors”
• Initially treat the wound bed with an antibacterial, as well
Bioburden
• Critical colonization– Clinical signs
• Delayed healing, increased pain, increased serous exudate, change in color of wound bed, abnormal odor, friable granulation tissue
– Bacterial load• 105 is not as magic as we think
• 108 bacteria have been shown in closing wounds
– Bacterial type• Beta hemolytic strep
• Synergistic combinations develop
• Resident microflora may be very hard to identify
• Biofilms: glycocalyx secreted by proliferating bacteria, protect microorganisms from antimicrobial agents
Cruse PJ, et al. Surg Clin North Am. 1980; 60(1):27-40. Cruse PJ. Classification of operations and audit of infection. In: Taylor EW, editor. Infection in Surgical Practice. Oxford: Oxford University Press, 1992;1-7. Culver DH, et al. Am J Med. 1991;91(3B):152S-157S. Ferraz EM, et al. Infect Control Hosp Epidemiol. 1992;13(8):457-462.
Bioburden (continued)
• The microorganisms in a wound change over time
– Possibly changing their virulence
– Possibly changing their phenotype
• Early– Normal skin flora
• Staphylococcus aureus, Beta hemolytic strep
• After 4 weeks– Proteus, Escherichia coli,
Klebsiella
– Anaerobic organisms may inhabit the deeper tissue
• Several months– Pseudomonas, Acinetobacter,
and Stenotrophomonas
• Organisms that should be treated no matter their density
– Beta hemolytic strep, mycobacteria, Bacillus anthracis, Yersinia pestis, Corynebacterium diphtheriae, Erysipelothrix, Leptospira, Treponema, Brucella, Histoplasma, Blastomyces, Coccidioides, Leishmaniasis
Bioburden Challenges
Planktonic Bacteria• Strain(s)• Resistance• Cross contamination• Nosocomial • Hospital-acquired infection• Host susceptibility
Biofilm• Strain(s)• Resistance• Extracellular polymeric substances
– Penetration– Disruption
• Anaerobes
Organisms that Probably Need toBe Covered No Matter What…
• Beta hemolytic strep
• Mycobacteria
• Bacillus anthracis
• Yersinia pestis
• Corynebacteriumdiphtheriae
• Erysipelothrix
• Leptospira
• Treponema
• Brucella
• Histoplasma
• Blastomyces
• Coccidioides
• Leishmaniasis
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Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Bioburden (continued)
• The microorganisms in a wound change over time
– Possibly changing their virulence
– Possibly changing their phenotype
• Early– Normal skin flora
• Staphylococcus aureus, Beta hemolytic strep
• After 4 weeks– Proteus, Escherichia coli,
Klebsiella
– Anaerobic organisms may inhabit the deeper tissue
• Several months– Pseudomonas, Acinetobacter,
and Stenotrophomonas
• Organisms that should be treated no matter their density
– Beta hemolytic strep, mycobacteria, Bacillus anthracis, Yersinia pestis, Corynebacterium diphtheriae, Erysipelothrix, Leptospira, Treponema, Brucella, Histoplasma, Blastomyces, Coccidioides, Leishmaniasis
Bioburden Challenges
Planktonic Bacteria• Strain(s)• Resistance• Cross contamination• Nosocomial • Hospital-acquired infection• Host susceptibility
Biofilm• Strain(s)• Resistance• Extracellular polymeric substances
– Penetration– Disruption
• Anaerobes
Organisms that Probably Need toBe Covered No Matter What…
• Beta hemolytic strep
• Mycobacteria
• Bacillus anthracis
• Yersinia pestis
• Corynebacteriumdiphtheriae
• Erysipelothrix
• Leptospira
• Treponema
• Brucella
• Histoplasma
• Blastomyces
• Coccidioides
• Leishmaniasis
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Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Current Treatment Best Practicesfor Infected Wounds
To Put the Patient First…
• Efficacy
• Availability/affordability
• Concordance/compliance
• Must follow the WUWHS’ consensus guidelines– Must address/take into consideration WRP
WUWHS = World Union of Wound Healing Societies; WRP = wound-related pain.WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.
WUWHS Guidelines
• Identify and treat the cause of the chronic wound and address concerns expressed by the patient, including a pain assessment at each visit
• Evaluate and document pain intensity and characteristics on a regular basis (before, during, and after dressing-related procedures)
• Cleanse wound gently, avoid the use of abrasive wipes and cold solutions
• Select an appropriate method of wound debridement and include the potential for causing WRP
• Choose dressings that minimize trauma/pain during application and removal
WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.
WUWHS Guidelines (continued)
• Treat infections that may cause WRP and inhibit healing
• Treat local factors that may induce WRP (eg, inflammation, trauma, pressure, maceration)
• Select an appropriate dressing to minimize WRP based on wear time, moisture balance, healing potential, and periwoundmaceration
• Evaluate each patient’s need for pharmacologic (eg, topical/systemic agents) and nonpharmacologic strategies to minimize WRP
• Involve and empower patients to optimize pain management
• Healthcare providers should ensure WRP control for every patient
WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.
