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com/article/188988-treatment Author: Hemant Singhal, MD, MBBS,

MBA, FRCS, FRCS(Edin), FRCSC; Chief Editor: John Geibel, MD, MSc, DSc,
AGAF  more...
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Most patients with wound infections are managed in the community.

Management usually takes the form of dressing changes to optimize
healing, which usually is by secondary intention. Occasionally, further
intervention in the form of wound debridement and subsequent packing
and frequent dressing is necessary to allow healing by secondary
intention. Guidelines for the management of SSI were published in 2014
 [21] 
by the Infectious Diseases Society of America (IDSA), in 2016 by the
 [22] 
World Health Organization (WHO), in 2017 by the Centers for Disease
 [23] 
Control and Prevention (CDC), and in 2019 by the Asia Pacific Society
(APSIC). Laboratory Studies
 [24] 
of Infection Control
The simplest, and usually the quickest, staining method involves obtaining a
Gram stain for infective organisms. Staining for fungal elements can be
obtained at the same time.
Most laboratories routinely will culture for both aerobic and anaerobic
organisms. Fungal cultures can be requested. Isolation of single colonies
allows further growth and identification of the specific organism. Sensitivity
testing then follows mainly for aerobic organisms.
Other techniques include the following:
 Tests for antigens from the organism through enzyme-linked
immunoassay (ELISA) or radioimmunoassay
 Detection of antibody response to the organism in the host sera
 Detection of RNA or DNA sequences or protein from the infective
organism by Northern, Southern, or Western blotting, respectively
 Polymerase chain reaction (PCR) to detect small amounts of microbial
DNA
Ultrasonography
Ultrasonography (US) can be applied to the infected wound area to assess
whether there is a collection for which drainage is required.

Antibiotic Prophylaxis
The use of antibiotics was a milestone in the effort to prevent wound infection.
The concept of prophylactic antibiotics was established in the 1960s when
experimental data established that antibiotics had to be in the circulatory
system at a high enough dose at the time of incision to be effective. [25, 26]
It is generally agreed that prophylactic antibiotics are indicated for clean-
contaminated and contaminated wounds (see Table 2 in Overview).
Antibiotics for dirty wounds are part of the treatment because infection is
established already. Clean procedures might be an issue of debate. No doubt
exists regarding the use of prophylactic antibiotics in clean procedures in
which prosthetic devices are inserted; infection in these cases would be
disastrous for the patient. However, other clean procedures (eg, breast
surgery) may be a matter of contention. [27, 28]
Criteria for the use of systemic preventive antibiotics in surgical procedures
are as follows:
 Systemic preventive antibiotics should be used in the following cases: A
high risk of infection is associated with the procedure (eg, colon
resection); consequences of infection are unusually severe (eg, total joint
replacement); the patient has a high NNIS risk index
 The antibiotic should be administered preoperatively but as close to the
time of the incision as is clinically practical; antibiotics should be
administered before induction of anesthesia in most situations
 The antibiotic selected should have activity against the pathogens likely
to be encountered in the procedure
 Postoperative administration of preventive systemic antibiotics beyond 24
hours has not been demonstrated to reduce the risk of SSIs
 The timing of administration is critically important because the concentration of
the antibiotic should be at therapeutic levels at the time of incision, during the
surgical procedure, and, ideally, for a few hours postoperatively.  [8] Antibiotics are
administered intravenously, generally 30 minutes prior to incision  [30] ; they should
not be administered more than 2 hours prior to surgery.
 Colorectal surgical prophylaxis additionally requires bowel clearance with
enemas and oral nonabsorbable antimicrobial agents 1 hour before
surgery. [18] High-risk cesarean surgical cases require antibiotic administration as
soon as the clamping of the umbilical cord is completed.  

Infection can develop in any type of wound. Wounds can be

surgical (a cut made during an operation) or due to trauma.

Traumatic wounds could be a result of falls, accidents,

fights, bites or weapons. They may be cuts, lacerations or

 grazes. In certain types of wounds, developing an infection is

more likely. Wound infections can be prevented.

https://patient.info/infections/wound-infectionAuthored by Dr Hayley

Willacy, Reviewed by Dr Sarah Jarvis MBE | Last edited 1 Nov 2020 | Meets Patient’s editorial

guideline How can I tell if a wound is infected?

