INFECTION
PREVENTION
Contents
Quick Reference Guide to the Diagnosis and
Treatment of Infection . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Fighting Infection in the Wound . . . . . . . . . . . . . . . . . . 3
Bacterial Colonization . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Biofilm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Contamination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Infected Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Irrigation Pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Swab Cultures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Soft Tissue Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Systemic Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Topical Antimicrobial Trial. . . . . . . . . . . . . . . . . . . . . . . 7
Preventing Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Clean Versus Sterile Technique . . . . . . . . . . . . . . . . . . 13
1
TIPS!
AN EASY WAY
TO REMEMBER
SUPERFICIAL
INCREASED
BACTERIAL BURDEN
Infection prevention is an important part of the wound care
clinician’s job. See the following tips on diagnosing and
treating infection.
Quick Reference Guide to the
Diagnosis and Treatment of Infection
1. Identify and correct the cause and co-factors that may
inhibit healing; address patient-centered concerns.
Nonhealing
Exudate
Red bleeding
3. Use topical antiseptics for non-healable or maintenance
wounds.
Debris
4. Determine if the wound is in bacterial balance. If not,
is the increased bacterial burden in the superficial
compartment, in the deep compartment, or both?
Smell
TIPS!
AN EASY WAY
TO REMEMBER SKIN
COMPARTMENT
INFECTION
Size is bigger
Temperature
increased
Os (probes to or
exposed bone)
New areas of
breakdown
Exudate
Erythema and/or
edema
Smell
2. Determine the wound’s ability to heal:
• Healable
• Maintenance
• Non-healable
5. Question the need and the procedure(s) for obtaining a
bacterial swab in selected patients.
6. Select an appropriate treatment for superficial increased
bacterial burden (NERDS) and benchmark the criteria for
monitoring the wound’s response to treatment.
7. Use appropriate systemic agents for increased deep and
surrounding skin compartment infection (STONEES) and
benchmark the criteria for monitoring the wound’s
response to treatment.
8. If the wound is not improving, reassess items one through
seven and the goals of treatment.
9. Do not use topical or systemic antibacterial agents long
term without weighing the benefits and risks. Discontinue
antibacterial agents after the wound is in bacterial balance
unless the patient is prone to reinfection due to local or
systemic factors such as being immunocompromised.
10. Empower the patient through education. Focus on
prevention, wound bed preparation through logical
consistent treatment plans.
2
Silver Preparations Used in Wound Management
Preparation Delivery
Mechanism
Product Name
Silver
amorphous
hydrogel
Silver chloride in
aqueous medium
•SilvaSorb® Gel
Low cytotoxicity, broadspectrum antimicrobial
barrier gel that contains
time-released silver for
3 days.
A secondary dressing may be
needed; however, because it does
not “melt,” the product will tend
to not slough away from the
wound, reducing the need for a
secondary dressing.
Silver sodium
chloride
polyacrylate
sheets
Silver chloride
• SilvaSorb Sheet
• SilvaSorb
Perforated Sheet
• SilvaSorb Cavity
Low cytotoxicity, broadspectrum antimicrobial
barrier dressing that
contains time-released
silver for 7 days. It donates
moisture or absorbs up to
five times its weight in
exudate.
Absorbs well, but slowly.
Silver-calciumsodium
phosphates
Co-extruded in a
polymer matrix
(film)
• Arglaes® Film
• Arglaes Island
Residual antimicrobial
activity lasts up to 7 days.
Limited absorption of fluid in
film form. Good absorption of
fluid in island form with a
calcium alginate pad.
Silver
chloride
site disc
Polyacrylate
silver chloride
• SilvaSorb Site
Protection for vascular and
non-vascular percutaneous
tubes. Barrier dressing that
contains time-released silver for 7 days. Translucent
and flexible with a low
profile.
Not self-adhesive, requires a
secondary adhesive product
for securement.
Silver salt/ calcium alginate
powder
Polymer silver
chloride in
alginate powder
• Arglaes Powder
Low cytotoxicity silver.
Antimicrobial activity
up to 5 days with fluid
management. Virtually
any size, shape or depth of
wound is managed easily
with this product.
Requires a secondary dressing
for coverage.
Silver calcium
alginate/
Carboxymethylcellulose
dressing
Silver sodium
hydrogen
zirconium
phosphate
• Maxorb® Extra
Ag
(Sheet or rope)
Low cytotoxicity
barrier dressing that
contains time-released
silver for 4 days. Superior
absorption and fluid-handling, vertical wicking and
one-piece removal. Alginate is bioresorbable.
Product not differentiated by its
color from non-silver alginate,
which may cause stocking and
tracking problems.
