WOUND CARE

Assessment, management and

prevention of infected wounds
Martyn Butcher
Eventually, if unchecked,
For the patient, wound infection can lead to poor healing outcomes bacterial numbers will increase to
and has the potential to result in life-threatening sepsis. For induce a state of localised infection
healthcare services, additional expense can be incurred due to the or widespread systemic infection.
need for remedial treatment and extra clinician time. Poor wound Kingsley (2001) describes this
infection rates also attract negative publicity and damage the direct relationship between wound
publics perception of care standards. This article examines the bioburden and the signs of infection
essential roles played by prevention of infection, early diagnosis as the wound infection continuum.
and the initiation of effective management strategies.
Biofilms
Biofilms are complex microbial
KEYWORDS: communities containing bacteria.
Wound bioburden Antimicrobial dressings Infection risk factors As the bacteria and microorganisms
in a wound multiply they eventually
become attached, synthesise and

C
ontamination of a wound
with organisms is inevitable
and clinicians should
recognise that no wound is truly
sterile (Bowler, 2002). Despite
this, the majority of wounds do
heal (Gilchrist and Reid, 1989).
However, in some cases wound
contamination can progress
to infection, which negatively
impacts on healing and may
pose a significant risk of systemic
disruption or life-threatening
sepsis unless adequately controlled.
Such infections also increase
healthcare expenditure, due to the
cost of treatment and the rise in
the number of patients needing
hospitalisation (Cook and Ousey,
2011).
The relationship between the
patient (the host) and the micro-
organisms present in the wound
(the wound bioburden) is dynamic
it is dependent on the numbers
of bacteria present, the ability of the
organisms to instigate a negative
effect on the host (virulence), and
the ability of the host to mount
an effective defensive response
Martyn Butcher, Independent Tissue Viability and
Wound Care Consultant, Devon
(Heggers et al, 1992; Mertz and
Ovington,1993 Rumbaugh et al,
1999; Bowler, 2002).
There is no universal definitive
volume of bioburden at which
an infection can be said to occur,
although a bacterial count of 105
colony-forming units per gram of
tissue is considered sufficient to
impede healing in most cases The protective matrix enhances
(Robson, 1997; Heggers, 1998).
While some organisms have little
effect on the body meaning that
high concentrations are required to
elicit changes in the local wound
environment or produce systemic
signs and symptoms other
organisms, such as haemolytic
streptococci, are virulent, and can have
a marked detrimental effect, even at
low numbers (Robson et al,1990).
In addition, pathogens work
synergistically to develop an
environment within the wound
in which proliferation is more
likely to occur (Bowler, 2003).
From very low numbers of bacteria
(contamination), the absence
of adequate host defences will
enable bacteria to multiply
(colonisation) until they impact on
the wound healing process (critical
colonisation).
secrete a protective matrix of sugars
and proteins (Wolcott et al, 2008).
Biofilms may comprise
single bacterial species, or more
commonly, multiple diverse
species, which continuously change
and adapt to the surrounding
conditions.
the tolerance of microorganisms
embedded in the matrix to the
immune system, antimicrobials
and environmental stresses,
making them difficult to eliminate
(Flemming et al, 2007). This may
account for many of the chronic
low-grade infections seen clinically
(Wolcott et al, 2008).
RISK FACTORS
In general terms, any pre-existing
condition that impairs the vascular
perfusion of the wound or reduces
the individuals ability to mount
an effective immune response
will increase the likelihood of
infection (McIntosh, 2007; World
Union of Wound Healing Societies
[WUWHS], 2008).
The risk of infection in the
acute wound is increased by
contamination, the presence of

JCN 2013, Vol 27, No 4 25

 WOUND CARE
debris (foreign material and non-
viable tissue) and delays in seeking
appropriate medical attention
(WUWHS, 2008).
By their very nature, chronic
wounds remain open for prolonged
periods of time, offering bacteria
the opportunity to contaminate the
wound and multiply to levels at
which they have a negative impact
on healing. Many patients with
chronic wounds have underlying
conditions, such as diabetes, which
make tissue repair problematic and
affect the individuals ability to
mount an effective defence against
bacterial attack. In addition, the
presence of high bioburden may
in itself slow the repair process
(Penhallow, 2005).
DIAGNOSIS OF WOUND
INFECTION
The diagnosis of wound infection
is based on the presenting clinical
signs and symptoms (Patel, 2010;
Cook and Ousey, 2011). The classic
signs are considered to be (Cutting
and Harding, 1994):
New or increasing wound pain
Erythema
Local warmth
Swelling
Purulent discharge.
