Signs, Symptoms and Actions for Superficial and Spreading Wound

Signs, Symptoms and Actions for
Superficial and Spreading Wound Infection
(All Etiology’s)
Classic Signs of Inflammation
• Calor, rubor, tumor, dolor
• Heat, redness, swelling and pain are the four
classical signs of inflammation, originally
recorded by the Roman Celsius in the 1st
century A.D
• However, we now know that infection may
produce different signs and symptoms in
wounds of different types and etiologies; and
• Superficial/localized infections are different
than /produce different signs than
deep/spreading infections; and
• Require different treatments
wairiotina.blog.com
3
Term
Clinical Interpretation
Clinical intervention
Need for
Prophylaxis
Wounds in at-risk individuals can quickly
progress to colonized or infected (could
include wounds with or where you want to
create dry stable gangrene)
1. Optimize general health of individual (nutrition,
medication, manage co-morbidities etc.)
2. Thorough cleansing, debridement if applicable, and
infection control practices to prevent introduction of
bacteria.
3. Utilize topical antimicrobial dressings
Contaminat
ed
Bacteria on surface only
No signs or symptoms
None
Colonized
Bacteria attached to surface
Starting to form colonies
Minimally invasive
No local tissue damage
None unless location of wound or host resistance put
patient at risk
Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014
1
Term
Clinical Interpretation
Clinical intervention
Localized
Infection
(Critical
Colonizatio
n)
Bacteria more deeply invasive
Local wound bed involved
Healing delayed or stalled
Subtle signs and symptoms
• Friable bright red tissue
• Increased or altered exudate
• Increased odour
• Increased pain
• Localized edema
Intervention required.
Local measures
• Effective debridement
• Topical antimicrobials to cleanse
• Antimicrobial dressings*
* Each etiology-based resource contains specific topical
dressing choices for infected wounds.
Spreading
Infection
Bacteria now involve surrounding tissue. In
addition to signs and symptoms of localized
infection:
• Erythema and induration beyond
wound edge
• Heat
• Increased pain
• Satellite lesions
• Lymphangitis
• General malaise
As for localized infection plus systemic antibiotics, which
need to correspond to the sensitivities of the actual
bacteria causing the infection. Sometimes coverage for
BOTH aerobic and anaerobic bacteria needs to be
ordered (especially with diabetic foot ulcers and pilonidal
sinuses), and more than 1 course of systemic therapy
may be needed.
 General Anti-infective Guidelines for Communityacquired Infections (www.mumshealth.com )
 Lower Leg Cellulitis: Table 4, Page 28 Antibiotics for
cellulitis/erysipelas in lymphoedema (developed by
the British Lymphology Society and Lymphoedema
Support Network) Available at:
http://ewma.org/fileadmin/user_upload/EWMA/Wo
und_Guidelines/Lymphoedema_Framework_Best_Pr
actice_for_the_Management_of_Lymphoedema.pdf
 Diabetic Foot Infections: K. Bowering, J.M. Embil.
