IWII Wound Infection in Clinical Practice consensus document: 2022 update.

ABSTRACT: Wound infection is a major challenge for clinicians globally, with accurate and timely identification of wound infection being critical to achieving clinical and cost-effective management, and promotion of healing. This paper presents an overview of the development of the International Wound Infection Institute (IWII)'s 2022 Wound Infection in Clinical Practice consensus document. The updated document summarises current evidence and provides multidisciplinary healthcare providers with effective guidance and support on terminology, paradigms related to biofilm, identification of wound infection, wound cleansing, debridement and antimicrobial stewardship. Integral to the update is revision of wound infection management strategies which are incorporated within the IWII's Wound Infection Continuum (IWII-WIC) and management plan. The aim of the 2022 IWII consensus document update was to provide an accessible and useful clinical resource in at least six languages, incorporating the latest evidence and current best practice for wound infection and prevention. Dissemination techniques for the consensus are discussed and highlighted.

Concurrent validity of biofilm detection by wound blotting on hard-to-heal wounds.

OBJECTIVE: Wound biofilms delay healing of hard-to-heal wounds. Convenient biofilm identification tools for clinical settings are currently not available, hindering biofilm-based wound management. Wound blotting with biofilm staining is a potential tool for biofilm detection, owing to its convenience. Although predictive validity of wound blotting has been established, it is necessary to confirm its concurrent validity. Furthermore, current staining systems employing ruthenium red have some disadvantages for clinical use. This study aimed to evaluate the usability of alcian blue as a substitute for ruthenium red. METHOD: Both in vitro and in vivo clinical samples were used to investigate validity and usability. RESULTS: The in vitro study showed that proteins and extracellular DNA in biofilms did not affect staining ability of ruthenium red and alcian blue in the detection of biofilms. In the in vivo study, using a wound biofilm model with Pseudomonas aeruginosa, the staining sensitivity of ruthenium red was 88.9% and 100% for alcian blue, with correlation coefficients of signal intensities with native polyacrylamide gel electrophoresis (PAGE) of r=0.67 (p=0.035) and r=0.67 (p=0.036) for ruthenium red and alcian blue, respectively. Results from clinical samples were r=0.75 (p=0.001) for ruthenium red and r=0.77 (p<0.001) for alcian blue. The sensitivities of wound blotting staining by ruthenium red and alcian blue were very high and had a good correlation with native PAGE analysis. CONCLUSION: Because the alcian blue procedure is more convenient than the ruthenium red procedure, wound blotting with alcian blue staining would be a promising tool to guide clinicians in delivering biofilm-based wound management.

Management and treatment of animal bites.

Animal bites account for 1% of ED visits and more than $50 million in healthcare costs annually in the United States. Managing bite wounds can be challenging and providers must consider the patient's tetanus status, species of animal inflicting the bite, and infection risk. This article describes treatment and care of bites and when rabies prophylaxis is indicated.

Chronic venous disease and wound infection: approaches, prevention and outcome measures from EWMA.

In May, BSN medical hosted two clinical symposia at the 2017 EWMA conference. These described the challenges in reducing the costs of treatment for patients with chronic venous disease (CVD), the importance of compression therapy and physical activity in the management and prevention of leg ulcers, and the obstacles in treating wound infection, among other topics. Camila Fronzo, JWC chief sub editor, was there to summarise the main points of each session.

Wound-bed preparation: a vital step in the healing process.

Non-healing wounds are a significant burden to healthcare systems, where it is estimated that 4-5% of the adult population has a problem wound at any one time ( Guest et al, 2017 ). It is suggested that infection is the most frequent complication in non-healing wounds where it can prolong patient treatment times and increase resource use ( Gottrup et al, 2013 ). Wound infection develops as a result of an imbalance between the patient's immune system and the conditions in the wound, which subsequently can promote bacterial proliferation ( Wounds UK, 2013 ). It can impact on the patient by delaying wound healing, increasing the risk of amputation and life-threatening conditions, and reducing quality of life. The use of antibiotics to treat wound infections has decreased due to the increased risk of antibiotic resistance ( Swanson et al, 2014 ). As a result alternative strategies for preventing and managing wound infection have been adopted, including wound debridement and the use of topical antiseptic/antimicrobial agents.