Local Infection Critical Colonization, Increased Bacterial Burden,
Covert Infection
NERDS
• Nonhealing
• Exudate (increased)
• Red friable granulation tissue
• Debris
• Smell
WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.
May be painful
NERDS
• Nonhealing
• Exudate (increased)
• Red friable granulation tissue
• Debris
• Smell
Deep and Surrounding Skin Infection
STONEES• Size increasing
• Temperature increased (surrounding skin)
• Os (probes or exposed bone)
• New areas of breakdown
• Erythema and/or edema
• Exudate (increased)
• SmellWUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.
Increased painmost reliable symptom and
may be clinically more usefulthan any one individual sign
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Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
WUWHS Guidelines (continued)
• Treat infections that may cause WRP and inhibit healing
• Treat local factors that may induce WRP (eg, inflammation, trauma, pressure, maceration)
• Select an appropriate dressing to minimize WRP based on wear time, moisture balance, healing potential, and periwoundmaceration
• Evaluate each patient’s need for pharmacologic (eg, topical/systemic agents) and nonpharmacologic strategies to minimize WRP
• Involve and empower patients to optimize pain management
• Healthcare providers should ensure WRP control for every patient
WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.
Local Infection Critical Colonization, Increased Bacterial Burden,
Covert Infection
NERDS
• Nonhealing
• Exudate (increased)
• Red friable granulation tissue
• Debris
• Smell
WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.
May be painful
NERDS
• Nonhealing
• Exudate (increased)
• Red friable granulation tissue
• Debris
• Smell
Deep and Surrounding Skin Infection
STONEES• Size increasing
• Temperature increased (surrounding skin)
• Os (probes or exposed bone)
• New areas of breakdown
• Erythema and/or edema
• Exudate (increased)
• SmellWUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.
Increased painmost reliable symptom and
may be clinically more usefulthan any one individual sign
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Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Signs of Critical Colonization
• Granulation tissue– Color
– Friability
– Absent or abnormal
• Odor: subtle or dramatic change
• Increased/high exudate levels in the presence of granulation tissue
– Wounds attempt to “flush out” foreign particles or chemicals
Colonization
Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.
Pain not usually present/related to bacteria
• Healthy granulation
Bamberg R, et al. www.woundsresearch.com/article/1074?page=0,0. Accessed April 1, 2013.
Diagnosis of Wound Infections Current Culturing Practices of US Wound Care Professionals
• Correlation of signs with wound data– 79% of the wounds with positive cultures have positive clinical
signs
– “However, as many as 21% of wound patients with potential wound infections may go undiagnosed if clinical signs and symptoms alone are utilized in diagnosis”
Clinical Presentation
AcuteWound Infection
or
Severe ChronicWound Infection
• Advancing erythema
• Fever
• Warmth
• Edema/swelling
• Pain
• Purulence
“Classic” Signs and Symptoms of Infection
Gardner SE, et al. Wound Repair Regen. 2001;9(3):178-186.
The Validity of the Clinical Signs and Symptoms Used to Identify Localized Wound Infection
• “Traditional” signs and symptoms need not be present for local wound infection to be present in chronic wounds
• Quantitative tissue biopsy demonstrated that “secondary” signs and symptoms occurred more often than “classic” in chronic wound infections
• No single sign or symptom is 100% sensitive, suggesting that none should be considered crucial or necessary to identify a chronic wound infection
• Increasing pain and wound breakdown considered sufficient
Gardner SE, et al. Wound Repair Regen. 2001;9(3):178-186.
Clinical Presentation
Gardner SE, et al. Wound Repair Regen. 2001;9(3):178-186.
Critically colonized–
Bacterial burden–
Local wound infection
• Delayed healing
• Change in color of wound bed
• Friable granulation tissue
• Absent or abnormal granulation tissue
• or abnormal odor
• Serous drainage
• Pain at wound site
Secondary Signs and Symptoms of Infection
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Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Clinical Presentation
AcuteWound Infection
or
Severe ChronicWound Infection
• Advancing erythema
• Fever
• Warmth
• Edema/swelling
• Pain
• Purulence
“Classic” Signs and Symptoms of Infection
Gardner SE, et al. Wound Repair Regen. 2001;9(3):178-186.
The Validity of the Clinical Signs and Symptoms Used to Identify Localized Wound Infection
• “Traditional” signs and symptoms need not be present for local wound infection to be present in chronic wounds
• Quantitative tissue biopsy demonstrated that “secondary” signs and symptoms occurred more often than “classic” in chronic wound infections
• No single sign or symptom is 100% sensitive, suggesting that none should be considered crucial or necessary to identify a chronic wound infection
• Increasing pain and wound breakdown considered sufficient
Gardner SE, et al. Wound Repair Regen. 2001;9(3):178-186.
