Management of wound infection

In this article, Professor Karen Ousey discusses the principles involved in managing a wound infection to ensure a speedy recovery.

Cleaning the wound bed

After assessing the wound bed, tissue management (debridement of devitalised tissue) is essential.

For cleaning the wound, consensus opinion is to gently irrigate the wound with normal saline at room temperature. The periwound area should be protected from any source of laceration.

Dressing choice will be based on the assessment of the patient and the wound. This can change as the wound progresses through the healing trajectory or as the infection begins to subside.

Management of wound infection

Wound dressing regimens should be designed to follow the principles of moist wound healing using products selected to optimally manage the patients’ symptoms while encouraging wound healing. It must provide an optimal environment to promote rapid healing.

Use antimicrobial agents appropriately. It is important to consider whether a wound is clinically infected or not. Restrict the use of systemic agents to occasions when they are specifically indicated.

Any dressing that you put on the wound should avoid topical sensitisation or allergic reactions.

Cleansing infected wounds

When we discuss antimicrobials for cleansing infected wounds, we are referring to disinfectants, antiseptics, and antibiotics. Disinfectants are substances recommended by the manufacturer for application to kill microorganisms and are not suitable for internal use. Antiseptics are also known as skin disinfectants. They have a destructive or a biocidal effect on bacteria, fungi, and viruses, depending on the type and the concentration of the preparation. These topical antiseptics are not selective and may be cytotoxic if not delivered to the wound in a sustained manner. This means they might kill skin and tissue cells involved in healing, thereby impairing the healing process. Many of the older antiseptics, such as hydrogen peroxide, and sodium hypochlorite, for example, Eusol, which was the Edinburgh University Solution of Lime are no longer recommended, due to the high risk of tissue damage associated with their use.

There is one exception for wound management: in low resource country settings, where alternative contemporary antiseptics are not always available. However, in general most healing wounds do not require the use of antimicrobial therapy.

Topical antiseptic therapies are recommended for preventive infections in individuals who have a considerably increased risk of wound infection, treatments of localised wound infection, and local treatment of wounds infection in cases of local spreading or systemic infection.

Duration of use should be individualised and based on regular wound assessment. Many clinicians recommend the use of a two-week challenge with total antiseptics. This is usually sufficient time for that agent to exert the beneficial activity. Usage should be reviewed after two weeks and the management plan adjusted as appropriate.

Surfactants can also be used. They lower the surface tension between the wound bed and the liquid. Therefore, they promote spread of the liquid across the wound bed and facilitate separation of loose and non-viable tissue. Hence, you should have a look at what’s available in your own areas and what’s recommended for use there locally.

Management of wound infection

EWMA (2016) states: “Where there are subtle changes in the patient and/or wound indicating infection it may be worth considering topical antimicrobial therapy.”

Further points to consider when selecting an antimicrobial are the specific wound management objectives and the ability of the dressing to meet these objectives:

• Frequency of dressing change

• Size of the wound

• Proposed time frame planned for use of the product

Additionally, it is important to be familiar with the manufacturers’ recommendations for use.

In the downloads section, table 1 summarises how to optimise individual host response, reduce wound microbial load, and promote environmental and general measures of wound management; table 2 elaborates upon steps of regular reassessment of wounds.

Please review the tables and reflect on how the information can be incorporated into your practice.