Biological effects and clinical application of negative pressure wound therapy: a review.

Negative pressure wound therapy (NPWT) has shown great advantages in the management of a wide range of clinical problems such as wound or chronic wound healing; open wounds with exposed bone, nerve, or tendon; and orthopaedic implants and related infection in the orthopaedics field. Even though it has shown positive efficacy in treating infection (wound infection or orthopaedic implant infection), its molecular mechanisms of action remain unclear and require further exploration. Since NPWT is widely used in the clinical setting, a comprehensive understanding of its biological effect will assist in appropriate clinical application. This review summarises the biological effect of NPWT on bacteria and cell growth as well as the possible mechanisms associated with NPWT applied in wound healing. We also highlight novel antibacterial dressings for NPWT. PubMed, and Web of Science database searches were conducted. Several search terms were used including negative pressure wound therapy, bacterial growth, growth factor, wound healing, dressing. All databases were searched from inception to 2015, references that lacked original resarch were eliminated.

Growth factors, silver dressings and negative pressure wound therapy in the management of hard-to-heal postoperative wounds in obstetrics and gynecology: a review.

PURPOSE: The last two decades witnessed the development of numerous innovative regimens for the management of patients with abnormally healing and infected wounds. Growth factors, negative pressure wound therapy (NPWT) and antiseptic dressings containing silver are examples of methods with best documented efficacy, being widely used in the treatment of acute and chronic post-traumatic wounds, burns and ulcers of various etiology. As far as obstetrics and gynecology are concerned, prevention and treatment of infected, hard-to-heal postoperative wounds is of crucial importance. This article reviews the available literature to discuss the possibilities for use, efficacy and cost-effectiveness of growth factors, NPWT and silver dressings in the treatment of difficult-to-heal postsurgical wounds in obstetrics and gynecology. MATERIALS AND METHODS: An extensive search of the English and Polish literature via PubMed and EMBASE databases was undertaken for articles published between January 1960 and April 30, 2014 to identify articles that described and assessed use, efficacy and cost-effectiveness of growth factors, silver dressings and NPWT in patients with hard-to-heal postoperative wounds following obstetric or gynecological surgery. CONCLUSIONS: Literature review regarding the use of growth factors, NPWT and silver dressings suggests that these methods may play an important role in the management of wounds after invasive obstetric and gynecological procedures. Obese patients, patients after vulvectomy or prior radiation therapy may benefit most, however, due to non-numerous randomized reports, prospective studies on the use of above-mentioned methods in the treatment of postsurgical wounds following obstetric and gynecological interventions are required.

Retained wound vacuum foam in non-healing wounds: a real possibility.

Negative pressure wound therpay (NPWT) has revolutionised the management of chronic wounds, particularly pressure ulcers (PU). Frequently, PUs are too large to close primarily, so NPWT is used to assist in management on an outpatient basis. If not closely monitored, NPWT closure foam can be accidentally left in patients. Here we describe two cases where NPWT closure foam was left in patients resulting in persistent infections. Additionally, some suggestions of how to help avoid these should be 'never' events are provided.

Clinical evaluation of gauze-based negative pressure wound therapy in challenging wounds.