Clinical Presentation
Gardner SE, et al. Wound Repair Regen. 2001;9(3):178-186.
Critically colonized–
Bacterial burden–
Local wound infection
• Delayed healing
• Change in color of wound bed
• Friable granulation tissue
• Absent or abnormal granulation tissue
• or abnormal odor
• Serous drainage
• Pain at wound site
Secondary Signs and Symptoms of Infection
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Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Identify and Treat the Cause of the Chronic Wound and Address Concerns Expressed by the Patient,
Including a Pain Assessment at Each Visit
• Electronic medical record/JACHO
– Pain assessment is a required field
– Not yet part of meaningful use
• Diagnose– Vascular supply– Venous outflow– Pressure surface– Nutrition– Bioburden
• Intervene– Debride within context of
patient acceptance– Cleanse within context of
patient acceptance– Treat bioburden within
context of patient acceptance
– Reduce pressure/offload– Improve blood flow– Maximize nutrition– Compress as necessary
JACHO = Joint Commission on Accreditation of Healthcare Organizations.
Evaluate and Document Pain Intensity and Characteristics on a Regular Basis
(before, during, and after dressing-related procedures)
• Part of all wound research trials• As noted, part of JACHO
guidelines• Does the patient experience
pain during or after dressing-related procedures?
• Quality– Describe the pain the last time
your dressing was removed
• Location– Where was the pain? Was it
limited to the immediate area of the wound or did you feel it in the surrounding area?
• Triggers– What part of the procedure
was most painful (eg, dressing removal, cleansing, dressing application, having the wound exposed)?
• Reducers– What helped to reduce the
pain (eg, time out, slow removal of dressing, removing the dressing yourself)?
• Timing– How long did it take for pain to
resolve after the procedure?
WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.
Topical Wound Treatment Solutions
The Playing Field
“Perhaps the most deceptively simple
of all therapeutic procedures is the treatment of
cutaneous infection with topical medication.
Despite the unique accessibility of the skin
to scientific investigation, it has for too long been
the playground of crude empiricism.”
Selwyn S. Microbial interactions and antibiosis. In: Maibach H, Aly R, eds. Skin microbiology: relevance to clinical infection. New York, NY: Springer-Verlag; 1981:63-74.
Role of Topical Antimicrobials
• Many wounds support relatively stable mixed communities of microorganisms, often without signs of infection
• In chronic wounds, reduction of certain microbial species, such as anaerobic bacteria, to limit undesirable odors
• Mixed communities of 4 or more bacterial species that impede healing is to be justified
• The eradication of beta hemolytic streptococci or staphylococci and Pseudomonas before grafting is essential
• Intervention to prevent the development of systemic infection in critically colonized or locally infected wounds is reasonable
Bowler PG, et al. Clin Microbiol Rev. 2001;14(2): 244-269. Hansson C, et al. Acta Derm Venereol. 1995;75(1):24-30. Bowler PG, et al. Wounds. 1999;11:72-78. Trengove NJ, et al. J Wound Care. 1996;5(6):277-80. Schraibman IG. Ann R Coll Surg Engl. 1990;72(2):123-124. Gilliland EL, et al. Ann R Coll Surg Engl. 1988;70(2):105-108.
Cleanse Wound Gently, Avoid the Use of Abrasive Wipes and Cold Solutions
• Irrigation: the practice of washing out or flushing a wound or body opening with a stream of a liquid solution
– High 50 psi (jet) vs low pressure 4 to 15 psi (gravity or bulb syringe)
– Continuous vs pulsatile
– Low vs high volume
– Solution (water, saline, antiseptics, or combinations)
• Lavage: the process of washing/irrigating out an organ, usually the bladder, bowel, paranasal sinuses, or stomach, for therapeutic purposes with a liquid solution
• Instillation: a procedure in which a liquid solution is slowly introduced into a cavity or passage of the body and allowed to remain for a specific length of time before being drained or withdrawn
Trevelyan J. Nurs Times. 1996;92(16):46-48. Fletcher J. Prof Nurse. 1997;12(11):793-796. Williams C. Br J Nurs. 1999;8(21):1460-1462. Oliver L. Nurs Stand. 1997;11(20):47-56. Davies C. Nurs Times. 1999; 95(43):71-72, 75. Bergstrom N, et al. Treatment of pressure ulcers. Clinical Practice Guideline, No. 15. 1994. AHCPR Publication No. 95-0652. Rockville, MD: U.S. Department of Health and Human Services. Public Health service, Agency for Health Care Policy and Research. Chisholm CD, et al. Ann EmergMed. 1992;21(11):1364-1367.