Foot Care, CDA Clinical Practice Guidelines. Can J
Diabetes (2013) 37:S145 to S149. Table 2 Empiric
antimicrobial therapy for infection in the diabetic
foot Page S147. Available at: guidelines.diabetes.ca
Systemic
infection
Classic signs of sepsis
• Fever
• Elevated or depressed WBC
• Tachycardia
• Tachypnea
• Multi-organ system failure
As for spreading infection
Need to rule out other sources of infection
Table adapted from SWRWC Toolkit: E.3. Wound Infection Treatment_ forTopicals_AntimicrobialRx_Biofilm_Jun_27_2011
Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014
2
Identification and Classification of Signs of Infection (NERDS & STONEES)i,ii
Mnemonics for Wound Infection
NERDS
(Sibbald, Woo, Ayello ‘06, Woo & Sibbald ‘09)
Non-healing
NERDS
Superficial:
Treat
topically
•
•
•
•
•
• Wounds that are not
20% to 40% smaller
in 4 weeks according
to patient history or
existing
documentation
Non-healing
Exudate
Red + Bleeding
Debris
Smell
Sibbald, Woo, Ayello ‘06, Woo &
Sibbald ‘09
©Connie Harris ET NOW 2006
Speaker, Title, Hospital
Adapted from CAWC Conference 2011 Dr. R.G.Sibbald
NERDS
Red
Exudate
NERDS
• Wound bed
tissue is bright
red with
exuberant
granulation
tissue
• Tissue bleeds
easily with gentle
manipulation
• Increase in wound
exudate can be
indicative of bacterial
pro-inflammatory
damage and leads to
periwound maceration
• More than 50% of the
dressing stained with
exudate
Sibbald, Woo, Ayello ‘06, Woo &
Sibbald ‘09
©Connie Harris ET NOW 2008
©Connie Harris ET NOW 2001
Sibbald, Woo, Ayello ‘06, Woo
& Sibbald ‘09
©Connie Harris ET NOW 2001
NERDS
NERDS
Debris
Smell
• Unpleasant or
sweet,
sickening odor
• Presence of
discolored
granulation
tissue,
slough, and
necrotic/nonviable
tissue
Sibbald, Woo, Ayello ‘06, Woo &
Sibbald ‘09
Sibbald, Woo, Ayello ‘06,
Woo & Sibbald ‘09
©Connie Harris ET NOW 2005
©Connie Harris ET NOW 2001
Validation of NERDS
Any 3 or more of the following indicate HIGH superficial bacterial infection:
• Non-healing
• Exudate increased
• Red friable
www.calgarylabservices.com
• Debris
• Smell
Woo, K.Y., Sibbald, R.G. A Cross-sectional Validation Study of Using NERDS and STONEES to Assess Bacterial
Burden OWM 2009;55(8):40 –48.
Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014
3
Identification and Classification of Signs of Infection (NERDS & STONEES)i,ii
Mnemonics for Deep or Spreading
Wound Infection
(Sibbald, Woo, Ayello ‘06, Woo & Sibbald ‘09)
STONEES
Deep:
Treat
Systemically
•
•
•
•
•
Size is bigger
Temperature ↑
Os (probes, exposed)
New breakdown
Erythema, Edema
(Signs of Cellulitis)
• Exudate,
• Smell
STONEES
Size Increased
• Size as measured by
the longest length
and the widest width
at right angles to the
longest length.
• Depth measured
with a probe straight
in
Sibbald, Woo, Ayello ‘06, Woo &
Sibbald ‘09
Speaker, Title, Hospital
Adapted from CAWC Conference 2011 Dr. R.G.Sibbald
STONEES
STONEES
Temperature
Os
• Increased periwound margin
temperature by
more than 3ºF
difference between
two mirror-image
sites
© CarePartners 2006
Infrared
Scanner
Thermometer
Sibbald, Woo, Ayello ‘06, Woo & Sibbald ‘09
• Wounds that have
exposed bone or
that probed to bone
at the time of
examination have
risk of osteomyelitis
CarePartners and www.amazonsupply.com
(DFUs have biggest risk—57 to
89% Positive Predictive Value)
Sibbald, Woo, Ayello ‘06, Woo & Sibbald ’09
Lavery, L. et al. Diabetes Care 30:270–274, 2007
http://www.radiologyassistant.nl/en/p4b6e855359a09/diabetic-foot-mri-examination.html
STONEES
STONEES
Erythema & Exudate
New
• Reddened skin in
periwound area
• Presence of swelling in
periwound area
• Increased amount of
drainage
• New areas of
breakdown or
satellite lesions
Sibbald, Woo, Ayello ‘06, Woo &
Sibbald ‘09
Sibbald, Woo, Ayello
‘06,
Woo & Sibbald ‘09
© Red Cross Care Partners 2013
Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014
© BWAT Pictorial Guide 2008
Used with Permission
4
Identification and Classification of Signs of Infection (NERDS & STONEES)i,ii
STONEES
Validation
STONEES
Any 3 or more of the following
indicate HIGH bacterial infection
in the deep compartment:
Smell
• Unpleasant or
sweet, sickening
odor
-Size increasing
-Temperature increasing
-Os; probes to bone
-New or satellites
-Erythema
www.calgarylabservices.com
-Edema
-Smell Woo, K.Y., Sibbald, R.G. A Cross-sectional Validation Study of
Sibbald, Woo, Ayello ‘06, Woo & Sibbald ‘09
Using NERDS and STONEES to Assess Bacterial Burden OWM
18
2009;55(8):40 –48.