Silver salt
containing
foam
Silver chloride
in a foam
• Optifoam® Ag
Provides bacterial balance
in a foam dressing.
Like all foams, it may return moisture, which can lead to irritation
and potential maceration of the
surrounding skin.
3
Advantages
Disadvantages
©Adapted from Sibbald, 2006, Orsted & Sibbald, 2005, Sibbald, 2004.
All products shown are distributed by Medline Industries, Inc. and are used for example purposes only.
Fighting Infection in the Wound
Controlling bacterial bioburden is necessary for a wound to
heal normally. An integral part of wound bed preparation includes assessing the bacterial balance and treating any infection. If excessive bacterial contamination is suspected, increase
the frequency of wound cleansing and consider the use of a
non-cytotoxic, non-ionic, commercial wound cleanser that
helps loosen and liquefy debris. Commercial wound cleansers
with an antimicrobial such as benzalkonium chloride (BZK)
further address overgrowth of pathogens.
To combat bioburden, use antimicrobial dressings that contain
agents such as silver, cadexomer iodine and polyhexamethylene biguanide (PHMB), which facilitate removal of bacteria
and superficial infection. Silver dressings are some of the
most advanced wound care products currently on the market.
They are effective against microbes such as Methicillin-resistant staphylococcus aureus (MRSA) and also provide a hostile
environment to fungus and viruses. Ionic silver, in the right
concentrations, is non-cytotoxic to proliferating granulation
tissue and has no known resistance, making it particularly
appealing with the threat of resistant bacteria. Also, the silver
in these dressings is time-released, offering longer wear time
and effective antimicrobial treatment. Additional versatile
antimicrobial dressings include amorphous silver hydrogels,
foams and alginates.
Other cutting-edge dressings such as polyacrylates fight
infection while providing moist wound healing. Saturated
with Ringer's solution, polyacrylates perform pain-free debridement by absorbing and irrigating simultaneously with simple
24-hour dressing changes. They also effectively remove biofilm
and dilute toxins, which can keep wounds in a chronic state.
Bacterial Colonization
Bacteria feed on dead material (slough and eschar) and debris
in the wound. White blood cells (WBC) cannot penetrate deep
layers of dry debris or thick areas of dead material. While we
should be concerned about the type and amount of bacteria,
we must also be concerned with the ability of the host to fight
bacteria. The host must have an adequate blood supply and
4
functioning WBCs if they are to fight bacteria, win the battle,
and achieve healing.
Stage II, III, and IV pressure ulcers, and partial- and full-thickness wounds are invariably colonized with bacteria. Bacterial
content can impair wound healing. By definition, a wound is
infected when the microorganism count reaches 100,000 (105)
microorganisms per gram of tissue. If the count is less, wound
healing may still be delayed. In most cases, adequate cleansing
and debridement prevent colonization from proceeding to
clinical infection.
Necrotic or devitalized tissue supports the growth of pathological organisms. Therefore, if debridement is the goal then it
should occur as quickly as possible. Adequate cleansing during
debridement is crucial. Cleansing will assist with reducing the
pathological organisms that are prevalent on the wound surface. The longer necrotic tissue remains in a wound, the more
potential for the development of systemic infection.
Worth
remembering ...
If you suspect
excessive bacterial
contamination,
increase the
frequency and
aggressiveness of
wound cleansing.
Biofilm
Of all the bacteria found on the earth, 10 percent live in dry
environments. Most bacteria in moist environments are found
in biofilm. This accounts for 90 percent of all bacteria on the
earth. Biofilm forms a polysaccharide protective coating,
which is likened to tooth plaque. Biofilm is the way bacteria
survive in these moist environments. Otherwise, the saliva in
your mouth would wash them away, or in a wound, simple
cleansing would wash them all away. Biofilm does not attach
to viable tissue, only to debris or non-living material.
Biofilm is impermeable to topical antimicrobials or antibiotics.
Under the protection of the polysaccharide coating, bacteria
acquire antibiotic resistance genes from other bacteria. This
rapid emergence of antibiotic resistance is strong against even
newly developed antibiotics; therefore, few effective antibiotics
will be available to us. Macrophages, phagocytes, and other
WBCs do not recognize biofilm as bacteria.
If you suspect excessive bacterial contamination, increase the
frequency and aggressiveness of wound cleansing. Consider
using a commercial wound cleanser and monitor the wound
5
closely for improvement. Think of your own mouth. Do you
feel a fuzzy biofilm coating (tooth plaque) on your teeth right
now? What if you went to the drinking fountain and rinsed
your mouth out? What has happened to the mass of biofilm
on your teeth? First, you need mechanical action. Second, you
need a surfactant (toothpaste) and friction (toothbrush).
