Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014 1

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 treatments3

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

Contaminated

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

wairiotina.blog.com

Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014 2

Term Clinical Interpretation Clinical intervention

Localized Infection (Critical Colonization)

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 Community-

acquired 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/Wound_Guidelines/Lymphoedema_Framework_Best_Practice_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 3

Identification and Classification of Signs of Infection (NERDS & STONEES)i,ii

Speaker, Title, Hospital

• Non-healing

• Exudate

• Red + Bleeding

• Debris

• Smell

NERDS Superficial:

Treat topically

Mnemonics for Wound Infection(Sibbald, Woo, Ayello ‘06, Woo & Sibbald ‘09)

Adapted from CAWC Conference 2011 Dr. R.G.Sibbald

NERDS

Non-healing• Wounds that are not

20% to 40% smaller

in 4 weeks according

to patient history or

existing

documentationSibbald, Woo, Ayello ‘06, Woo &

Sibbald ‘09

©Connie Harris ET NOW 2006

NERDS

Exudate• 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

NERDSRed

• Wound bed

tissue is bright

red with

exuberant

granulation

tissue

• Tissue bleeds

easily with gentle

manipulationSibbald, Woo, Ayello ‘06, Woo

& Sibbald ‘09

©Connie Harris ET NOW 2001

©Connie Harris ET NOW 2001

NERDS

Debris

• Presence of

discolored

granulation

tissue,

slough, and

necrotic/nonviable

tissueSibbald, Woo, Ayello ‘06, Woo &

Sibbald ‘09 ©Connie Harris ET NOW 2001

NERDS

Smell

• Unpleasant or

sweet,

sickening odorSibbald, Woo, Ayello ‘06,

Woo & Sibbald ‘09

©Connie Harris ET NOW 2005

Validation of NERDS Any 3 or more of the following indicate HIGH superficial bacterial infection:

• Non-healing • Exudate increased • Red friable • 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.

www.calgarylabservices.com

Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014 4

Identification and Classification of Signs of Infection (NERDS & STONEES)i,ii

Speaker, Title, Hospital

• Size is bigger

• Temperature ↑

• Os (probes, exposed)

• New breakdown

• Erythema, Edema (Signs of Cellulitis)

• Exudate,

• Smell

STONEES

Deep:

Treat Systemically

Mnemonics for Deep or Spreading Wound Infection

(Sibbald, Woo, Ayello ‘06, Woo & Sibbald ‘09)

Adapted from CAWC Conference 2011 Dr. R.G.Sibbald

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 inSibbald, Woo, Ayello ‘06, Woo &

Sibbald ‘09

STONEES

Temperature• Increased peri-

wound margin

temperature by

more than 3ºF

difference between

two mirror-image

sitesInfrared

Scanner

ThermometerSibbald, Woo, Ayello ‘06, Woo & Sibbald ‘09

© CarePartners 2006

STONEES

Os• Wounds that have

exposed bone or

that probed to bone

at the time of

examination have

risk of osteomyelitis(DFUs have biggest risk—57 to

89% Positive Predictive Value)

Sibbald, Woo, Ayello ‘06, Woo & Sibbald ’09Lavery, L. et al. Diabetes Care 30:270–274, 2007

CarePartners and www.amazonsupply.com

http://www.radiologyassistant.nl/en/p4b6e855359a09/diabetic-foot-mri-examination.html

STONEES

New

• New areas of

breakdown or

satellite lesions

Sibbald, Woo, Ayello ‘06, Woo &Sibbald ‘09

© Red Cross Care Partners 2013

STONEES

Erythema & Exudate

• Reddened skin in

periwound area

• Presence of swelling in

periwound area

• Increased amount of

drainage

Sibbald, Woo, Ayello‘06, Woo & Sibbald ‘09

© BWAT Pictorial Guide 2008

Used with Permission

Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014 5

Identification and Classification of Signs of Infection (NERDS & STONEES)i,ii

STONEES

Smell

• Unpleasant or

sweet, sickening

odorSibbald, Woo, Ayello ‘06, Woo & Sibbald ‘09

©Connie Harris ET NOW 2002

Validation

18

STONEES

Any 3 or more of the following

indicate HIGH bacterial infection

in the deep compartment:-Size increasing

-Temperature increasing

-Os; probes to bone

-New or satellites

-Erythema

-Edema

-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.

Other Signs /Symptoms of Deep or Spreading Infectioniii,iv

Pilonidal Sinus Wounds:Premature Bridging of Epithelial or Granulation Tissue &

Pocketing in the Base

Single Symptom of Infection• New, increased or altered PAIN is individually

highly indicative of infection.

Pain in a previously insensate DFU

– is indicative of

infection and

possible

osteomyelitis

©Connie Harris ET NOW 1997

Other Predictors of Osteomyelitis in Diabetic Foot Ulcers • 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

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

All 3 photos ©CarePartners

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Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014 6

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

www.asdk12.org

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)

howshealth.com

BWAT Pictorial Guide Superficial Surgical Site Infection (SSI) Spreading 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

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 7

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

• 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.

22

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

23

extww02a.cardinal.com

• There is a linear relationship between

quantitative tissue biopsy and swab for

culture using a specific method (Levine)

24

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

Validated method

Limitations of Swabs

• The c&s results may not reflect the presence or absence of biofilm, or test for all bacteria present

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.

25

Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014 8

Levine Method Swab for Culture and Sensitivityvi,vii

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

26

Procedure

• Thoroughly rinse wound with normal saline (non-

bacteriostatic).

• 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

Procedure

• Don’t swab:

– pus

– exudate

– hard eschar

– necrotic tissue

• Results will only show what is on the surface,

not what is actually in the live (viable) tissue

28

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

29

©Connie Harris ET NOW 1996

© Parkwood Wound Care Team 2011 for SWRWCF

Procedure

• Remove protective cap from culture medium and

insert cotton tipped applicator into the culture

medium without contaminating the applicator

shaft

30

Hold Here!

Procedure

• 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

©CarePartners ©CarePartners

www.calgarylabservices.com

Signs, Symptoms and Actions for Superficial and Spreading Wound Infection Oct 20, 2014 9

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