©Connie Harris ET NOW 2002
Other Signs /Symptoms of Deep or Spreading Infectioniii,iv
Pilonidal Sinus Wounds:
Single Symptom of Infection
Premature Bridging of Epithelial or Granulation Tissue &
Pocketing in the Base
• New, increased or altered PAIN is individually
highly indicative of infection.
All 3 photos ©CarePartners
Other Predictors of Osteomyelitis in Diabetic Foot Ulcers
Pain in a previously insensate DFU
– is indicative of
infection and
possible
osteomyelitis
•
•
•
•
•
•
An ulcer area greater than 2cm²
Erythema, Soft tissue edema or joint effusion
Lethargy, malaise, fever
ESR (erthrocyte sedimentation rate) of more than 70
mm/h
Xray flat plate / MRI if available
If MRI is unavailable or contraindicated, a labeled
white blood cell scan is the best alternative
©CarePartners
©Connie Harris ET NOW 1997
Remember that signs and symptoms of deep or spreading infection include Size, Temperature, Os (Probes to
bone), New areas of satellite breakdown (beyond the original wound) and/ or recurrence of wounds within a
short period of time, Erythema and Smell (STONEES).
Cellulitis is a spreading bacterial infection of the dermis and subcutaneous tissues, where the edge of the
erythema may be well-defined or more diffuse and typically spreads rapidly. Systemic upset with fever and
Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014
5
Other Signs /Symptoms of Deep or Spreading Infectioniii,iv
malaise occurs in most cases, and may be present before the localising signs such as the local symptomsv seen
with STONEES.
Lower leg cellulitis can be extremely serious with long-term morbidity, including lower leg edema. It requires
prompt recognition by health care providers and appropriate interventions.
Note that lower leg cellulitis usually affects only one leg, not both. If both legs are affected, it is likely venous
dermatitis or allergic contact dermatitis, but this does not mean that it could never be cellulitis in both legs.
Risk Factors for Lower Leg Cellulitis
• Takes only a pin-point opening in the skin for bacteria to
enter
• Maceration between toes in web space
• Tinea pedis (Athlete’s foot)
• Lower leg oedema of any etiology especially lymphedema
• Obesity
• Recent surgery (especially vein harvesting for bypass
grafting)
• Venous stasis dermatitis
• Any blunt trauma to the leg
• Leg ulceration
• White ethnicity
Halpern et al 2008 Br J Dermatol
Lower Leg Cellulitis
• Symptoms: may have fever, area painful
and may not tolerate current compression
esp. elastic types
• Signs:
– Cellulitis appears as a diffuse, bright red, hot leg
with tenderness and often fever.
– Clear serous exudate will “pour” out of the small
openings, saturating the dressings quickly.
– May have blisters or bullae unrelated to venous
disease
• Investigations: high WBC, increased ESR and
C-reactive protein.
• Blood culture usually negative; swabs C&S
usually negative unless necrotic tissue is
swabbed (which is inappropriate)
BWAT Pictorial Guide
www.asdk12.org
Superficial Surgical Site Infection (SSI)
Specific signs of superficial Surgical Site Infection (SSI) Involves only skin and subcutaneous tissue around the
incision, occurring within 30 days of the procedure, and
have at least one of the following criteria.
