Managing Wound InfectionsDemystifying the Role ofTopical Antimicrobials

Faculty

Dot Weir, RN, CWON, CWSClinical Coordinator

The Wound Healing Center

Osceola Regional Medical Center

Kissimmee, Florida

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Learning Objectives

• Discuss approaches to managing wound infection with topical antimicrobials

• Review cases illustrating the use of topical antimicrobials in the management of wound infections or protection from wound infection

• Implement patient-centered approaches to reduce tissue trauma and pain associated with dressing changes

Hospital-Acquired Infections

• Infections that patients contract while receiving treatment for medical and surgical conditions

• The US Centers for Disease Control and Prevention reports that HAIs contracted in US hospitals account for approximately 2 million infections—99,000 deaths

• Estimated $4.5 billion in excess costs annually

• Rates may be dropping, but it has also been estimated that 5% to 15% of all hospitalized patients experience an HAI and that these cases are widely underreported

HAIs = hospital-acquired infections.Oregon Healthcare Acquired Infection Prevention Plan. www.cdc.gov/HAI/pdfs/stateplans/or.pdf. Accessed January 11, 2012.

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Surgical Site Infections

Prevalence—United States

• ~500,000 SSIs/year

• 2% to 5% of patients undergoing inpatient surgery

Mortality

• 2 to 11 times higher risk of death

• 77% of deaths among patients with an SSI are directly attributable to the SSI

Morbidity

• Pain issues

• Long-term disabilities

SSIs = surgical site infections.Anderson DJ, et al. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S51-S61. Gray D. Wounds UK.2009;5(4):118-120.

Chronic Wounds?

• Unspecific epidemiologic data– Organism-specific available

• Individual institutions also track specific organisms, specifically MDROs

• Usually circles back to HAIs

MDROs = multidrug-resistant organisms.

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The Spectrum of Wound Bioburden

Sterile Infected

Contaminated Colonized CriticallyColonized

Infection: Clinical Picture

• Swelling

• Induration

• Erythema

• Warmth

• Pain

• Odor

Weir D. Assessing and controlling bioburden. In: McCulloch JM, Kloth LC, eds. Wound Healing: Evidence Based Management. 4th ed. Philadelphia, PA: F.A. Davis; 2010:105-119.

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Superficial Pseudomonasinfection

Deeply infected diabetic foot

Infected Wounds

Consequences ofUntreated Infected Wounds

• Impedes spontaneous healing and surgical closure of wounds

• Increases patient discomfort and risk of loss of tissue and/or limb

• Increased healthcare cost and hospital stays

• Increased need for antibiotic usage (promoting resistant strains)

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Techniques for Assessing Infection

• Gram stain– Provides early information while waiting for culture results

– Know if lab you are using includes gram stain automatically

• Qualitative– Presence or absence of bacteria

• Semiquantitative– Presence of bacteria with 1+, 2+, 3+, 4+ to designate correlation of number

• Quantitative– Performed with tissue

– Gives actual colony count (eg, 100,000 colony forming units per gram of tissue)

Weir D. Assessing and controlling bioburden. In: McCulloch JM, Kloth LC, eds. Wound Healing: Evidence Based Management. 4th ed. Philadelphia, PA: F.A. Davis; 2010:105-119.

Topical AntimicrobialsBased on Individual Dressing

Characteristics

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Role of Topical Antimicrobials

• Barrier to bacterial growth in patients at increased risk of wound infection

• Management of localized wound infection

• Local treatment of wound infection spreading or systemic wound infection in conjunction with systemic antibiotics

Vowden P, et al. Wounds International. 2011;2(1):1-6.

Addressing the Dressing

• Is the wound bed dry?– Hydrate it

• Is the wound draining?– Absorb it

• Is there space?– Fill it

• Is it filled in?– Cover it

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Types of Antimicrobial Dressings

• Silver

• PHMB

• Cadexomer iodine

• Bacteriostatic PVA foam

• Medicinal honey

PHMB = polyhexamethylene biguanide; PVA = polyvinyl alcohol.