14 15
Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
The Playing Field
“Perhaps the most deceptively simple
of all therapeutic procedures is the treatment of
cutaneous infection with topical medication.
Despite the unique accessibility of the skin
to scientific investigation, it has for too long been
the playground of crude empiricism.”
Selwyn S. Microbial interactions and antibiosis. In: Maibach H, Aly R, eds. Skin microbiology: relevance to clinical infection. New York, NY: Springer-Verlag; 1981:63-74.
Role of Topical Antimicrobials
• Many wounds support relatively stable mixed communities of microorganisms, often without signs of infection
• In chronic wounds, reduction of certain microbial species, such as anaerobic bacteria, to limit undesirable odors
• Mixed communities of 4 or more bacterial species that impede healing is to be justified
• The eradication of beta hemolytic streptococci or staphylococci and Pseudomonas before grafting is essential
• Intervention to prevent the development of systemic infection in critically colonized or locally infected wounds is reasonable
Bowler PG, et al. Clin Microbiol Rev. 2001;14(2): 244-269. Hansson C, et al. Acta Derm Venereol. 1995;75(1):24-30. Bowler PG, et al. Wounds. 1999;11:72-78. Trengove NJ, et al. J Wound Care. 1996;5(6):277-80. Schraibman IG. Ann R Coll Surg Engl. 1990;72(2):123-124. Gilliland EL, et al. Ann R Coll Surg Engl. 1988;70(2):105-108.
Cleanse Wound Gently, Avoid the Use of Abrasive Wipes and Cold Solutions
• Irrigation: the practice of washing out or flushing a wound or body opening with a stream of a liquid solution
– High 50 psi (jet) vs low pressure 4 to 15 psi (gravity or bulb syringe)
– Continuous vs pulsatile
– Low vs high volume
– Solution (water, saline, antiseptics, or combinations)
• Lavage: the process of washing/irrigating out an organ, usually the bladder, bowel, paranasal sinuses, or stomach, for therapeutic purposes with a liquid solution
• Instillation: a procedure in which a liquid solution is slowly introduced into a cavity or passage of the body and allowed to remain for a specific length of time before being drained or withdrawn
Trevelyan J. Nurs Times. 1996;92(16):46-48. Fletcher J. Prof Nurse. 1997;12(11):793-796. Williams C. Br J Nurs. 1999;8(21):1460-1462. Oliver L. Nurs Stand. 1997;11(20):47-56. Davies C. Nurs Times. 1999; 95(43):71-72, 75. Bergstrom N, et al. Treatment of pressure ulcers. Clinical Practice Guideline, No. 15. 1994. AHCPR Publication No. 95-0652. Rockville, MD: U.S. Department of Health and Human Services. Public Health service, Agency for Health Care Policy and Research. Chisholm CD, et al. Ann EmergMed. 1992;21(11):1364-1367.
14 15
Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Instillation with NPWT Can be a Very Effective Way to Do This…
NPWT = negative-pressure wound therapy.Raad W, et al. Int Wound J. 2010;7(2):81-85.
Select an Appropriate Method of Wound Debridement and Include the Potential for Causing WRP
Strategy Description Examples
Mechanical Removal of necrotic tissue by mechanical means
Wet-to-dry dressings, hydrotherapy, ultrasound
Surgical (excisional/sharp) Removal by surgical instrument
Scalpel, scissors, hydrosurgery, lasers, curettes
Biosurgical Sterile larvae selectively digest necrotic tissue and bacteria
Sterile blowfly or housefly larvae
Autolytic
Uses the body’s own enzymes to dissolve necrotic tissue; assisted with moisture-retentive dressings
Films, hydrogels, hydrocolloids
Enzymatic Topical application of enzymes to liquefy necrotic tissue Collagenase
Active Enzymatic Debridement Can Have Very Nice Results with Minimal Pain
*On day 2, P < .05.Hansbrough JF, et al. J Burn Care Rehabil. 1995;16(3 Pt 1):241-247.
Pain of topical collagenase with polysporin powder vs silver sulfadizine
7
4
2
0
1Visu
al A
nalo
g Sc
ore
53Days
7 9
3
42 6 81
6
5
During Debridement
Collagenase Ointment
Silvadene
*
2 Principle Debridement Strategies
Episodic Debridement Continuous Debridement
Primary Role • Initial debridement • Maintenance debridement
Secondary Role • Maintenance debridement • Initial debridement
Advantages
• Rapid• Good in large wounds• Economic incentive to
physician
• Maintains healing environment
• Prevents necrotic buildup • Does not harm wound bed• Selective
Disadvantages
• Necrotic tissue reaccumulates between procedures
• Harms wound bed and may impede healing
• Bleeding risk
• Slower than surgical/sharp debridement
• May not be appropriate for initial debridement of large wounds
Choose Dressings that Minimize Trauma/Pain during Application and Removal
• Cadexomer iodine dressings
– 72-hour wear times
• Silver-containing foams– Minimal pain
• NPWT with instillation 72-hour wear times
• Others
• Maintenance of moist wound healing
• Atraumatic to the wound and surrounding skin
• Absorbency capacity (fluid handling/retention capacity)
• Allergy potential
• Select dressings that stay in situ for a longer period to avoid frequent removal
Schwartz JA, et al. Int Wound J. 2013;10(2):193-199. Lantis JC II, et al. J Wound Care. 2011;20(2):90-96. Raad W, et al. Int Wound J. 2010;7(2):81-85.