Wound cleanser with a non-cytotoxic surfactant and an
appropriate level of pounds per square inch (PSI) will help
remove the biofilm.
Contamination
Protect pressure ulcers from contamination by urinary or fecal
incontinence, as these contaminated wounds are slower to
heal. Exposure to urine or feces can increase the level of
bacterial colonization.
Worth
remembering ...
If the wound is
clinically infected,
the goal should be
to focus on reducing
the bioburden in
the wound bed.
If the wound is
systemically
infected, the goal
should be to focus
on reducing the
bioburden and
treating the
systemic infection.
Infected Wounds
If the wound is clinically infected, the goal should be to focus
on reducing the bioburden in the wound bed (surface overgrowth of bacteria), ensuring aggressive frequent cleansing
and appropriate topical antimicrobial therapy. If the wound
is systemically infected, the goal should be to focus on reducing the bioburden and treating the systemic infection, while
ensuring aggressive frequent cleansing.
Irrigation Pressure
Use enough irrigation pressure to enhance wound cleansing
without causing trauma to the wound bed. Safe and effective
ulcer irrigation pressures range from 4 to 15 PSI; 8 psi is optimal. A trigger spray bottle containing commercial cleanser
used on the stream setting or a 35 ml syringe with a 19-gauge
needle will generate approximately 8 psi.
6
Swab Cultures
Worth
remembering ...
The Agency for
Healthcare Research
and Quality (AHRQ)
guidelines do not
recommend swab
cultures to diagnose
wound infection,
because all pressure
ulcers are colonized,
and it is widely
believed that they
only detect surface
colonization.
The level of bacteria in the ulcer tissue can best be determined by a tissue biopsy or needle aspiration. These culturing
methods, however, are not often available. The Agency for
Healthcare Research and Quality (AHRQ) guidelines do not
recommend swab cultures to diagnose wound infection,
because all pressure ulcers are colonized, and it is widely
believed that they only detect surface colonization.
However, if it is determined that a swab culture should
be done, it should be a quantitative bacterial culture and
should observe the following procedure:
•
•
•
•
Scrape excess debris or loose necrotic tissue from the
wound bed.
Irrigate vigorously with 100 to 200 cc of normal saline using
a 35 cc syringe and 19-gauge needle or angiocatheter.
Gently rotate the swab in a one centimeter square area of
the viable tissue in the wound bed.
Place the swab in the culture medium and send it to the lab.
Osteomyelitis
Osteomyelitis is a bone infection, which is a complication of
pressure ulcers that can result in delayed healing, more extensive tissue damage, and higher mortality rates. A bone biopsy
is the best diagnostic tool but may not be the most appropriate
in certain settings. WBC count, erythrocyte sedimentation
rate, and x-ray provide a predictive value of 69 percent when
all three are positive. When probing to bone in a wound, there
is a very high chance that the bone is infected.
Soft Tissue Infection
Soft tissue infection may require needle aspiration or tissue
biopsy for diagnosis. Advancing cellulitis is indicative of
invasive tissue infection. It should be treated with appropriate antibiotics and monitored closely to ensure an
appropriate response.
7
Systemic Antibiotics
Systemic antibiotics are only appropriate for signs or symptoms of bacteremia or sepsis (unexplained fever, tachycardia,
hypotension, or deterioration in mental status), advancing
cellulitis or osteomyelitis. Obtaining blood cultures will allow
the initial empirical treatment regimen to be focused and
simplified if the causative organism(s) can be identified.
Systemic antibiotics are not required for pressure ulcers with
only clinical signs of local infection.
Topical Antimicrobial Trial
Clean pressure ulcers or chronic wounds that are not healing
or are continuing to produce exudate after 2 to 4 weeks of
optimal care may be considered for a two week trial of topical
antibiotics or antimicrobials. The antibiotic or antimicrobial
should be effective against gram-negative, gram-positive and
anaerobic organisms (e.g. SilvaSorb, Arglaes, silver sulfadiazine,
triple antibiotic).
Preventing Infection
TIPS!
Multiple-drug
resistant organisms
(MDROs) are
microorganisms,
primarily bacteria,
which have developed a resistance
to at least one class
of antimicrobial
agents.
Treatment aimed at prevention of wound infections, such as
keeping wounds clean and covered, has been identified as a
first line of defense against antimicrobial resistance and
infection.
•
•
•
Debridement of necrotic tissue reduces the microbial burden
of wounds.
Resistant organisms are often found in healthcare workers
noses and on their hands.
Gram-negative organisms can live and multiply in saline and
antiseptic solutions used for wound care.