The aim of this randomised clinical study was to evaluate the effectiveness and safety of gauze-based negative pressure wound therapy (NPWT) in patients with challenging wounds. A total of 50 consecutive patients who had wound drainage for more than 5 days, required open wound management and had existence of culture positive infection were included the study. In this study, gauze-based NPWT was compared with conventional dressing therapy in the treatment of patients with difficult-to-heal wounds. The patients were randomly divided into two groups. Group I (n = 25) was followed by conventional antiseptic (polyhexanide solution) dressings, and group II (n = 25) was treated with saline-soaked antibacterial gauze-based NPWT. The wounds' sizes, number of debridement, bacteriology and recurrence were compared between group I and group II. The mean age of the patients was 59·50 years (range 23-97). In group I, average wound sizes of pre- and post-treatment periods were 50·60 ± 55·35 and 42·50 ± 47·92 cm(2), respectively (P < 0·001). Average duration of treatment was 25·52 ± 16·99 days, and average wound size reduction following the treatment was 19·99% in this group. In group II, the wounds displayed considerable shrinkage, accelerated granulation tissue formation, decreased and cleared away exudate. The average wound sizes in the pre- and post-treatment periods were 98·44 ± 100·88 and 72·08 ± 75·78 cm(2) , respectively (P < 0·001). Average duration of treatment was 11·96 ± 2·48 days, and average wound size reduction following the treatment was 32·34%. The patients treated with antibacterial gauze-based NPWT had a significantly reduced recurrence (2 wounds versus 14 wounds, P = 0·001), and increased number of the culture-negative cases (22 wounds versus 16 wounds, P < 0·047) in a follow-up period of 12 months. There was a statistically significant difference between two groups in all measurements. As a result, we can say that the gauze-based NPWT is a safe and effective method in the treatment of challenging infective wounds when compared with conventional wound management.

The development, implementation and evaluation of a cross organisational clinical guideline for the management and prevention of wound infection.

BACKGROUND: The Tissue Viability services in acute and primary care in Leeds had concerns about the increasing inappropriate use of topical antiseptic dressings for wound management and were aware that the use was disproportionate to the evidence supporting their prescribing. A scoping exercise of the use of topical antiseptics and systemic antibiotic usage in Leeds led to the identification of heterogeneous prescribing of systemic antibiotics and an almost £500,000 spend on topical antiseptics across Leeds community. METHODS: The project involved the following stages. 1- Local scoping of topical antiseptics and systemic antibiotic prescribing. 2- A cross organisational working group to develop and implement a clinical best practice guideline for the prevention, diagnosis and management of wound infection. 3- Development of a revised local dressings formulary. 4- The establishment of a new referral process to Tissue Viability for wounds requiring topical antiseptic treatments. 5- Evaluation of the new guideline through- monitoring prescribing- monitoring wound sampling- monitoring A & E admissions- collecting patient feedback through the 'Tell Tissue Viability' process. RESULTS: *Expenditure on topical antiseptic dressings for the period Oct 2009-Dec 2009 was £128,864 and this reduced to £65,604 for the period Nov 2011-Jan 2012. This demonstrates an overall saving of £63,260 with a projected annual saving of £237,584 within the community trust alone. *A reduction in the number of wound swabs sent to microbiology from inpatient locations by 1500/year comparing 2008/9 with 2010/11. *An increase in wound swabs sent from GPs by 100/year comparing 2008/9 with 2010/11. *A reduction in penicillin V and co-fluampicil prescriptions and an increase in flucloxacillin prescriptions in general practise suggesting greater concordance with local antibiotic prescribing recommendations. CONCLUSION: The implementation of a clinical guideline in association with support from the specialist team, for patients requiring topical antiseptics has resulted in a reduction in the inappropriate use of topical antiseptics in hospital and community. Wound sampling practises and prescribing practises have changed. No apparent increased risk for patients has been identified but it has not been easy to obtain details about admission to Accident and Emergency with cellulitis and optimising surveillance remains a challenge for the future.

Integrated negative pressure wound therapy system with volumetric automated fluid instillation in wounds at risk for compromised healing.