Treat Infections that May Cause WRPand Inhibit Healing
• Cadexomer iodine dressings
– 1 log reduction in the chronic wound
• Silver-containing foams
– 1 log reduction in the chronic wound
• NPWT with instillation
– 1 log reduction in the chronic wound
• Others
Individual ResultsMultiple ResultsMean
76
4
0
2
Leve
l of B
iobu
rden
(log1
0 cf
u/g
tissu
e)
Baseline Week 8Assessment
100
80
40
0
20
Patie
nts
With
Clin
ical
Sign
s of
Infe
ctio
n (%
)
Baseline(0)
42Time (weeks)
8 12
Schwartz J, et al. Int Wound J. 2013;10(2):193-199.
60
5
3
1
100
83
55
4233
Median
16 17
Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
2 Principle Debridement Strategies
Episodic Debridement Continuous Debridement
Primary Role • Initial debridement • Maintenance debridement
Secondary Role • Maintenance debridement • Initial debridement
Advantages
• Rapid• Good in large wounds• Economic incentive to
physician
• Maintains healing environment
• Prevents necrotic buildup • Does not harm wound bed• Selective
Disadvantages
• Necrotic tissue reaccumulates between procedures
• Harms wound bed and may impede healing
• Bleeding risk
• Slower than surgical/sharp debridement
• May not be appropriate for initial debridement of large wounds
Choose Dressings that Minimize Trauma/Pain during Application and Removal
• Cadexomer iodine dressings
– 72-hour wear times
• Silver-containing foams– Minimal pain
• NPWT with instillation 72-hour wear times
• Others
• Maintenance of moist wound healing
• Atraumatic to the wound and surrounding skin
• Absorbency capacity (fluid handling/retention capacity)
• Allergy potential
• Select dressings that stay in situ for a longer period to avoid frequent removal
Schwartz JA, et al. Int Wound J. 2013;10(2):193-199. Lantis JC II, et al. J Wound Care. 2011;20(2):90-96. Raad W, et al. Int Wound J. 2010;7(2):81-85.
Treat Infections that May Cause WRPand Inhibit Healing
• Cadexomer iodine dressings
– 1 log reduction in the chronic wound
• Silver-containing foams
– 1 log reduction in the chronic wound
• NPWT with instillation
– 1 log reduction in the chronic wound
• Others
Individual ResultsMultiple ResultsMean
76
4
0
2
Leve
l of B
iobu
rden
(log1
0 cf
u/g
tissu
e)
Baseline Week 8Assessment
100
80
40
0
20
Patie
nts
With
Clin
ical
Sign
s of
Infe
ctio
n (%
)
Baseline(0)
42Time (weeks)
8 12
Schwartz J, et al. Int Wound J. 2013;10(2):193-199.
60
5
3
1
100
83
55
4233
Median
16 17
Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Treat Local Factors that May Induce WRP (eg, inflammation, trauma, pressure, maceration)
• ↑ MMPs; tissue damage; immune complex deposition; bradykinin, and related substance activation
• Activated inflammatory mediators and tissue injury associated with nerve damage
• Ischemic injury with tissue damage and nerve fiber irritation, reperfusion injury
• ↑ Local interstitial pressure leading to tissue injury (impaired nutrient exchange: accumulation of waste products)
• Topical and systemic anti-inflammatory
• Protect exposed nerve fibres(eg, moist wound healing dressings)
• Pressure redistribution
• Venous, lymphatic: compression, mechanical pumps congestive heart failure, ↓ albumin; treat the cause
WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.
Absorptive Capacity• Minimal
– Starch molecules• Medium
– Foam– Alginates
• High– Alginates/hyrofibresplus…– Mini negative
pressure units• Very high
– NPWT
Therapeutic Effect• Can it deliver an agent?
– Antibacterial• Iodine• Intrinsic to honey??• Silver-based• Topical antseptic
– Analgesic/anti-inflammatory• Intrinsic to honey??• Nonsteroidal anti-inflammatory drugs• Topical anesthetic
– Growth enhancing• Growth factors• Extracellular matrix
– MMP binding• ORC/collagen
Select an Appropriate Dressing to Minimize WRPBased on Wear Time, Moisture Balance,
Healing Potential, and Periwound Maceration
ORC = origin recognition complex.