Multiple-drug resistant organisms (MDROs) are microorganisms, primarily bacteria, which have developed a resistance
to at least one class of antimicrobial agents. An increasing
number of patients are being admitted from the community
with MDROs that are either unrecognized or may not have
been acquired prior to admission. Carrier status of some
microorganisms is generally increased when patients are
8
immunosuppressed or taking antibiotics or cortisone. Most,
but not all, microorganisms are shed from the perineal area.
However, even intact upper body skin may be colonized with
Vancomycin-resistant Enterococcus (VRE).
Worth
remembering ...
Contact precautions must be used
with all patients
who have known
MDRO infections
and as directed by
hospital policy.
TIPS!
Wash hands with
soap and water
when they are visibly contaminated
or dirty, as recommended by the
CDC. If your hands
are not visibly
soiled, decontamination with an
alcohol-based
antimicrobial is
often acceptable.
9
It is important for healthcare personnel to remember that
infection can occur in a number of ways:
1.
2.
3.
Contaminants can be spread from direct contact with hands
or through secondary contact with supplies and surfaces that
have been contaminated, especially those in close proximity
to the patient.
Environmental contamination with VRE is common.
Nurses’ gloves become contaminated by touching surfaces in
patients’ rooms even without touching the patient or bed
linens. VRE and MRSA can survive for weeks to months on
room surfaces.
Hand washing remains the most important intervention in
preventing transmission of infection. In most surveys of hand
washing compliance, healthcare personnel washed their hands
appropriately only 25 percent to 50 percent of the time. Know
and consistently follow your hospital policies regarding hand
hygiene and infection control. Review your hospital policies
and contact your manager, hospital infection control nurse or
educator to clarify any ambiguity regarding infection control
measures in your facility. Follow standard precautions as recommended by the Centers for Disease Control and Prevention
(CDC) during all patient encounters and implement contact
precautions routinely for patients with known MDROs.
Wash your hands with soap and water when they are visibly
contaminated or dirty, as recommended by the CDC. If
your hands are not visibly soiled, decontamination with an
alcohol-based antimicrobial is often acceptable. Applying
compatible lotions or creams can minimize irritant dermatitis
associated with hand hygiene. This may protect you from cross
contamination by keeping skin flora intact and reduce
microbial shedding.
Identify problems and suggest solutions such as placing clean
glove boxes or disposal containers in a convenient location for
ready access in a patient room, or positioning sinks and hand
cleansers for easy access or at the point of use. It is important
for healthcare workers to be direct when these problems are
identified and propose changes to improve infection control
safety within their facilities. It has been found that ease of
access to hand antiseptic agents by healthcare personnel
can influence compliance with hand washing policies.
What you can do to reduce the chance of infection:
1.
Use masks according to hospital policies for certain
specific infective or identified colonized organisms
along with eye protection whenever performing
procedures likely to result in splashing, such as
wound irrigation. Discard and change masks
when moist.
2.
Use face shield masks to protect your face and eyes.
This is especially important when irrigating wounds.
3.
Use gowns and gloves during contact with uncontrolled
secretions, draining wounds, pressure ulcers, fecal
incontinence and ostomy appliances and tubes.
4.
Use barrier gowns to prevent contamination of your arms
and clothing when working with very large, wet wounds.
10
Treatment-related precautions:
11
1.
Plan ahead when performing dressing changes.
a. Prepare to change gloves frequently.
b. Do not reach into glove boxes or supply cabinets
with contaminated hands.
c. Take enough clean gloves with you when performing
wound and personal care procedures. Place them on a
clean surface within reach so you can remove contaminated gloves and put on fresh ones when moving from
clean to more heavily contaminated body parts, and before
touching wounds and moist mucous membranes.
d. Remove contaminated gloves before touching side rails,
bedside tables, and other environmental surfaces as well as
the outside of wound care products.
e. Put on clean gloves before touching potentially contaminated supplies and surfaces, according to contact
precautions.
2.
Consider positioning open plastic disposal and linen bags
within reach so that soiled linens, underpads and contaminated wound supplies can be placed directly into them to
avoid spreading contaminates to room surfaces, including
the floor.
3.
Plan to safely and promptly transport contaminated,
reusable instruments to soiled utility rooms.
4.
Use sterile scissors for sterile procedures. If the clean technique is being used, some facilities designate a single pair of
scissors for a single patient. Carefully disinfect them between
procedures with antiseptic wipes and store them in a clean
plastic bag in a secure location in the patient’s room. If this
practice is adopted, they must be kept in a safe location and
care must be taken to avoid sharp injury during scissor decontaminating. Do not place scissors in uniform pockets to
be used on other patients, even if they are wiped down with
antiseptics. They must be cleaned and reprocessed before use
on another patient.