 Greenish/ brown/ pus or foul smelling drainage
 Increased pain or tenderness in the area of the
incision or wound
 Increased swelling, firmness, redness or heat
surrounding the incision/wound
 Fever higher than 38°C (100°F) --- older individuals
may have fever at a lower temperature 37°C (99°F)
 A closed incision that opens up and starts to drain
 A tired feeling that doesn’t go away
 Localized swelling + increased exudate
 Organisms isolated from an aseptically obtained
culture of fluid or tissue from the incision
 The incision is deliberately opened by a surgeon,
unless the culture is negative
 The following are NOT considered superficial SSIs:
 Stitch abscesses
 Infection of an episiotomy or neonatal circumcision
site
howshealth.com
Spreading Surgical Site Infection (SSI)
Deep tissue infection: involves the deep tissue including
muscle and fascia
Organ or space infection: involves body or cavity where
surgery took place
As for superficial infection PLUS:
 Further extension of erythema
 Lymphangitis - Thin red lines observed running
along the course of the lymphatic vessels in the
affected area, accompanied by painful
enlargement of the nearby lymph nodes- known as
“blood poisoning in layman’s terms)
 Crepitus in soft tissues
 Wound breakdown/dehiscence
Specific Signs of deep incision Surgical Site Infection (SSI) ,
affecting the fascia and muscle layers, or organ or space
related to the procedure, which involves any part of the
anatomy other than the incision that is opened or
manipulated, within 30 days or within one year if implant
in place, and have at least one of the following criteria:
 purulent drainage from the incision but not from
the organ/space of the surgical site
 a deep incision spontaneously dehisces or is
deliberately opened by a surgeon when the patient
has at least one of the following signs or symptoms
Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014
6
Other Signs /Symptoms of Deep or Spreading Infectioniii,iv
- fever (>38°C), localised pain or tenderness unless the culture is negative
 an abscess or other evidence of infection involving
the incision is found
 diagnosis of a deep incisional SSI by a surgeon or
attending physician
Levine Method Swab for Culture and Sensitivityvi,vii
Determining Type &
Amount of Bacteria
Determining Type &
Amount of Bacteria
• Tissue biopsies are considered the “gold
standard” for quantifying bacterial bioburden in
wounds
• Not practical in many settings due to high cost
and limited accessibility
• Culture and sensitivity (c&s) results are not
necessary to confirm the presence or absence
of infection
• Important to determine what bacteria is present
and which antibiotic they are sensitive to.
extww02a.cardinal.com
22
23
Validated method
Limitations of Swabs
• There is a linear relationship between
quantitative tissue biopsy and swab for
culture using a specific method (Levine)
• The c&s results may not reflect the presence
or absence of biofilm, or test for all bacteria
present
Levine, N.S., Lindberg, R.B., Mason, A.D. and Pruitt, B.A. (1976) The quantitative
swab culture and smear: a quick, simple method for determining the number of viable
aerobic bacteria on open wounds. J Trauma.16(2): 89-94
Edwards-Jones,V., Schultz, G. & Douglass, J. The significance of Biofilms in Wound Infections.
International Wound Infection Institute. Available at: http://www.woundinfection-institute.com/
James G.A., Swogger E., Wolcott R. et al. Biofilms in chronic wounds. Wound Repair Regen.
2008; 16: 1, 37–44.
24
Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014
25
7
Levine Method Swab for Culture and Sensitivityvi,vii
Procedure
Procedure
• The laboratory will require a lab requisition from the
physician/ primary care provider
• Use sterile pre-packaged collection and transport
system
• Do not allow transport medium to freeze or become
overheated in your car before using it.
• If both aneorobic and aerobic cultures are desired,
ensure that the swab kit has this capability and that
you have requested both tests in the lab requisition
• Thoroughly rinse wound with normal saline (nonbacteriostatic).
• If this is a cavity wound and you will be
sampling tissue at the bottom of the cavity, blot
any excess NS with a sterile gauze to prevent
dilution of the sample
• If the wound is quite dry you should pre-moisten
the swab in the culture medium before pressing
on the tissue.
