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Essential Wound Care: Basics Every Dermatologist S ...
Wound Bed Preparation 2021-24 Update on Infection: ...
Wound Bed Preparation 2021-24 Update on Infection: Management Including Biofilms
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Hello, everybody. My name is Dr. Gary Sibbold. I'm a professor of medicine and public health at the University of Toronto, director of the International Interprofessional Wound Care Course, and project lead on Echo Ontario Skin and Wound, along with the co-editor and chief of Advances in Skin and Wound Care. Today, we're going to look at infection. And on the next slide, I do have some conflicts of interest. Two days a week, I work for the Ministry of Health, and I do do some consulting for Perfuse, which has a device that's not marketed in the States at the present time. Next slide. We're going to assess the wound bed paradigm as a basis for appropriate wound infection. We're also going to manage infection with a mnemonic, NERDS for the superficial infections, and STONIES for the deep and surrounding infection. And we're going to look at a new International Wound Infection Institute 2022 best practice, especially concentrating on biofilms. Here's the paradigm, and this is the eighth version of Wound Bed Prep. And a person at risk or with a chronic wound, we're going to treat the cause first and foremost. Secondly, we're going to address patient-centered concerns, and this includes pain, quality of life, and their support structure. The ability to heal will divide individuals that were able to treat the cause and have enough blood supply as healable versus maintenance where the patient doesn't adhere to treatment or the healthcare system doesn't provide a necessary step. And then non-healable wounds are somebody dying of cancer, a negative protein balance, and they're not going to produce granulation tissue because it's protein. So we're really looking at a non-healable wound. Local wound care really revolves around documentation and three steps. Debridement, is it necessary and how? Infection and inflammation. Moisture management. And then number eight, if a wound is not in a healing trajectory, it should be 30% smaller. By week four to heal by week 12. And if not, then we may need an interprofessional assessment. Have we got the right diagnosis? Do we need other investigations? Does the patient need a biopsy? Infection and inflammation often is the reason that that wound's not healing. We need to look at that, but if the wound is healable, but stalled without another cause, we can look at the edge effect. And in the edge effect, we're really looking at things like negative pressure wound therapy. We may be looking at specialized devices such as electrical stimulation, maybe skin grafts, maybe skin substitutes. Number 10 is healthcare system. Have we got things right? What could we do to improve our approach to wounds, our approach to the care of patients in general? Here are the steps in wound bed prep. And again, you see the arterial supply is key here for a healable wound. Even a maintenance wound may have enough blood supply, but the patient doesn't adhere to treatment. And we are going to concentrate on superficial and deep and surrounding infections and the use of infrared thermometry in this presentation. Okay, here's your first polling question. What's the purpose of a bacterial swab? Is it to diagnose infection, to detect antibiotic resistance, to direct antimicrobial treatment? Is it all of the above? Are it options to detect antibiotic resistance and to direct antimicrobial treatment? Why don't you pause the video in time to decide on your answer, and then we'll give you the correct answer on the next slide. Let's move on to the next slide. Here we see a swab is performed with the Levine technique. Cleanse the wound, but use saline or potable water, nothing bacteriostatic or xydal. Once you've cleaned the debris away, look for what appears to be viable tissue. You want to take the swab and press down lightly till you extract a little fluid, and then you're going to rotate 360 degrees and then put the swab in the transport media. If it's a relatively dry surface, you can put the swab in the transport media first, and that may be important. We diagnose infection on the next slide based on looking at the wound and looking at clinical signs, sometimes the symptom of pain without another etiology, but some wounds, the wound surface is small, but the surrounding tissue, okay, is a much larger space. As you can see in the diagram, you see the wound surface, but this wound covers a much larger space, and unless you debride, if it's a healable wound, you don't want to create a bigger wound that you can't heal. If you debride it to attached edges, you're more likely to get a positive result, but here you see a bone within the wound. I'm not so sure this is a healable wound the way it is, and this person may need surgical management. Here is the second question. Which of the following would be best to pack a non-healable wound? Normal saline, tap water, povidone-iodine-soaked ribbon gauze, Dakin solution, which