Features of theIdeal Antimicrobial Dressing

• Sustained antimicrobial activity

• Moist wound-healing environment

• Consistent delivery of the antimicrobial over entire wound surface

• Allows for monitoring of the wound with minimal interference

• Manages exudate appropriately

Maillard JY, et al. EWMA J. 2006;6(1):5-7.

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Features of theIdeal Antimicrobial Dressing

• Is comfortable and conformable

• Provides effective microbial barrier

• Absorbs and retains bacteria

• Avoids wound trauma on removal

Maillard JY, et al. EWMA J. 2006;6(1):5-7.

Is There ONE That Is the BEST?

• Must show that they do what they say that they do– Level of microbial reduction or kill

– Length of time this is maintained

• Testing against known wound pathogens– MRSA, VRE, Staphylococcus aureus, Pseudomonas

aeruginosa, etc

MRSA = methicillin-resistant Staphylococcus aureus; VRE = vancomycin-resistant enterococci.

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Zone of Inhibition

In Vitro Log Reduction Testing

E. coliS. pyogenesP. aeruginosaS. aureus

3 hours2 hours1 hourStart

0

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Log

Red

uctio

n in

Bac

teria

A 5-log reduction=99.999% decrease in bacteria

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Silver Release over 7 Days

7652

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5

0

Silv

er R

elea

se (p

pm)

3 41

ppm = parts per million.

Day

Role of Silver Dressings as aTopical Antimicrobial

• Well-established history as an antimicrobial

• Increased interest within medical community due to antibiotic resistance

• Number of silver-based dressings on the market aimed at improved healing by controlling the wound bioburden

• Development of novel materials and technologies enabled silver to be directly incorporated into range of dressings

• Benefit from – Improved efficacy

– Safety

– Resistance profile

Maillard JY, et al. EWMA J. 2006;6(1):5-7.

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Silver Materials

• Alginates

• Hydrofiber

• Films

• Hydrocolloids

• Hydrogels

• Foams

• Combination dressings– ORC/collagen, collagen, activated charcoal

ORC = oxidized regenerated cellulose.Pal S, et al. J Am Chem Soc. 2009;131(44):16147-16155. Woodward M. Primary Intention.2005;13(4):153-160. DermNet NZ. dermnetnz.org/procedures/dressings.html. Accessed January 23, 2012.

Case StudiesWound Assessment and Treatment

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Case 1

• Male, age in mid-60s

• Medical history– Obesity, diabetes

• Underwent coronary artery bypass grafting

• Vein harvest site on lower extremity– Infected, ulcerated

Case 1: Exudate Management with Antimicrobial Absorbent Dressing

• Wound exhibiting high bioburden and signs of infection

• Patient treated with systemic antibiotics and silver alginate dressing under multilayer wrap

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Case 1: Exudate Management with Antimicrobial Absorbent Dressing

• Exudate strike-through 3 days later

• Silver alginate dressing, showing vertical wicking of exudate

Case 1

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Case 2

• 67-year-old male, ulcers to left lower extremity since at least 1999 (10 years)

• Medical history– Type 2 diabetes, rheumatoid arthritis, HTN, pulmonary HTN, deep

vein thrombosis, pulmonary embolism, venous insufficiency, lymphedema, antithrombin III deficiency, coronary artery disease, obesity, chronic anemia

• Retired banker from NJ, works at Walt Disney World but is on leave

• Past treatments– Everything—compression including short- and long-stretch, multilayer

compression, compression pump at home

HTN = hypertension.

Case 2: Initial Presentation

• To return to regular wound clinic and consider plastic surgery

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Case 2: Plastic Surgery Clinic

Case 2

• 2/23/2009: STSG, placement of NPWT bolster

• 2/26/2009: Removal of NPWT, dressed with xeroform, multilayer compression wrap, discharged home

STSG = split-thickness skin graft; NPWT = negative pressure wound therapy.