27
www.calgarylabservices.com
26
Procedure
Procedure
• Prepare the client/patient for momentary
discomfort
• Rotate the swab tip in a 1 cm square area of
clean granulation tissue x 5 seconds, using
gentle pressure to release tissue exudate
Don’t swab:
– pus
– exudate
– hard eschar
©CarePartners
– necrotic tissue
©CarePartners
• Results will only show what is on the surface,
not what is actually in the live (viable) tissue
•
©Connie Harris ET NOW 1996
© Parkwood Wound Care Team 2011 for SWRWCF
29
28
Procedure
Procedure
• Remove protective cap from culture medium and
insert cotton tipped applicator into the culture
medium without contaminating the applicator
shaft
Hold Here!
• Follow hospital or institutional practices for
getting the swab to the lab.
• DO NOT REFRIGERATE!
• In the community sector, the patient or their
family/care providers should transport the
specimen to the laboratory at room
temperature within 24 hours.
• Within one hour is ideal….the sooner the
better.
31
30
Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014
8
Assessment and Evaluation of Response to Treatment (page 2) for Infections







If there are clinical indications for use of an antimicrobial dressing, carry out a two week challenge.
At each dressing change, reassess the wound for signs of NERDS/STONEES/PAIN etc.
If there are still signs of localized infection, continue with topical treatment for another two weeks,
If there are ongoing signs and symptoms of spreading infection, or the infection does not seem to be
responding to antibiotic therapy, communicate with the physician or primary care provider immediately and
directly to have systemic antibiotics reassessed/continued or changed and document action regarding this
IF at any point, signs and symptoms of SYSTEMIC INFECTION are present, this can be life-threatening and needs
immediate medical attention.
When the signs and symptoms are resolved, you should STOP the antimicrobial dressings, but continue the
systemic (ORAL OR IV) antibiotics until the course is completed.
If patients are on antimicrobial dressings for longer than a four week period, review the dressing regimen and
consider referral to appropriate clinical specialist e.g. ET, Nurse or Physician Wound Care Specialist, or Specialist
Podiatrist for further discussion on management planviii.
i
Sibbald, R.G., Woo, K., Ayello, E. 2006. Increased bacterial burden and infection: The story of NERDS and STONES, Advances in Skin
and Wound Care 19 (8), pp. 447- 461.
ii
Woo, K.Y.; Sibbald, R.G. A Cross-sectional Validation Study of Using NERDS and STONEES to Assess Bacterial Burden Ostomy Wound
Manage 2009: 55(8):40-44.
iii
Halpern J, Holder R, Langford NJ (2008) Ethnicity and other risk factors for acute lower limb cellulitis: a UK-based prospective case
control study. Br J Dermatol 158(6): 1288–92.
iv
Burrows, C., Miller, R., Townsend, D., Bellefontaine, R., MacKean, G., Orsted, H.L.,and Keast, D.H. (2006) Best Practice
Recommendations for the Prevention and Treatment of Venous Leg Ulcers: Update 2006. Wound Care Canada 4(1):R130‐38.
v
Fulton, R. et al. Guidelines on the management of cellulitis in adults. CREST. 2005.
www.acutemed.co.uk/.../Cellulitis%20guidelines,%20CREST,%2005.pdf
vi
Levine, N.S., Lindberg, R.B., Mason, A.D. and Pruitt, B.A. 1976. The quantitative swab culture and smear: a quick, simple method for
determining the number of viable aerobic bacteria on open wounds. The Journal of Trauma 16(2), pp. 89-94.
vii
Stotts, N. 1995. Determination of Bacterial Bioburden in Wounds. Advances in Wound Care 8(4), pp. 28 - 46.
viii
NHS GREATER GLASGOW AND CLYDE WOUND FORMULARY DRESSINGS OF CHOICE. April 2010. Accessed at:
http://www.glasgowformulary.scot.nhs.uk/Wound%20formulary%20April%202010.pdf
Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014
9