Innovations in the assessment and diagnosis of wound infection
01/02/11 | Assessment and diagnosis, Complex wounds, Infection | Terry Swanson
This article describes the latest significant research concerning wound infection and the effect this has had on the day-to-day practice in a regional hospital in Australia. The author highlights the importance of tackling biofilms when dealing with chronic wound infection and the need to standardise swabbing techniques. The author also outlines the impact that wound care research has had on her personal vision of wound care.
Identifying and diagnosing an infection in a chronic wound can be a subjective and challenging experience. Given the global financial and health implications of wound infections, all clinicians have a responsibility to understand the signs and symptoms of wound infection.
Although clinical indicators for chronic wound infection were reported in the early 1990s and expanded upon in 2005, there is a lack of consensus regarding the identification of infection as well as when and how to treat infected wounds [1,2]. Clinicians and scientists continue to advance our understanding of identification criteria and appropriate management and this short discussion will highlight a few important research developments and documents that have made an impact on day-to-day practice in an Australian regional hospital.
RESEARCH AND ITS IMPACT ON LOCAL PRACTICE
A significant implication for the management of wound healing and infection is the biofilm paradigm. A study in 2008 found that in the 50 chronic wounds examined, 60% contained a biofilm . If this rate is typical, then it is imperative that clinicians understand the mechanisms of biofilms and how they can be managed. One accepted strategy is the concept of biofilm-based wound care (BBWC), which involves serial debridement, the use of selective biocides, biofilm suppressants and selective antimicrobials.
A study involving the use of BBWC  was conducted on 190 patients with critical limb ischaemia and wound healing was reported in 77% of the participants (n=146). It was concluded that managing biofilms in chronic wounds can improve wound healing even in a significantly compromised host. There is still controversy surrounding biofilms, with microbiologists adamant that 'biofilms cannot be seen', but in a recent article describing clinical indicators of biofilm infection, two case studies illustrated how biofilm-infected wounds can improve using BBWC .
The importance of wound bed preparation and the prevention of biofilm formation is accepted as good practice at the author's facility. Two new debridement technologies have been implemented there - Versajet™ (Smith & Nephew) and Sonoca 185™ (Söring). The Versajet was initially bought for the wound management nurse practitioner but it is now also used for debridement by the surgical team. The Versajet creates a Venturi effect that enables the clinician to hold, cut and remove tissue while irrigating and aspirating the wound. The Sonoca 185 uses low frequency ultrasound debridement (LFUD), which facilitates debridement through the processes of cavitation and acoustic streaming. The Sonoca 185 is jointly used by the podiatry department and the nurse practitioner in wound management.
The third new innovation implemented in the author's locality was the introduction of Prontosan® Wound Irrigation Solution and Gel (B Braun). The product has been available in Australia for several years, however, some clinicians were sceptical about introducing another antiseptic. The evidence regarding Prontosan's efficacy in disrupting biofilm formation is limited but it has been suggested that it is well tolerated and has proven to be an effective cleanser . In a recent publication, Cutting also discusses biofilm management and agrees with the concept of the BBWC approach . His review of the evidence suggests improved efficacy in reducing biofilms when Prontosan is used for cleansing.