5.
Use the clean technique for tape dispensing. Do not share
contaminated tape rolls between patients.
6.
Dispose of wound cleansing and irrigation solutions, including saline, according to product labeling and hospital
policy. This is usually after a single use or 24 hours. Rather
than using large bottles of irrigation solution for small
wounds, use containers that hold the smallest amount of
solution you expect to use.
Treatment-related precautions (continued):
7.
Store unused wound supplies in a clean closed container
or bag in the patient’s room.
8.
Keep topical medicines in a secured area. Dispense the
medications onto clean or sterile (depending on the dressing
technique) moisture-impermeable package surfaces, into
small medicine cups, or onto sterile tongue blades in order to
prevent contamination of the tubes and jars.
9.
Keep non-medicated ointments and lotions with other
dressing supplies in the patient’s room. Use the same
dispensing technique to avoid package contamination.
10. Utilize no-touch techniques when possible for additional
surfaces that are at risk for contamination such as pagers,
phones, pens and pencils, computer key boards, stethoscopes, and hand-held Doppler equipment. Follow your
facility’s procedures for safe disinfection of these items
when contamination does occur.
What to avoid:
1.
Do not touch the outside of unused, clean, sterile
packages and bottles with contaminated gloves.
2.
Do not pour solution onto gauze that is lying on the packing material unless it is waterproof. There is confirmation
that microbial contaminates from bedside table surfaces are
able to quickly wick through packaging material and can
contaminate the gauze.
3.
Avoid stocking excess wound care supplies in patient’s
rooms. This reduces the risk of packages becoming contaminated and minimizes potential costly waste incurred when
unused supplies are disposed of when dressing protocols
change or the patient is discharged. This can also decrease
clutter to make decontaminating surfaces easier.
12
Clean Versus Sterile Technique
A controversial issue is whether to use the clean or sterile
technique when performing wound care. Currently, there
is insufficient evidence regarding whether the use of the clean
or sterile technique affects the incidence of wound healing
rates or infection. Expert opinions are based on anecdotal
notes and current practice, not on scientific evidence. The
intent of the Wound, Ostomy & Continence Nurses Society
(WOCN) position statement on the sterile technique is to
reduce microbial exposure and maintain areas and objects as
free from microbes as possible. This involves meticulous hand
washing, use of sterile fields, sterile supplies, sterile gloves and
sterile instruments.
The clean, or nonsterile, technique involves hand washing,
maintaining a clean environment with a clean field, using
sterile instruments and clean gloves, and preventing direct
contact with materials and supplies.
The aseptic technique involves purposeful measures to
prevent the transfer of organisms from person to person,
keeping the microbe count to a minimum.
The no touch technique is a way of changing surface dressings without directly touching either the wound or any
surface that may be exposed to the wound.
The WOCN position statement recommends considering the
following factors as you plan chronic wound care:
a)
b)
Determine what is sterile, clean and contaminated.
Keep items separated by using a no touch technique.
Consider the extent and type of wound care procedure.
Is it a simple or a complex multi-step procedure, will
debridement be done, and how deep is the wound?
Sterile supplies, gloves, and instruments are recommended for
bedside conservative sharps debridement. For most other
chronic wound supplies, clean gloves can be used. However,
dressing supplies, solutions, and instruments should be initially sterile and maintained as clean according to the established facility policy. The facility policy should address product
expiration dates, cost, and manufacturer’s recommendations.
13
The WOCN position statement also recommends additional
factors be considered. These include:
•
•
•
Type of wound
Patient-specific condition or risk factors
Level of expertise of the caregiver
For example, consider using the sterile technique and supplies
for patients who are particularly vulnerable to infection or
have extensive wounds. The CDC recommends covering
surgical incisions that have been closed primarily (closed
during the initial surgical procedure) with a sterile dressing
for 24 to 48 hours. If the dressing needs to be changed, use the
sterile technique. There are no recommendations for covering
a primarily closed incision beyond 48 hours.
There is still much controversy regarding when to use the
clean, aseptic, sterile and no touch techniques. To avoid
debate, it may be helpful to adopt a practice of universal
aseptic technique for all wounds in the hospital. Using the
aseptic technique means applying principles for preventing
cross contamination, purposefully preventing transfer of
microbes, and assuring that healthcare workers’ actions do
not result in contamination of the wound. This is a logical
accompaniment to standard precaution for infection control.
Regardless of the technique used, the attitude and practice of
the individual healthcare worker plays the largest role in
preventing cross-contamination.
14
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