Nearly all wounds are at risk for compromised healing due to excessive exudation, oedema, contaminants and presence of inflammatory mediators. Compromised wounds have the potential to develop complications, such as infection, which may lead to delayed wound healing, prolonged hospitalisation and more frequent readmissions. It is generally believed that the wound advances from contamination to colonisation when the bacteria on the wound's surface begin to replicate and increase their metabolic activity. Heavy bacterial bioburden increases the metabolic requirements, stimulates a proinflammatory environment and encourages the in-migration of monocytes, macrophages and leukocytes - all of which can negatively impact wound healing. Bacteria also secrete harmful cytokines which can lead to vasoconstriction and decreased blood flow. Thus, controlling or preventing infections is essential for normal wound healing process to occur. While the mainstay of treating wound infection has historically included intravenous, oral and/or topical antimicrobials in addition to frequent gauze dressing changes, a shift towards wound management with advanced modalities, such as negative pressure wound therapy (NPWT), has occurred during the past decade. This review will provide expert opinion and scientific support for the use of NPWT with instillation (NPWTi; V.A.C. Instill® Wound Therapy and V.A.C. VeraFlo™ Therapy, KCI USA, Inc., San Antonio, TX) for the treatment of at-risk and complicated wounds.

On-Demand Changeable Theranostic Hydrogels and Visual Imaging-Guided Antibacterial Photodynamic Therapy to Promote Wound Healing.

Antibacterial wound dressings are confronted with the challenges in real-time imaging of infected wounds and effective removal of bacterial debris after sterilization to promote the healing process. Herein, injectable theranostic hydrogels were constructed from antimicrobial peptide ε-polylysine (ePL) and polydopamine (PDA) nanoparticles for real-time diagnosis of infected wounds, imaging-guided antibacterial photodynamic therapy (PDT), and on-demand removal of bacterial debris. Ureido-pyrimidinone was conjugated on ePL to produce PLU hydrogels through quadruple hydrogen bonding, and the inoculation of tetrakis(4-carboxyphenyl)porphyrin (TCPP)-loaded PDA (PTc) nanoparticles introduced Schiff base linkages in PLU@PTc hydrogels. The double-cross-linked networks enhance mechanical performance, adhesion strength, and self-healing properties of hydrogels, and the dynamic cross-linking enables their photothermal removal. The injection of PLU precursors and PTc NPs generates in situ sol-gel transformation, and the acid-triggered release of TCPP restores fluorescence emissions for real-time imaging of infected wounds under 410 nm illumination. Then, the released TCPP in the infected wounds is illuminated at 660 nm to launch a precise antibacterial PDT, which is strengthened by the bacterial capture on hydrogels. Hydrogels with wrapped bacterial debris are removed under illumination at 808 nm, and the hydrogel dressing change accelerates healing of infected wounds through simultaneous relief of oxidative stress, regulation of inflammatory factors, acceleration of collagen deposition, and promotion of angiogenesis. Thus, this study demonstrates a feasible strategy for wound infection theranostics through bacterial infection-triggered visual imaging, efficient nonantibiotic sterilization, and on-demand dressing change and bacterial debris removal.

A clinical evaluation of the efficacy and safety of singlet oxygen in cleansing and disinfecting stagnating wounds.

OBJECTIVE: This cohort study evaluated the clinical efficacy of singlet oxygen, ActiMaris (AM) a hypertonic (3%) ionised (pH 9.8) sea water solution. It was assumed that when used for wound cleansing, disinfection and the reduction of inflammation, AM would be safe and effective. METHOD: Between May 2008 and May 2009, ambulant patients presenting at one of four wound healing centres were included in the study. Patients had critically colonised and/or infected, malodorous wounds, covered with slough/fibrin or wounds showing inflammation of the periwound skin. Wounds were assessed in terms of percentage changes in fibrin, slough and granulation tissue, they were assessed clinically and high resolution digital photographs were scored by a physician who was blinded to treatment allocation. Results were compared at baseline (week 0) and following 42 days of AM treatment (week 6). RESULTS: Seventy-three patients were included in the analysis. Dressing changes were at 2-day intervals on average, and the median treatment period was 46.04 days (range: 3-197). At 42 days, 33% (n=24) of included wounds had healed, 57% (n=42) had improved and 10% (n=7) remained stagnant. Cleansing and wound disinfection with AM was effective. In 31 patients (42%) wounds had showed clinical signs and symptoms of critical colonisation and/or infection at day 0, whereas at day 42 the infection was completely eradicated. Inflammation was reduced in 60% (n=44) of cases and patients did not report pain or discomfort when using AM. CONCLUSION: The use of singlet oxygen was shown to be safe and the results of this study indicate AM to be useful for wound cleansing, disinfection, reducing inflammation and promoting wound healing. CONFLICT OF INTEREST: The centres were supplied with the study product by the sponsor. The authors have no financial interest in writing this article.