Other Factors to Remember
• Evaluate each patient’s need for pharmacologic (topical/systemic agents) and nonpharmacologicstrategies to minimize WRP
• Involve and empower patients to optimize pain management
• Healthcare providers should ensure WRP control for every patient
Clinical Considerations
• Anatomical location• Patient positioning• Relation to gravity• Complexity
– Tunnel
– Undermining
• Infection• Hardware
– Size
– Areas
• Volume• Others
Wound Closure ConceptSt. Luke’s – Roosevelt Hospital, Division of Vascular Surgery
• We do not know thebioburden/do not recognizethe burden
• We do not know theproliferative capacity
• We do not know the exactdeficiencies
• We have to regain balance
• We have to managebacterial burden…
• …but we have to put the patient’s needs first
Wound Cleansing ConceptSt. Luke’s – Roosevelt Hospital, Division of Vascular Surgery
• Obtain quantitative culture prior to debridement• Debride—sharp or hydrotherapy
– Debridement only reduces planktonic bacteria by 1 log
• Pulse irrigate– Debridement still only reduces planktonic bacteria by 1 log
• Obtain quantitative culture postdebridement• Decide on topical therapy
– Needs of the patient• Are they willing to be hospitalized?
• Are they a candidate for near-immediate closure?
– Based on goal of therapy– Size of wound – Amount and number of bacteria– Duration and etiology of wound
Schwartz JA, et al. Presented at: SAWC Spring/WHS Symposium; May 1-5, 2013; Denver, Colorado.
18 19
Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Clinical Considerations
• Anatomical location• Patient positioning• Relation to gravity• Complexity
– Tunnel
– Undermining
• Infection• Hardware
– Size
– Areas
• Volume• Others
Wound Closure ConceptSt. Luke’s – Roosevelt Hospital, Division of Vascular Surgery
• We do not know thebioburden/do not recognizethe burden
• We do not know theproliferative capacity
• We do not know the exactdeficiencies
• We have to regain balance
• We have to managebacterial burden…
• …but we have to put the patient’s needs first
Wound Cleansing ConceptSt. Luke’s – Roosevelt Hospital, Division of Vascular Surgery
• Obtain quantitative culture prior to debridement• Debride—sharp or hydrotherapy
– Debridement only reduces planktonic bacteria by 1 log
• Pulse irrigate– Debridement still only reduces planktonic bacteria by 1 log
• Obtain quantitative culture postdebridement• Decide on topical therapy
– Needs of the patient• Are they willing to be hospitalized?
• Are they a candidate for near-immediate closure?
– Based on goal of therapy– Size of wound – Amount and number of bacteria– Duration and etiology of wound
Schwartz JA, et al. Presented at: SAWC Spring/WHS Symposium; May 1-5, 2013; Denver, Colorado.
18 19
Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Wound Cleansing ChoiceSt. Luke’s – Roosevelt Hospital, Division of Vascular Surgery
• Ambulatory – DFU: cadexomer/iodine
– Venous/painful: silver-containing foams
– Vasculitic painful: silver-containing foams
– Others: honey-based products (as part of trials)
• Larger wounds (>40 sq cm?) – That can be hospitalized: NPWT with instillation
– That need quick closure:• Pain
• Other surgery planned
– Anatomically appropriate
– Need jump start
NPWT with Instillation ProtocolSt. Luke’s – Roosevelt Hospital, Division of Vascular Surgery
• Obtain quantitative culture prior to debridement
• Debride
• Pulse irrigate
• Obtain quantitative culture postdebridement
• Use NPWT with instillation—place directly in the operating room
• Change 2 to 3 times in 7-day treatment course
– 10-minute soak followed by 50-minute NPWT to 3.5-hour NPWT
– Quarter strength Dakin’s solution
How Do We Do This?
• Algorithm
• Decide size of the foam
– L x W x D (2 cm) x .20 cc
• Decide what solution
– Dakin’s 0.125??
• Decide the time to dwell
– Many factors
– We are doing 10 minutes dwell/50 minutes NPWT
– Have moved to 10 minutes dwell/3.5 hours NPWT
How Do I Choose a Solution?
• Hypochlorite-based solutions– Dakin’s solution, Dermacyn®, Microcyn®
• Sulfur-based solutions– Sulfamylon®, mafenide acetate solution
• Silver nitrate solution– Various
• Biguanides (PHMB)– Prontosan®
• Cationic solutions – Octenidine, benzalkonium chloride
• Isotonic solutions– Normal saline solution, Lactated Ringer’s solution
PHMB = polyhexanide.
Clinical Questions
• What agents?– Different bacteria—different choices?
• How long to dwell?– Different agent—require different dwells
• Dakin’s—very reactive, short dwell
• PHMB—minimum 20-minute dwell
• How long to provide negative pressure?– What potentiates—macro and micro deformation?