There may also be wound
malodour and pyrexia (WUWHS,
2008). If infection spreads and
systemic infection is present,
pyrexia becomes more common
and erythema may spread from the
immediate wound area, tracking
towards the proximal lymph nodes
in particular. These, in turn, may
become swollen (lymphangitis).
An increase in wound size, wound
breakdown and/or dehiscence is also
likely to occur (WUWHS, 2008).
In chronic wounds, the presence
of infection may be less obvious.
Underlying conditions such as
sensory neuropathy and altered
immune-competence may mean
that signs become muted or hidden,
and systemic signs such as pyrexia
may not be present until the
infection is well-established (Ousey
and McIntosh, 2009). As well as
the more obvious signs, changes in
26 JCN 2013, Vol 27, No 4
wound odour, increased exudate
volume and pain may all indicate
localised infection.
Within the wound, tissues
may become discoloured, more
friable and likely to bleed and
healing may be delayed or halted
altogether. When granulation does
occur, bridging (the formation of
strands of granulation or epithelial
tissue over non-healed tissue)
and pocketing (non-healing tissue
surrounded by active granulation)
may be observed (European Wound
Management Association [EWMA],
2006; WUWHS, 2008).
The diagnosis of wound
infection is based on
presenting signs and
symptoms.
While microbiological analysis
(obtained from the culture of
swab samples) is a useful tool in
investigating the likely causative
organism and is an essential
part of the clinicians armoury
in effectively managing infected
wounds it has its limitations.
Cultures of any swab are likely to
reveal a number of bacterial species,
but whether these are responsible
for the infection or are simply
surface-colonising organisms is
debatable (Gilchrist, 1996).
Although wound swabbing is
the commonest investigation, it is
not without error and care must be
taken in interpreting its findings.
If infection is suspected (by clinical
signs in acute and chronic wounds
and/or when chronic wound healing
has stalled despite appropriate
treatment), swabs should be taken
after wound cleansing and removal
of non-viable tissue (WUWHS,
2008). The sample should be sent
to the laboratory accompanied by
a full patient and wound history to
aid analysis (WUWHS, 2008).
Despite the prevalence of
swabbing, wound biopsy is a
far more accurate method of
determining infection status, but
is rarely available in the general
community setting (Dowsett et
al, 2004). For patients displaying
overt systemic signs of spreading
infection, blood cultures should
be obtained and urgent expert
assistance sought (WUWHS, 2008).
PREVENTING INFECTION
AND MANAGING INFECTED
WOUNDS
Optimising the host reaction is a
key component in the prevention
and management of infection
(WUWHS, 2008), and thus it
is essential that the patients
nutritional and hydration status
is maintained.
Management of incontinence
will help prevent contamination
of the wound and any dressings
with faecal debris particularly
significant when the wound is in
the pelvic region or on the leg.
For patients with diabetes, the
importance of tight glycaemic
control should be explained and, if
required, blood sugar levels should
be monitored more frequently. This
is particularly significant if infection
is present, as blood sugar levels may
become unstable.
Tissue oxygenation and vascular
perfusion should be optimised
(WUWHS, 2008), and to encourage
blood flow patients with known
vascular disease should be advised
to exercise (within the limits of
their condition). Where dependent
oedema is present, elevation of the
affected limb will reduce venous
congestion and assist local perfusion
by dispersing extracellular fluid.
Respiratory function and,
therefore, tissue oxygenation can
be improved by even moderate
exercise and postural improvement,
and patients that smoke should be
given advice and support to reduce
or stop.
LOCAL WOUND MEASURES
Steps should be taken to reduce
contamination of the wound.
Adhering to universal precautions
when dressing the wound
prevents inoculation with potential
pathogens and, if infection has
 WOUND CARE
become established, helps to
reduce the risk of microorganisms
spreading to other patients. In the
community, the patient and their
informal carers will need to be
trained, as many will have an active
role in managing the wound.
Leakage of exudate through the
dressing (strikethrough) provides a
portal for the ingress of pathogens
into the wound (Thomas, 2010;
White, 2011). Clinicians should
select dressings that are able to cope
with elevated volumes of exudate
and the frequency of dressing
change should be increased (White,
2011). If soiling of the outer structure
of the dressing has occurred, the
dressing should be replaced.
Necrosis
The presence of necrotic material
within the wound provides a
nutrient-rich base for bacterial
proliferation (EWMA, 2006;
WUWHS, 2008) and a barrier
Expert opinion
Kate Arkley, Community RGN, Galway, Ireland
T
his is an excellent article
highlighting the clinical
challenges faced by community
nurses in the assessment and
prevention of wound infection. It
clearly demonstrates the complexities
of wound management, while
outlining the multiple levels of
knowledge and clinical judgement
required to prevent and treat wound
infection in clinical practice.