[Treatment of purulent wounds using vacuum-therapy].

The results of treatment of complex wounds in 115 patients, in 56 of whom vacuum-therapy was conducted, were analyzed. The duration of a bandage holding constitutes 1 - 3 days at average. The peculiarities of clinical course, the dynamics of the wounds microbic spillage, cellular content in the wounding prints, phagocytic activity and phagocytic number, the phagocytosis completeness index were estimated and calculated. Application of vacuum-therapy have promoted the earlier cleansing and epithelization of the wounds as well as the tissues reparation occurrence and the laboratory indices normalization.

Medicinal plants from the Himalayan region for potential novel antimicrobial and anti-inflammatory skin treatments.

BACKGROUND AND OBJECTIVES: Adequate treatment of wounds remains one of the major medical needs globally, most notably in the regions with poor or limited access to health care. In many local and traditional systems of medicine, plants are often widely used for treating infected wounds. AIM AND OBJECTIVES: The overarching aim of this project was selection of potential species for use in a future treatment by combining with plant resources with aspects of antimicrobial photodynamic therapy (aPDT). Specifically, we focussed on species used locally in the Himalayan region for the treatment of skin disorders and then assessed the existing pharmacological evidence for key species based on the published evidence available. METHODS: Database searches were performed to identify relevant publications describing local and traditional uses of plants in the Himalayan region of Bhutan, PR China, India, Nepal and Pakistan. Using the Global Biodiversity Information Facility (GBIF), species were researched in terms of their distribution including in different climatic regions, focussing on species mostly found in higher climatic zones (based on the Köppen-Geiger climate classification). For species used in three or more countries and restricted to the higher altitudes, data on safety, pharmacology, as it relates to dermatological conditions, and phytochemistry were retrieved. KEY FINDINGS: The study identified a total of 606 species that are used in the treatment of various skin conditions often associated with infections reported in 84 articles. Common weeds like Ageratum conyzoides and Bidens pilosa, widely used and cultivated species like Centealla asiatiaca and Prunus armenica were excluded. This ultimately led to the identification of a core group of five widely used species restricted to the Himalayan region (Cedrus deodara, Nardostachys jatamansi, Pinus wallichiana, Pinus roxburghii and Valeriana jatamansi). CONCLUSIONS: Here we apply a novel approach comprising an assessment of the published information on the use of medicinal plants (i.e. local and traditional knowledge) in the context of their potential to be used in a biomedical form of clinical treatment - aPDT. Then, once sustainable sourcing based on access and benefit-sharing arrangements is in place, these species are investigated for their potential in wound treatment. Ultimately, the goal is to develop a new baseline for primary health care in some of the regions of the world with poor or limited access to health care.

Nanosilver Dressing in Treating Deep II Degree Burn Wound Infection in Patients with Clinical Studies.