is sodium hypochlorite on a gauze ribbon, or would you put chlorhexidine on that gauze ribbon? Let's have you vote. Pause the video until such time as you've decided on your vote, and we'll move on to the next slide. Here we see that saline-soaked gauze will donate moisture to the wound, but it's not antibacterial. Plain dry gauze will absorb exudate, but again, not antibacterial. PHMB, which is AMD gauze, will kill bacteria entering the gauze, and this is a polyhexamethylene biguanide, and PHMB is an AMD gauze antimicrobial dressing. It has very little release and is neutral to the wound surface, so you really should, before you put the gauze in, apply something to the wound surface if you want to treat the wound surface. Chlorhexidine-soaked gauze will donate to the wound surface, and as long as there's chlorhexidine in the gauze, it'll act to kill bacteria, and mouthwashes have a low alcohol concentration, and this may be very, very useful, and they can be bought at a relatively cheap price, and if it can be used in the mouth, it's less likely to sting when we put this in a wound surface. Popadone-iodine-soaked gauze releases iodine to kill bacteria in the wound, and this includes biofilms. Iodine is a small molecule, and it gets into the glycocalyx quite well, but we have to use with caution on large areas with thyroid disease. Remember, it's pro-inflammatory to the wound surface, and that may be desirable, but once we've got rid of the bacterial burden, we may want to go back to a neutral saline-soaked or plain dry gauze, depending on the wound characteristics. This is for non-healable or maintenance wound. Local wound care should be to debride only non-viable slough. You want to reduce bacteria, and you want to reduce moisture because the moisture is going to help the bacteria more than the host, and so moisture balance and active debridement is contraindicated. Topical antiseptics will decrease bacteria. Bacterial surface counts go down, and you're going to decrease the penetration of bacteria into the surface or even the deep and surrounding tissue. Topical PHMB gauze and chlorhexidine-soaked gauze, povidone iodine, and some countries have the povidone iodine in a polyethylene glycol base, but that's not true of the United States. Here we see the good, the bad, and the ugly, and chlorhexidine or PHMB, low toxicity, broad spectrum. It actually kills the bacteria. Povidone iodine has a broad spectrum, good penetration at the biofilm glycocalyx, as previously mentioned. It lowers hypochlorous acid, lowers pH, and will treat pseudomonas, so will hypochlorous acid as well, and it acts as a disinfectant. Saline or water is neutral and not antibacterial. Dyes like scarlet, red, and proflavin select a gram negative, so that's like toilet water. Sodium hypochlorite deacons are useful, unfortunately may be toxic, and it's really bleach that's better on countertops and not so much for wounds. Hydrogen peroxide is good in the emergency department to remove debris, but once the fizzing stops after a few seconds, it's not useful. It's not antibacterial, and if you pack it in a deep cavity, the action, the fizzing, may actually lead to an air embolus if it gets into tissues. Paternary ammonia compounds like cetramide have a higher tissue toxicity. Here's the effectiveness of PHMV versus MRSA, and this is scanning electron micrographs, and you can see here the circles represent biofilms or colonies of bacteria incubated for up to 168 hours and reviewed at 24, 72, and 168. You see a standard foam in all kinds of organisms. PHMV-coated foam, there's only a few organisms, and they're not normal. When we press the button, we can see gauze with the same phenomena, and you can see these biofilms building up on the gauze, but when PHMV is coated, there's a paucity of MRSA, so this is a very effective modality. Next slide. Let's look at the infection and inflammation, and when we look at the wound bed, perhaps in the 10 final statements, assess and treat wounds for infection and inflammation, treat local infection, three or more NERDS criteria with topical antimicrobials, and they're listed there, including silver, iodine, PHMV chlorhexidine, methylene blue, crystal violet foam, and surfactants. Consider treating deep and surrounding infection, three or more STONIES criteria with systemic antimicrobials, and evaluate and alleviate persistent inflammation, including consideration of anti-inflammatory agents in your topical dressings or even systemic medications, and dermatologists are familiar with doxycycline, clotrimoxazole, and erythromycins as having anti-inflammatory properties as well as anti-bacterial effects. The updated definitions and concepts related to wound infection, International Wound Infection Institute 2022. You can freely download this. And on the next slide, these are the five conditions that can exist within a wound. And we see contamination, organisms are present, but in colonization, they're present and there's limited proliferation, but it's not damaging the tissue. The next two I kind of consider together here. Local wound infection is covert and subtle, three plus nerds, and I'll show