Changing demographics and
the increased likelihood of patients
presenting with comorbidities can
negatively influence the natural
healing process. From a clinical
perspective, the section on dressings
offers practical information to enable
effective decision-making.
The article emphasises the
need for clinicians to recognise
the difference between acute and
28 JCN 2013, Vol 27, No 4
to topical antimicrobials and
antibiotics (Weir et al, 2011). This,
therefore, should be debrided
(WUWHS, 2008).
Similarly, the presence of high
volumes of bacteria-rich exudate
provides an environment for
proliferation (Adderley, 2010).
Wounds should be drained of this
fluid to reduce bacterial numbers
(WUWHS, 2008). Although it
is recognised that wound bed
cleansing is unnecessary at each
dressing change, the exception
is the infected wound, where
cleansing at dressing change may
be beneficial (Cutting, 2010). This
also offers the opportunity for
gentle debridement of the wound
bed, which, through its mechanical
action, reduces necrotic burden
within the wound and may
disrupt biofilms.
REDUCING BIOBURDEN
Reduction in wound bioburden is
a key element in the management
of the colonised or infected wound.
chronic infection. It is essential
that community nurses are able
to interpret wound bed changes
accurately. This knowledge will
determine the need for swab
collection if infection is suspected.
In my experience, the fact that
wound swabs need collecting post-
cleansing should be emphasised.
Also, the importance of providing a
detailed history on the request form
ensures that pertinent information,
including symptoms and current
medication, will be routinely
reported. This allows lab technicians
to perform informed microculture
and sensitivity lab testing.
This article is clear, concise and
provides an excellent reference
for community nurses attempting
to minimise wound infection and
promote healing in their practice.
Guidelines on the management
of wound infection (EWMA, 2006;
WUWHS, 2008) have suggested
that topical antimicrobial dressings
may be useful in reducing wound
bioburden. Some have active agents
that disrupt bacterial proliferation
or are toxic to cells, whereas others
contain substances that bind
bacteria to the dressing.
In addition, the structure and
function of some dressings base
materials means that they are able
to effectively manage the negative
sequelae of wound infection (White,
2011). For example, absorbent
agents such as alginates, hydrofibres
and foam-based dressings can help
to reduce exudate volume, while
offensive odours may be neutralised
by charcoal-based products
(Williams, 2001).
Products based on the
antimicrobial agents iodine,
silver, honey and latterly
polyhexamethylene biguanide
(PHMB) are considered by many
to be the first line of treatment in
the management of bioburden,
particularly in chronic wound care,
as they have the following benefits:
Provide a high antimicrobial
concentration at the site of
infection (White et al, 2001;
Cooper, 2004)
Have bactericidal effects against
multiresistant organisms such as
methicillin-resistant Staphylococcus
aureus (MRSA) (Lawrence, 1998;
Sibbald et al, 2001)
Do not interfere with the
protective bacterial flora in other
parts of the body
Are less likely to produce an
allergic reaction.
Silver
Silver-based products have been
particularly successful in burns
(Klasen, 2000a; Klasen, 2000b;
Demling and DeSanti, 2001), and as
an antimicrobial in general wound
care (Armstrong, 2002; Clarke,
2003) with skin discolouration
(argyria) being the only visible side-
effect (Wright et al, 1998).
Silver ions are highly reactive
and affect multiple sites within
bacterial cells, ultimately causing

bacterial cell death. They bind to
bacterial cell membranes, causing
disruption of the bacterial cell wall
and cell leakage. Once transported
into the cell, silver ions interrupt
the cells function by binding to
proteins and interfering with energy
production, enzyme function and
cell replication (Lansdown, 2002;
Hermans, 2007).
Silver ions are active against
a broad range of bacteria, fungi
and viruses, including many
antibiotic-resistant bacteria, such
as MRSA and vancomycin-resistant
Enterococci (VRE) (Parsons et al,
2005). Studies have suggested that
silver may reduce bacterial adhesion
and destabilise the biofilm matrix
(Chaw et al, 2005), as well as killing
bacteria within the matrix. Silver
dressings represent one in seven of
all wound dressing prescriptions in
the UK (Iheanado, 2010).
Iodine
Iodine-based products have been
used in wound care for many
years. Exposure of bacteria to
iodine causes changes in cells
walls, membranes and cytoplasm,
resulting in rapid death (Gottardi,
1983) through leakage of cellular
materials (Schreier et al, 1997).