In Vitro Biofilm DataNPWT with Instillation of the Appropriate Solution
May Control Bacteria Known to Form Biofilm
• Mature biofilm starts to form within 4 to 10 hours, providing a window of opportunity during biofilm development where biofilm can be disrupted
• Immature biofilms were exposed to antimicrobial solutions
– 0.1% PHMB
– 5% mafenide acetate
– 0.004% sodium hypochlorite + 0.003% hypochlorous acid
• Intermittent exposure of developing biofilm to antimicrobial solutions reduced the number of mature biofilm bacteria by 1 to 2 log CFU
Control Saline 0.1%Poly-
haxanide
5%MafenideAcetate
0.004%SodiumHypo-
chlorite+ 0.003%
HypochlorousAcid
1.00E+08
1.00E+07
1.00E+09
1.00E+06
1.00E+05
1.00E+04
1.00E+03
1.00E+02
1.00E+00
1.00E+01
Aver
age
CFU
/mL
CFU = colony-forming unit.Cowan L, Philips P, Stechmiller J, et al. Antibiofilm Strategies and Antiseptics. In: Willy C, ed. Antiseptics in Surgery Update 2013. Berlin, Germany: Lundqvist Books; 23-30.
20 21
Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
How Do I Choose a Solution?
• Hypochlorite-based solutions– Dakin’s solution, Dermacyn®, Microcyn®
• Sulfur-based solutions– Sulfamylon®, mafenide acetate solution
• Silver nitrate solution– Various
• Biguanides (PHMB)– Prontosan®
• Cationic solutions – Octenidine, benzalkonium chloride
• Isotonic solutions– Normal saline solution, Lactated Ringer’s solution
PHMB = polyhexanide.
Clinical Questions
• What agents?– Different bacteria—different choices?
• How long to dwell?– Different agent—require different dwells
• Dakin’s—very reactive, short dwell
• PHMB—minimum 20-minute dwell
• How long to provide negative pressure?– What potentiates—macro and micro deformation?
In Vitro Biofilm DataNPWT with Instillation of the Appropriate Solution
May Control Bacteria Known to Form Biofilm
• Mature biofilm starts to form within 4 to 10 hours, providing a window of opportunity during biofilm development where biofilm can be disrupted
• Immature biofilms were exposed to antimicrobial solutions
– 0.1% PHMB
– 5% mafenide acetate
– 0.004% sodium hypochlorite + 0.003% hypochlorous acid
• Intermittent exposure of developing biofilm to antimicrobial solutions reduced the number of mature biofilm bacteria by 1 to 2 log CFU
Control Saline 0.1%Poly-
haxanide
5%MafenideAcetate
0.004%SodiumHypo-
chlorite+ 0.003%
HypochlorousAcid
1.00E+08
1.00E+07
1.00E+09
1.00E+06
1.00E+05
1.00E+04
1.00E+03
1.00E+02
1.00E+00
1.00E+01
Aver
age
CFU
/mL
CFU = colony-forming unit.Cowan L, Philips P, Stechmiller J, et al. Antibiofilm Strategies and Antiseptics. In: Willy C, ed. Antiseptics in Surgery Update 2013. Berlin, Germany: Lundqvist Books; 23-30.
20 21
Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
In Vitro Biofilm DataNPWT with Instillation of the Appropriate Solution
May Control Bacteria Known to Form Biofilm
• In vitro biofilm model using pig skin
• Instilled 6 times in 24 hours with 10-minute soak time using V.A.C. Instill® wound therapy
• Solutions used
• 0.9% sodium chloride (normal saline)
• 0.1% polyhexamethylene biguanide(PHMB or polyhexanide)
• Instillation therapy with antimicrobial solutions reduced biofilm bacteria by 3 log CFU
Untreated V.A.C.®Therapy
V.A.C.VeraFlo™Therapy
With0.1%
PHMB
V.A.C.VeraFlo™Therapy
WithNormalSaline
1.00E+07
1.00E+08
1.00E+06
1.00E+05
1.00E+04
1.00E+03
1.00E+02
1.00E+00
1.00E+01
Aver
age
CFU
/mL
Cowan L, Philips P, Stechmiller J, et al. Antibiofilm Strategies and Antiseptics. In: Willy C, ed. Antiseptics in Surgery Update 2013. Berlin, Germany: Lundqvist Books; 23-30.
Sodium Hypochlorite Solutions
• Device class– Antimicrobial Agent
• Commercially available names– Dakin’s, Dermacyn®, Microcyn®
• FDA cleared for topical application?– Yes
• FDA indication– Wound cleansing
• Common available forms– Solution available in variety concentrations 0.5% (full strength), 0.25% (half strength), and
0.125% (quarter strength)
• Common irrigation concentrations (%)– Concentration commonly used 0.025% or 0.125%; NPWT instillation recommended– Concentration max is 0.125% (quarter strength)
• Common clinical usage – Useful against nonsystemic infections due to drug-resistant microorganisms
Gerit D, et al. Wounds. 2007;19(7):173-182.
