Wound Infections, Best Practice

[dsharrison]

Hi all,

I am running into a lot of trouble with differing opinions about how to approach wound infections (or possible infections.) I am a home care nurse and work with many different physicians who all believe their way is the only way.

So, in the case of a possible infection, what do you think about wound cultures? Both to superficial and deep wounds? Necessary or no? Beneficial or not?

In treating wound infections, are PO abx only good for cellulitis type infections, and in that case, topical abx (bacitracin, etc.) for other wound infections?

In many difficult situations such as this, I've been fortunate in that Medihoney seems to clear up many infected or possibly infected wounds.

How about identifying infections? Sometimes it's really hard when the periwound is kind of a darker pink and could either maybe be infection, or maybe healing?? I tend to think infection, but some of the physicians I work with think not...

[Davidaugustyn]

OK.

I never advise to culture a wound, and that is best practice.

A wound is full of bacteria. There's nothing that can be done about that.

Unfortunately there my be MRSA or somethings else in the wound that won't be killed with just any ABTX. Doesn't matter though because oral ABTX are practically useless to a wound. Fortunately, you don't need to kill wound bacteria internally as you would pneumonia. (Unless it's getting severe and spreading)

Dakin's solution.

I'm not one to put bleach in an body cavity, but I have seen some very successful results from a low concentrated dakins (1/16) in reducing signs of infection.

I always use dakins for a week or two on excessive green drainage.

Silver if not yet severe.

I've never really been one for honey. Though I love natural benefits, I find honey better for internal healing where dakins can't go. I use a diluted honey for pink eye in our house. Works every time.

[BostonFNP, APRN]

OK.

I never advise to culture a wound, and that is best practice.

A wound is full of bacteria. There's nothing that can be done about that.

Unfortunately there my be MRSA or somethings else in the wound that won't be killed with just any ABTX. Doesn't matter though because oral ABTX are practically useless to a wound.

Can you please share you sources on this? I find it very interesting as I regularly culture purulent open wounds in primary care to ensure adequate coverage of empiric therapy with oral antibiotics.

Sent from my iPhone.

[Davidaugustyn]

I'm sorry I was in a mindset when I wrote that. What I should have more clearly stated was that topical antibiotics were useless, and oral antibiotics, unless broad spectrum, have little efficacy due to the way we culture a wound. I do agree with punch biopsy, but only as a means to diagnosing infection. (which I believe can be done with a look and a temp)

On that note, Dakins is not best practice either. I have a tendency to speak on the results I see along with the knowledge I've gained. I can see the results with Dakins. (for short periods only)

Here is the link to article that sums it up well.

http://www.o-wm.com/content/bacterial-swabs-and-chronic-wound-when-how-and-what-do-they-mean

I would encourage you to stay minimal with the culturing purulent wounds. It's not a good indicator or the bacterial bioburden. Also purulent drainage is not always an indicator of infection.

[mommy.19, MSN, RN, APRN]

Best practice is quantitative culture and I would suggest PCR (polymerase chain reaction) DNA assay to determine type of species and sensitivities. One would be hard pressed to find a chronic wound without biofilm, which requires multimodal therapy to eradicate. Yes, all wounds are colonised, however, this does not mean that all is lost and we should ignore that. Dakin's solution is toxic to fibroblasts and keratinocytes, and if a wound is infected enough to use sodium hypochlorite, it probably needs a decent degree of sharps debridement, local wound care, and potentially a biopsy as others have discussed to elucidate the exact species of bacteria.

It sounds like you are in a home care setting, that that can provide difficult when trying to assess and communicate recommendations to providers who are not physically seeing the patient's wound. Also, some patients may only show a few of the signs of infection due to suppression of the immune system that accompanies many comorbid conditions. Generally, changes in wound condition are more indicative of infection than one assessment alone. Increase in wound size, drainage, pain, or presence of odor despite thoroughly cleansing the wound and disposing of soiled dressings (also in the absence of necrotic tissue, as this is generally a source of odor), can indicate infection. Topical antibiotics are frowned upon because as others have already said, there are many species contributing to the biofilm. Biofilm is like a tumor. Some bacteria on the outside of the biofilm are senescent, and the antimicrobial agent, being local or systemic, may still not reach the pathogenic species at the root of the problem.

Medihoney is a great product, it can actually compete with binding sites on cells with bacteria. It is great for odor and conforms well to the contours of the wound.

[Davidaugustyn]

Well said mommy.19