Povidone-iodine is not as
effective as some other biocides in
eradicating Staphylococcus epidermidis
within in-vitro biofilms (Presterl
et al, 2007), but cadexomer iodine
provides enough iodine for biofilm
suppression while not causing
significant host damage (Akiyama et
al, 2004; Rhoads et al, 2008).
Honey
The antibacterial action of honey
is due to its high osmolarity, which
inhibits microbial growth (Molan,
2001), and the action of intrinsic
enzymes, which release hydrogen
peroxide into the wound (Molan
and Betts, 2004). Some honeys,
particularly the manuka honeys,
have been found to retain their
bactericidal properties even without
the presence of hydrogen peroxide,
and are effective against both
antibiotic-sensitive and antibiotic-
resistant organisms (Cooper et al,
2002a; 2002b).
PHMB
Although the use of PHMB is
widespread in German-speaking
Europe and the US, these dressings
are a relatively new development
in the UKs wound management
armoury. PHMB is a fast-acting
biguanide compound composed
of a synthetic mixture of polymers.
It has a broad spectrum of activity
against bacteria, viruses and fungi,
inducing cell death by disrupting
cell membrane integrity (Moore and
Gray, 2007).
However, PHMB does not
interfere with the proteins that
make up animal cell membranes
and has an effect on both
planktonic bacteria and those
in biofilms (Seipp et al, 2005;
Pietsch and Kraft, 2006; Harbs
and Siebert, 2007). A significant
body of evidence is now emerging
to support PHMBs use in the
management and eradication of
wound bioburden (Butcher, 2012).
The antibacterial action
of honey is due to its high
osmolarity, which inhibits
microbial growth.
Dialkyl carbamoyl chloride
An alternative approach to
bioburden management is offered
by products containing dialkyl
carbamoyl chloride (DACC)
technology. DACC is a fatty
acid derivative, which is applied
to dressing materials during
manufacture. It provides the dressing
with strongly hydrophobic properties
bacteria become irreversibly
bound to the wound dressing itself,
preventing them from proliferating
or releasing harmful exotoxins. At
each dressing change inert bacteria
are removed from the wound bed
along with the dressing product,
thus reducing the bacterial load
(Cutting and Butcher, 2011).
CONCERNS REGARDING
TOPICAL ANTIMICROBIAL
DRESSINGS
Recently, concern has been
raised regarding the cost and
cost-effectiveness of topical
WOUND CARE
antimicrobial dressings (Bergin
and Wraight, 2006; Chaby et al,
2007; Michaels et al, 2009), and
their safety in respect to the
systemic absorption of antimicrobial
elements and potential for systemic
toxicity (Wan et al, 1991; Parsons et
al, 2005; Burd et al, 2007; Denyer,
2009; Wang et al, 2009).
The results of studies such as
the VULCAN trial (Michaels, 2009),
which appear to indicate that silver-
based antimicrobial products are
not cost-effective, have added to
this controversy, although alleged
methodological flaws in this particular
study have led to widespread criticism
of its recommendations (Calderon et
al, 2007; Gottrup and Apelqvist,
2010; Leaper and Drake, 2010; White
et al, 2010).
To date, however, there has
been no conclusive evidence
that, when used appropriately,
topical antimicrobial dressings
pose a significant risk. Thus,
to aid clinicians a number of
recommendations for safe use
have been developed (Bowler et al,
2001; EWMA, 2006; Best Practice
Statement, 2011; International
Consensus, 2012).
Most importantly,
antimicrobial use should be
targeted to those at most risk or in
whom wound infection has been
diagnosed. Treatment should also
be measured and time-limited
widespread, inappropriate use
increases healthcare costs with no
outcome gain.
Once initiated, if the signs of
infection subside and the patient
shows no signs of systemic
infection, the antimicrobial agent
may be discontinued. If the
wound continues to show signs
of infection, a systemic antibiotic
should be considered (EWMA,
2006). Similarly, a lack of a
noticeable healing response within
two weeks may necessitate the use
of other topical or systemic agents
(Bowler et al, 2001; Best Practice
Statement, 2011).
The prophylactic use of
antimicrobial preparations is
JCN 2013, Vol 27, No 4 29
 WOUND CARE
Five-minute test
Answer the following questions
about this article, either to test the
new knowledge you have gained
or to form part of your ongoing
practice development portfolio.
1 What are some of the risk factors
for wound infection?
2 Name some of the ways in which
wound infection can be diagnosed.
3 What are the common symptoms
of wound infection?
4 Name some of the main techniques
for helping to reduce bioburden.
5 Can you identify the main
components of the most common
antimicrobial dressings?
controversial. However, the use
of these products can be justified
in individuals whose immune
capability is severely restricted,
or where there is a high risk of
infection.