BACKGROUND: Patients' clinical antibiotic treatment of deep II degree burns usually fails to achieve the ideal effect; in order to avoid the late result in pigmentation, scarring, and even limb dysfunction, it also needs to deal effectively with burn wounds. AIM: The purpose of this study is to evaluate nanosilver dressing in treating deep II degree burn wound infection in patients with clinical studies. MATERIALS AND METHODS: 106 burn patients were classified into the Sulfadiazine Silver Cream (SSC) group (n = 53) and the Nanosilver Burn Dressing (NSBD) group (n = 53). Both of them received basic wound treatment, and wound healing time and pigmentation fading away time of all patients were recorded. And the wound healing rate of the patients was calculated. Serum levels of tumor necrosis factor alpha (TNF-α) and interleukin-1beta (IL-1ß) were detected pre- and posttreatment. RESULTS: After basic treatment for all patients, Sulfadiazine Silver Cream was used in the SSC group, and Nanosilver Burn Dressing was used in the NSBD group. It was observed that after treatment, compared with the SSC group, there was significant efficiency; wound healing rate, healing time, and pigmentation fading away time were shortened in the NSBD group, and IL-1ß levels were decreased, and the positive rate of bacterial culture was decreased (all P < 0.05). CONCLUSION: Nanosilver Burn Dressing in treating deep II degree burns can effectively reduce the wound infection and promote wound healing. The curative effect was distinct, which was worthy of popularization and application.

[Advancement of maggot including living body to treat chronic infected wounds].

Human has used maggot to treat diseases for thousands of years. In recent years, with abuse of antibiotic and the rising incidence of antibiotic resistance, maggot therapy, as a surgical alternative, is mainly applied to treat chronic infected wounds on account of its low cost, efficacy and safety. Its mechanisms are disinfection, bio-debridement and enhancement of tissue regeneration. Maggot therapy which serves as a kind of biological therapy is promising. However, living maggot therapy could result in inevitable complications, so that we should apply traditional Chinese medicine theory to investigate and develop new delivery method of maggot. The review summarizes the past and present of maggot therapy.

Management of hard-to-heal wounds arising as a result of surgical oncology treatment- usage of the modern wound dressings.

The problem of hard-to-heal wounds concerns 1-1.5% of the total population and about 3% of the population above 60 years of age. The risk factors associated with impaired wound healing are diabetes, arterial and venous insufficiency, advanced atherosclerosis, obesity, and inadequate wound supply. As a result of these pathological processes may develop localized wound infection, disseminated infection, tissue necrosis, and even chronic inflammation carcinogenesis. In the group of patients with malignant tumors, there are wounds arising in the course of the underlying disease and as a result of medical treatment. Wound healing is a significant problem and is often complicated due to the patient's general condition, comorbidities and complex treatment of cancer, which includes surgery, radiotherapy, and chemotherapy. Radiotherapy used for local-regional control of disease after surgical treatment has a negative effect on healing by causing fibrosis of tissues and blood vessels damage, while chemotherapy interferes with the process of cell proliferation.

Prevention and management of infections associated with combat-related thoracic and abdominal cavity injuries.

During wartime, abdominal and thoracic trauma constitutes approximately 20% of combat-related injuries. Rates of infection vary based upon organ of injury with the highest rates noted for trauma to the colon. This review focuses on the management and prevention of infections related to injuries of the thoracic and abdominal cavity. The evidence upon which these recommendations are based included military and civilian data from prior published guidelines, clinical trials, where available, reviews, and case reports. Areas of focus include antimicrobial therapy, irrigation and debridement, timing of surgical care, and wound closure. Overall, there are limited data available from the modern battlefield regarding the prevention or treatment of these infections and further efforts are needed to answer best treatment strategies.

Prevention and management of infections associated with burns in the combat casualty.

Burns complicate 5% to 10% of combat associated injuries with infections being the leading cause of mortality. Given the long term complications and rehabilitation needs after initial recovery from the acute burns, these patients are often cared for in dedicated burn units such as the Department of Defense referral burn center at the United States Army Institute of Surgical Research in San Antonio, TX. This review highlights the evidence-based recommendations using military and civilian data to provide the most comprehensive, up-to-date management strategies for burned casualties. Areas of emphasis include antimicrobial prophylaxis, debridement of devitalized tissue, topical antimicrobial therapy, and optimal time to wound coverage.