PHMB Solutions
• Device class– Wound cleanser
• Commercially available name – Prontosan®
• FDA cleared for topical application?– Yes
• FDA indication– Intended for cleaning wounds and for moistening and lubricating absorbent wound
dressings for ulcers, burns, postsurgical wounds, and abrasions
• Common available forms– 0.1% solution
• Common irrigation concentrations (%)– 0.1% solution
• Common clinical usage– Aids in the removal of dirt and debris from chronic wounds, skin ulcers, and abrasions,
even when surfaces are difficult to access, such as skin folds, fissures, and wound pockets
Gerit D, et al. Wounds. 2007;19(7):173-182.
Cases
• DFU with bone resection
• Infected venous leg ulcer
• Traumatic amputation
• Necrotizing fasciitis of sacral wound
• Open abdominal wound
• Acute postoperative dressings
• Other lower-extremity wounds
Diabetic Charcot Foot
Postdebridement12x106 Coagulase
negative staphylococci
Postoperative Day 4 Rare—Gram-positive cocci in pairs,
rare gram-negative rods
Postdebridement and initiation of NPWT with instillationQuarter strength Dakin’s solution
10-minute soak followed by 50-minute NPWT
Infected DFU
April 16
May 25 September 10
April 2Initial application of NPWT
22 23
Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Cases
• DFU with bone resection
• Infected venous leg ulcer
• Traumatic amputation
• Necrotizing fasciitis of sacral wound
• Open abdominal wound
• Acute postoperative dressings
• Other lower-extremity wounds
Diabetic Charcot Foot
Postdebridement12x106 Coagulase
negative staphylococci
Postoperative Day 4 Rare—Gram-positive cocci in pairs,
rare gram-negative rods
Postdebridement and initiation of NPWT with instillationQuarter strength Dakin’s solution
10-minute soak followed by 50-minute NPWT
Infected DFU
April 16
May 25 September 10
April 2Initial application of NPWT
22 23
Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
ORC/Collagen as an Adjunct toNPWT Wound Closure
Week 1 Week 2
Week 5 Week 8
Use of NPWT and Instillation to Prepare Pseudomonas-Infected Wound for STSG
Debride in OR10 days later with
NPWT with instillation
STSG in OR 30 days post-STSGSTSG = split-thickness skin graft.; OR = operating room.Raad W, et al. Int Wound J. 2010;7(2):81-85.
Sacral Wound Necrotizing Fasciitis
Follow Same Standards for Postoperative Dressings?
• Decrease frequency of dressing changes
• Decrease edema
• Maintain moist wound environment
Other Wound Types and Transitions
• Infected saphenectomy site– >105 S. aureus– Debride in OR– 4 days NPWT with instillation– Discharge to skilled nursing facility
on NPWT system– Planned STSG – Also has open transmetatarsal
amputations with NPWT
• Medial thigh ischemic wound• Now revascularized
– >105 MRSA; 25,000 CFUs of Pseudomonas; 25,000 CFUs of corynebacterium
– 4 days of NPWT with Dakin’s instillation
– Discharged on NPWT – Planned STSG
MRSA = methicillin-resistant Staphylococcus aureus.
Techniques to Facilitate Closure of Complex Abdominal Wounds
24 25
Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Follow Same Standards for Postoperative Dressings?
• Decrease frequency of dressing changes
• Decrease edema
• Maintain moist wound environment
Other Wound Types and Transitions
• Infected saphenectomy site– >105 S. aureus– Debride in OR– 4 days NPWT with instillation– Discharge to skilled nursing facility
on NPWT system– Planned STSG – Also has open transmetatarsal
amputations with NPWT
• Medial thigh ischemic wound• Now revascularized
– >105 MRSA; 25,000 CFUs of Pseudomonas; 25,000 CFUs of corynebacterium
– 4 days of NPWT with Dakin’s instillation
– Discharged on NPWT – Planned STSG
MRSA = methicillin-resistant Staphylococcus aureus.
Techniques to Facilitate Closure of Complex Abdominal Wounds
24 25
Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
NotesSummary
• We assume most chronic wounds are infected/critically colonized
• Minor colonizations can be treated with debridement; then—
– Topical antimicrobial
• Major colonizations can be treated with debridement; then—
– Irrigation and NPWT
26 27
Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
262626 27
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Notes
26 27
Patient-Centered Approaches to Managing Wound Infection
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
26 27
to the NACCME representative before leaving the grand rounds.
27
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Notes
28 29
To receive documentation of credit, please complete and return the pre-activity survey and post-activity evaluation to the NACCME representative before leaving the grand rounds.
Notes
28 29