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Case 2: 2nd Clinic Visit, 3/6/2009

Case 2: 3rd Clinic Visit, 3/10/2009

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Case 2:4th Clinic Visit, 3 Weeks Post-Graft

Case 2: Treatment

• Soak/cleanse with hypochlorous acid

• Dress with silver/calcium alginate

• Multilayer compression wrap

• Started on linezolid

• Received outpatient blood transfusion—2 units

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Case 2: 2 Weeks Later

Case 3

• 76-year-old male admitted with acute respiratory distress syndrome, on multiple medications including methylprednisolone and enoxaparin

• Became very restless and banged hand into bed rail resulting in large hematoma

• Photos show wound after debridement of hematoma

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Case 3

• Silver gel used to maintain moisture, but over next few days developed necrosis/coagulum over surface, edges macerating

• 5/13/2009: Started bacteriostatic foam dressing

Case 3

• Day 2 • Day 5

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Case 3

• Over next few days, wound cleaned up and began to granulate

• 5/26/2009: STSG done with minimal debridement, bolstered with NPWT

• 6/01/2009: Removal of NPWT

Case 3

Final visit

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Case 4

• 77-year-old male, status post Mohs surgery for squamous cell cancer of forehead

• After ultrasonic debridement in clinic, ORC/collagen/silver matrix dressing initiated due to depth of wound and proximity to bone

Case 4

• 1 week later, patient had not been moistening dressing• Areas of wound dry

• Wound cleansed, patient and wife instructed again in dressing change technique

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Case 4

• 2 weeks later, wound clean, but bone exposed, referred to surgeon

• MRI negative for osteomyelitis at this point

• With continued use of ORC/collagen/silver matrix, rapid granulation noted over next week

MRI = magnetic resonance imaging.

Case 4

• Still some bone exposed, bioengineered tissue ordered to be applied the following week

• Continued same treatment

• The following week, bioengineered tissue cancelled because of continued rapid healing

• No change in treatment

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Case 4

2 weeks later, wound closed

Consider the Pain

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Pain Issues

• Increased recognition of pain and trauma at dressing changes and implications on wound healing

• Nonadherent dressings are a key importance to patients with wounds

• International wound survey of 2018 patients revealed 40.3% indicated that pain at dressing change was the worst part of living with a wound

– 53.8% reported pain “quite often” to “all the time”

Price P. The psychology of pain and its application to wound management. In: White R, Harding K, eds. Trauma and Pain in Wound Care. Wounds UK, Aberdeen; 2006:162-179.

Impact of Infection on Wound Pain

• Wound infection responsible for increased pain severity• Inflammatory response stimulated by infectious

microorganisms– Release of inflammatory mediators – Stimulation of production of enzymes and free radicals

• Direct stimulation of peripheral pain receptors by– Mediators– Tissue damage– Swelling that occurs as part of the inflammatory response

Mudge E, et al. Wounds International. 2010;1(3):1-6.

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Impact of Infection on Wound Pain

• Inflammatory cell damage may also increase the sensitivity of the pain receptors and central nervous system

• Other factors:– Friable granulation tissue that bleeds easily

– Increased exudate

– Wound breakdown

– Others

Mudge E, et al. Wounds International. 2010;1(3):1-6.

Plan for the Pain

• Have nursing unit premedicate patient

• Have patient take pain medication prior to coming to the clinic or once they arrive

• Consider topical anesthetics

– Cleanse wound before culture

• Assess pain before, during, and after dressing changes

• Query patient related to delayed pain following treatments

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Novel Antimicrobials withNonadherent Properties

• Use of dressings that are nontraumatic on removal may be of benefit

– Efficacy of silver

– Nonadherent layer

– High absorbent capacity

• Minimizes damage to wound surface

• Reduce trauma and pain with removal

World Union of Wound Healing Societies. Principles of Best Practice. www.wuwhs.com/pdfs/A_ consensus_ document_ -_Minimising_pain_at_wound_dressing_related_ procedures.pdf. Accessed January 20, 2012. Gray D. Wounds UK. 2009;5(4):118-120.

Summary

• Appropriate assessment and early recognition of wound bioburden can allow for early intervention

• Appropriate choice of an antimicrobial dressing should be based on a thorough wound assessment

• We must keep the elimination or reduction of pain and trauma related to the wound care we provide at the center of our management decisions

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