Diagnosing Infection
To diagnose an infection, look for the following clinical signs:

• no change or an increase in dimensions after a 3-week time frame;
• increase in tunneling and undermining caused by lack of granulation that has been inhibited or digested by bacteria along some areas of the wound bed;
• increased exudates;
• increase in devitalized tissue in the wound bed, i.e., slough, eschar or grey, stringy devitalized tissue;
• tissue friability either with dressing changes or wound cleansing under normal circumstances;
• discoloration of the granulating tissue to dull, with green or yellow to the core (change in color of exudates reflects a change in the organism present);
• foul odor caused by gram-negative bacilli, pseudomonas or anaerobic bacteria.³;
• Obtain significant information regarding how the wound occurred, the environment in which it occurred, presence of systemic infection, effects of prior treatment on healing and past infection management. (This is very important when dealing with patients with a history of MRSA or osteomyelitis. Include factors that affect management, such as age, cognitive ability, functional ability, level of mobility, caregiver ability, medications, nutritional status and concurrent conditions.

Culturing Wounds
Cultures guide antimicrobial therapy, but should not be the only diagnostic tool in infection determination. Don't culture a wound if there's no evidence of infection or impaired healing, except in the following situations:

• signs of healing don't occur in 2 weeks;
• there is pain in a neuropathic extremity;
• sudden high-glucose levels;
• pus in a wound;
• fever or leukocytosis;
• as the CDC indicates for resolution of MRSA. (Culturing for MRSA includes not only the wound, but nares and rectum). MRSA is no longer active in a patient if there are two negative sequential cultures from all these sites.¹²

Use the swab technique or tissue aspiration to get a culture. Cleanse the wound first with isotonic wound cleanser, then superficially debride it so the cultures from the superficial wound closely resemble those in the deeper wound. Don't attain cultures from pus or devitalized topical tissue. Note that culture swabs should reflect aerobic and anaerobic bacteria, particularly if the core of the wound contains slough or devitalized tissue.

Lab data for wound management pertains to a CBC with differential. White blood cells that are elevated, low lymphocyte counts and elevated neutrophils indicate infection.

Measure the degree of inflammatory response by presence and quantity of neutrophils per high power field. When a wound is at the dermal level, order a chemistry panel with albumin levels to check for malnutrition and dehydration. In some cases, the patient may need significant supplementation or possible placement of a gastric tube for adequate healing to occur.

Infection Management
The first step to managing infection in a chronic wound is to assess the patient for underlying causes that could be impeding wound healing. Simultaneous treatment of underlying conditions - such as heart failure, uncontrolled diabetes, inadequate compression and poor nutritional intake - need management and stabilization to affect healing.

To decrease bacterial load in wounds with slough or eschar, sequential debridement may be necessary. Sharp debridement should not occur in patients with clotting disorders or who are on blood thinners. With albumin levels below 3.0, don't perform sharp debridement at the bedside.

Hydrodebridement is warranted in any immunosuppressed patient with pulsed irrigation to the wound site. Pulsed irrigation systems use isotonic wound cleanser or saline, in sufficient pressure and quantity, to safely decrease bacterial load. Pulsed irrigation is reimbursable under prospective payment systems.

Treatment consists of wound cleansing to reduce surface contaminants, antimicrobial dressings, debridement of devitalized tissue, increased frequency of dressing changes and systemic antibiotics. Corrective measures include pressure relief, revascularization of ischemia and control of edema.

Antimicrobial Dressings
Antimicrobial dressings, which have proliferated in the marketplace, are now designed in several formats. The first 2 weeks of infection management are critical in decreasing bacterial load with these products. Over time, as the infection is resolved, use conservative management products so the patient doesn't build a resistance to the antimicrobial agents or new biofilms that render the product ineffective.

Diabetic patients with infection need stable blood sugars in conjunction with topical management to support a decrease in bacterial load. This may include cadoxemer iodine-based products or glycerine-based products to repel bacteria or topical antibiotic products.

If the patient's family chooses palliative care, alter management to a less aggressive approach. Instead, focus on keeping the wound clean and free from cross contamination and use products to decrease bacterial load, i.e. silver impregnated products.

Mary Foote is CEO at Woundcare on Wheels Inc., Naperville, IL.