Practical perspective on wound infection

Why are wound infections so dangerous and important to avoid?

Kim Wilde: Infection is an ever-present threat in chronic wounds. In the worst cases, it could result in patients losing limbs or dying, and it puts significant strain on health systems. Diabetic wounds are particularly challenging because diabetes disturbs the wound-healing process by prolonging the inflammatory phase and delaying the formation of granulation tissue. Unhealed ulcers and foot infections are the leading cause of foot amputation. Even a minor amputation can mean a patient loses a large proportion of their foot, reducing mobility and independence, as well as creating a large financial and psychological burden.

Diabetic foot infections also account for approximately 20% of the sepsis cases in the UK. As sepsis can lead to tissue damage, organ failure and death, patients who present with moderate and severe infection now have their clinical observations checked to assess for sepsis.

Do you think there is adequate awareness of these threats among patients and HCPs?

From my experience, I would say there isn’t, because the quality of wound care varies significantly around the UK. In the case of DFUs, many foot amputations could be avoided with more proactive care and faster referrals.

Issues like peripheral neuropathy often mean patients might be slow to notice a chronic wound. As such, education needs to be reiterated each time a patient presents for treatment, and this should be reinforced with a patient leaflet. In the trust I currently work for, we use posters specifically highlighting that foot ulcers can kill.

HCPs may also find it harder to spot infections in some diabetic foot ulcers. For example, pain and tenderness may be reduced or absent in patients who have neuropathy, whereas erythema may be absent in those with vascular disease.

Different clinical disciplines also record the presentation of infection differently. Podiatry teams tend to use a wound classification score that incorporates levels of infection, but there isn’t any consistency between clinical staff, which makes evaluation of wound infection difficult.

How do HCPs know which product to use if there are signs of infection?

Looking at the infection continuum helps with identifying the stages of an infection, from contamination (which is present in all chronic wounds) through colonisation (when contaminating microbes multiply) to local infection (when the immune system can no longer cope with them). If there is inadequate wound dressing selection at the local infection, the infection will spread beyond the borders of the actual wound, moving into deeper tissue and, eventually, across the whole body, risking a systemic infection and severe sepsis, organ failure and even death.

Antimicrobial dressings such as Askina Calgitrol are initiated when the wound is at the local infection stage. What I like about Askina Calgitrol is that it has a better silver content than other silver dressings, and the concentration of silver ions in the wound is maintained for seven days at a therapeutic level (60 ppm). Wound access areas are particularly difficult on the feet and toes. That’s why, Askina Calgitrol Paste is ideal when dressing such part of the body. The versatility of the product range means it can be easily used in a variety of wounds.

Clinically infected wounds are reviewed on a weekly basis, and silver usage is recommended for two weeks, then is stepped down if the infection is under control. Askina Calgitrol can be used longer, depending on the state of the infection and at the discretion of the HCP. It’s, therefore, important to have a silver product with a high silver content, such as Askina Calgitrol.

After the infection has been resolved, treatment can be ‘stepped down’ to Prontosan Gel X to maintain the improved wound condition, preventing biofilm reformation and infection. Prontosan Wound Irrigation Solution should be used throughout treatment as standard care for wound bed preparation.

What if the infection is under control but the wound still doesn’t heal?

It is extremely important to look at a patient holistically when we are considering why a wound is not healing. You have to consider issues like blood sugar, diet, blood supply, pressure on the wound, and how well the patient is sticking to their treatment plan.

The wound itself must also be assessed, as most chronic wounds are likely to be stuck in the inflammatory phase of healing. A large proportion of wounds remain in the inflammatory phase because of the presence of a biofilm. Podiatrists can disrupt biofilms with debridement. We also use Prontosan Solution and Prontosan Debridement Pads at each dressing change to aid removal and prevent reformation of the biofilm.

Prontosan Gel X can then be used as the primary dressing to prevent the formation of a biofilm and prevent infection. Clinicians need to take into consideration that not all dressings have a biofilm indication, and to support progression to healing, Prontosan products are an excellent choice.