SYSTEMIC INFECTIONS
Spreading infection has potentially
serious implications for patient
well-being. Wound and blood
cultures are used to identify the
offending organism and to assess for
differential diagnosis. Appropriate
systemic antibiotic therapy should be
implemented straightaway (EWMA,
2006; WUWHS, 2008).Topical
antimicrobial dressings should also
be used to help reduce the wound
bioburden (EWMA, 2006;
WUWHS, 2008).
Antibiotics are administered
orally or intravenously. Most
reduce bacterial numbers by
targeting bacterial functions or
growth processes (Calderon and
Sabundayo, 2007). Most have a
narrow band of effectiveness,
with particular antibiotics being
needed to treat particular bacteria
species or strains. However, there
are problems with the use of
antibiotics:
30 JCN 2013, Vol 27, No 4
Systemic antibiotics treat the
whole patient, not just the
wound. Therefore, they can affect
normal wound flora leading
to unpleasant side-effects and
systemic complications such as
Clostridium difficile infections
Systemic antibiotics require an
adequate blood supply to reach
the point of infection, and so
may be ineffective in treating
wounds with a high necrotic
burden or in patients with
underlying arterial insufficiency
The use of antibiotics can
select for resistant bacterial
strains as antibiotics eliminate
species that are sensitive to
their specific action, while
leaving unaffected those in
which genetic modification
has enabled the evolution
of defence mechanisms.
This means antibiotics can
enable the resistant species to
proliferate and dominate the
wound micro-flora (Huovinen
et al, 1994). Resistance to
antibiotics has become a serious
problem for those involved
in wound care (White et al,
2001). Easterbrook (1998)
suggested that widespread and
often indiscriminate use of
antibiotics is a major factor in
the emergence of drug-resistant
bacteria
The emergence of bacterial
resistance has reduced the
treatment options for many
systemic infections. It is,
therefore, important that new
antibiotic options are developed
if the medical world is to have
new weapons to treat disease.
Currently, there are no new
antibiotic preparations in
development and no new
products on the horizon. This is,
therefore, a potential time-bomb
in emerging nations and the
developed world
Systemic antibiotics have limited
effect on biofilm colonies (Moss
et al, 1990; Marr et al, 1997;
Costerton and Stewart, 2001).
Thus, due to the limited
efficacy of systemic antibiotics
and the need to reserve them for
serious infections they are not
recommended for wounds that
KEY POINTS
Wound infection results from the
inability of the patients body to
control the burden of bacteria
within a wound.
Identifying those factors which
increase the likelihood of
infection and maximising the
patients natural defences are
essential steps in preventing
infection.
If infection occurs, it is important
that clinicians are able to identify
the signs and symptoms and
initiate speedy and appropriate
treatment.
Judicious use of topical
antimicrobial wound dressings
has proven to be an effective
method of reducing bioburden,
and enables clinicians to reserve
the use of antibiotics to those
patients in greatest need.
Spreading infection has
potentially serious implications
for patient wellbeing and wound
and blood cultures are used to
identify the offending organism
and to assess for differential
diagnosis.
The emergence of bacterial
resistance has reduced the
treatment options for many
systemic infections.
Due to the limited efficacy
of systemic antibiotics and
the need to reserve them for
serious infections, they are
not recommended for wounds
that only show signs of local
infection.
only show signs of local infection
(Bowler et al, 2001). In addition,
topical antibiotics are linked to
the development of bacterial
resistance and can provoke delayed
hypersensitivity reactions (Zaki
et al, 1994), and so are neither
recommended nor have a role in
the management of chronic wounds
(WUWHS, 2008).
CONCLUSION
Wound infection occurs when
 WOUND CARE
the body is unable to mount a
sufficiently robust defence to
control the burden of bacteria
within a wound or when defence
mechanisms are overwhelmed by
the numbers and virulence of the
pathogens present.
While the clinician must accept
that some degree of contamination
of the wound with environmental
microorganisms is inevitable,
the escalation of this to a state
of infection should be avoided.
Identifying those factors which
increase the likelihood of infection
becoming a problem, taking
preventative actions to control
them, and maximising the patients
natural defences, are all essential
steps in preventing infection.
However, if infection occurs it is
important that the clinician is able
to identify the signs and symptoms
and initiate speedy and appropriate
treatment to control and reduce
bacterial numbers and re-establish
an equilibrium within the wound,
which will support the repair
process. Judicious use of topical
antimicrobial wound dressings has
proven to be an effective method
of reducing bioburden, enabling
clinicians to reserve the use of
antibiotics just for those patients in
greatest need. JCN
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