you what these criteria are in a second. And this is where we can use topical antisepsis. Local wound infection with overt or classical infection. There are seven criteria for stonies, three or more systemic antibiotics or antimicrobials. Spreading infection is when the deep and surrounding infection has prepotous, lymphagitis or lymph nodes. And this is where intravenous antibiotics may be used. And then with the systemic infection as above, but malaise, lethargy, sepsis, shock, and even death. Here's a practice point. Consider wound infection in the presence of multiple indicative signs and symptoms rather than the presence of any individual sign or symptom. So let's look at that in the next slide. And this is the nerds and stonies, pneumatic and covert or subtle infection. We're looking at nerds. Non-healing means over two to four weeks, the length and width hasn't changed. An increased exudate may be serous, sanguineous, or pustular. Always put the predominant component first, serosanguineous, serosanguineous, pustular. Red and bleeding, probably too much VEGF, vascular endothelial growth factor. And this, if you take a dressing off, you see this red pribal tissue. There may be a mountain. That's not healthy. Healthy tissue is pink and firm, and at the level of the epithelium surrounding the wound. Debris are dead cells. And this may be black, it may be brown. It's sitting on the top of the wound. And smell means gram-negatives or anaerobic. Stonies looks at the sides of a soup bowl, and there are four components on the side and three on the bottom. We often don't think of a wound as having a continuum between the two sides and the bottom or the base of the wound. Size is bigger. A temperature and infrared thermometry should be part of your wound care practice. Infrared thermometers, non-touch, can be up to a foot away. We've validated cheap ones you can get in a hardware store for $30 to $50 versus the exergen, the scientific standard, which is $700 or more. And so I think it is an important thing to think about, but you still need two other stonies criteria. The third sign on the sides of the wound are new areas of breakdown. You often get satellites that join up again, and erythema and edema greater than two centimeters is known as cellulitis. Exudate and smell are in both, so we need an additional stonies criteria for deep and surrounding, or an additional NERDS criteria clinical sign for superficial. Increased pain, if you haven't got another reason for that increased pain, and it's local around or in the base of the wound, then I think you should consider that in lieu of one of the clinical signs. Next one. What is the bacterial relationship with this non-healing wound? Is it contaminated, colonized, covert, or subtle infection? Is it over classical infection, deep and surrounding, or there are no bacteria in the wound? Okay, what do you think? We're going to ask you to pause the video, and I will give you the answer before I go on. So please pause if you haven't decided on an answer. Okay, my answer is that, first of all, it's non-healing. Second of all, you see the white areas around the wound, and those white areas around the wound represent maceration. So we know the dressing is not handling all the exudate, and in the center of the wound, we have retriable tissue. So we have three components. So this is really the covert infection. Next slide. Here we see NERDS criteria. You can see the maceration, the red pribal tissue, increased exudate from the maceration, and that green pyrosinin from Pseudomonas, you can smell that down the hall before you even go in the room. The one on the bottom right actually shows black tissue within the wound itself. So you really got lots of criteria. And if they're non-healing, other than getting larger, then you realize that you're dealing in local or covert infection. Then we have honey, although Cochrane reviews tell us there's not enough evidence. Slow-release iodine, like Codexamer. Silver, which comes in nanoparticles. Silver must have moisture to be active. It has to be ionized. And be careful not to put zinc oxide or other competing molecules around this that will, if you like, compete with the silver and its ionization. PHMB or chlorhexidine are static. They often stay in the preparation. So you have to use something to spray on or coat the wound itself first if you're going to treat the superficial compartment. And this also holds for a methylene blue, crystal violet type of foam, which is hydrophobic, and it is static rather than sidle. Here's the biofilm. And how successful are the following to eradicate that? So I'll show you in a minute. But here's the biofilm story with contamination. There's bacteria, planktonic, colonization. They start joining up and they start collaborating and they form a glycocalyx. With biofilm development, you get an inflammatory host response. And this is more prevalent with two surfaces of different viscosity. So we really do need to clean that surface wound. And with quorum sensing, the biofilms start to work as cohesive units. And every once in a while, they release planktonic bacteria, which can then seed the surrounding area. And really, this is why in chronic wounds, you can get recurring, spreading, and systemic infection. Okay, here we've looked at in vitro cleansing and irrigation and you can see all of these agents except silver might be used for that function. In vitro topical action, it's all of them. But when we look at biofilms, honey, but not when it's diluted, but when it's hyperosmolar and manuka honey has a little bit more antibacterial properties. So it will help with biofilms. Povidone iodine and cadexamer also very useful. And iodine's a small molecule gets into the glycocalyx very well. THNB and chlorhexidine a little bit better, but silver is not that active against biofilms. So this is something that is problematic. And when we look at sodium hypochlorite, and this is the bleach type of solutions, it's not active either. Hydrochloric acid, however, has a very good action. And actually, when we look at therapeutic index, we see that it's much less active against host cells and much more specific to bacteria. So with E. coli, it has a very good therapeutic index as well as Staph and Pseudomonas. The very best therapeutic index for MRSA was actually with PHNB. Let's look at the next slide. This is the Stoney's criteria. You see probing to bone. You see satellite areas on the left upper top. There's cellulitis surrounding on the two lesions on the right. You can see the maceration with excess exudate. You also see some pus at the base of the large toenail. And when that toenail was lifted up, there was actually exposed bone. And that wouldn't have cleared with systemic antibiotics without the good local wound treatment and wound hygiene. Next slide. Dermal thermometry, three degrees Fahrenheit or higher, but unequal blood supply and trauma like repeated injury of patients with repeated trauma. And David Armstrong and Larry Lavery have shown with infrared thermometers, if there's four degrees Fahrenheit or higher increase compared to the rest of the foot, patient should rest because that tells us they're at risk of breaking down, causing an ulcer. And the ultimate trauma deep in surrounding is the charcoal foot where the bones disintegrate and you absolutely got to keep that patient off weight bearing. So if you have a hot foot and an ulcer, think osteomyelitis or deep infection. If you have a hot foot without an ulcer, think of charcoal. But very occasionally those two things occurred together. Let's look at the next slide. Here with osteomyelitis, a classic paper in JAMA by Grayson. It was more specific than sensitive, but Lavery in 2007 in diabetes care as showed it was both sensitive and specific. The Grayson study had better positive predictive value than the Lavery study. Reliability, there's a gap, but probing to bone, especially in diabetic foot ulcers is a really good indication that you may have osteomyelitis. MRI is best, X-ray and bone scans are less reliable. Check probing to bone and ESR is a test that doesn't normalize quickly when elevated and a lot of infectious disease expert like an ESR over 50, some of them wanted even over 100 for osteomyelitis CRP is often elevated in the 20 or 30 range with a infection and it does normalize much faster than ESR. In developing countries, the probing to bone, ESR and C-reactive protein are often very important indicators of infection along with the local signs and symptoms. Okay, what have we done? We've assessed the wound bed prep paradigm and this is a basis for your approach to infection. Think of the NERDS and STONI's mnemonic, think of biofilms, think of wound hygiene, think of peelability. Hopefully we've taught you something new. You've got new things in your toolkit. We hope you can use them. It's been a great pleasure talking with you and I'm sure you'll enjoy the rest of the presentations in this series. Thank you.
Video Summary
Dr. Gary Sibbold, a public health professor, offers a comprehensive overview of wound care focusing on infection management. He introduces the wound bed paradigm, highlighting steps like debridement and infection control. Through mnemonics NERDS and STONIES, he categorizes infections to guide treatment, ranging from superficial to deep and surrounding infections. Emphasis is placed on the International Wound Infection Institute's 2022 guidelines, particularly for addressing biofilms.<br /><br />Dr. Sibbold also presents proper techniques for wound documentation, use of topical antiseptics, and implementing patient-centered care. The presentation underscores the importance of assessing arterial supply for healable wounds and adapting treatment based on patient-specific factors like adherence and comorbidities. Through polling questions, he engages the audience on effective infection diagnostic techniques. Additionally, Dr. Sibbold discusses the role of infrared thermometry and the effectiveness of various antibacterial agents, aiming to enhance wound healing by integrating evidence-based practices.
Asset Subtitle
by Gary Sibbald, MD, FAAD
Keywords
wound care
infection management
wound bed paradigm
biofilms
patient-centered care
evidence-based practices
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