A wound which has become, or is becoming, infected may:

 Become more painful, instead of gradually improving.

 Look red around the skin edges. This red area may feel warm or hot.
 Look swollen.
 Ooze a yellow material (pus) which may be smelly.
If the infection spreads further, the redness will keep spreading to more areas
of skin. You may feel unwell in yourself, with a temperature and aches and
pains.

 you think a cut from an operation (a surgical wound) is infected, you should
speak to the nurse or doctor at your surgery as soon as possible. They may
want to see you in the surgery to take a sample of any discharge from an
infected cut with a stick which looks like a large cotton bud. This is called a
swab. The swab is sent to the laboratory to find out which germs are causing
the infection. Your nurse or doctor will help keep your wound clean, and
prescribe treatment if needed (see below.)

If you have a laceration, cut or graze, watch it carefully. If a very small injury
has become just a little bit red, you may be able to prevent further infection.
Keep it clean by bathing it with warm water and clean cotton wool. Try an
antiseptic cream, such as Savlon®. If the redness is spreading or the wound
starts to ooze pus then see your doctor or nurse. If it is a larger wound and
seems to be developing infection then see your doctor or nurse straightaway.

How do you treat an infected wound?

How do you treat an infected wound?

Unless the infection is very minor, antibiotics are usually needed to treat the
infection and stop it spreading. If the wound and/or area of infection are small
then an antibiotic cream such as fusidic acid may be prescribed. If the wound
is larger, or the infection seems to be getting worse, then an antibiotic to be
taken by mouth (oral antibiotic) is needed.
The nurse will also cleanse your wound and provide suitable dressings to
cover and protect it.

Do I need a tetanus injection?

Tetanus is a serious disease caused by germs which mostly live in soil or
manure. Wounds which have been in contact with soil or manure, or which are
particularly 'dirty', may put you at risk of developing tetanus. Most people are
protected from tetanus by the routine vaccination programme.
If you have a 'dirty' wound and have not had the full tetanus vaccination
course, or if you are not sure, contact a nurse (at your general practice or at
A&E) as soon as possible as you may need a 'booster'.

What are the complications of an infected wound?

If a wound infection is not quickly and successfully treated, it may spread. The
surrounding skin may become red and swollen and sore. The infection may
spread to the deeper tissues beneath the skin. This spreading infection is
called cellulitis. As the infection spreads, it may spread through the blood right
 through your system, making you feel unwell in yourself. This can give you a
temperature and may develop into severe infection called sepsis.

Preventing infection in wounds from injuries

Tips to avoid infection of traumatic wounds:

 Clean the wound and skin around it as soon as it happens. Use cool boiled
water, or drinking-quality water.
 If you think there are still bits of foreign bodies in the wound, see your
surgery nurse or go to your nearest Minor Injuries Unit or A&E to have it
professionally cleaned out.
 If it is a very deep wound, or the edges are very far apart, or you cannot
stop the bleeding, go to your nearest Minor Injuries Unit or A&E in case it
needs stitches.
 Use an antiseptic around the wound area to help keep the germs away.
 Put a clean dressing over your wound to protect it from germs. Do not use
gauze or a type of dressing which will stick to the wound. Your pharmacist
should be able to advise you if the wound is too big for an ordinary plaster.
 Bites are very likely to become infected - seek medical advice at the earliest
signs of this. If the injury is large, or there are multiple bite wounds, it may
be worth having antibiotics 'in case'. Seek advice straightaway in this case,
rather than waiting for signs of infection to develop.
 Keep a close eye on the wound and seek medical advice if you think
infection is developing.
 Arrange for a tetanus vaccination if needed. 
Next article
Wound: Secondary healing

To promote healing by secondary intention, perform wound

toilet and surgical debridement.

1. Surgical wound toilet involves:

- Cleaning the skin with antiseptics

- Irrigation of wounds with saline

- Surgical debridement of all dead tissue and foreign

matter. Dead tissue does not bleed when cut. Figure 5.1

2. Wound debridement involves:

- Gentle handling of tissues minimizes Control residual bleeding with

compression, ligation or cautery.

- Dead or devitalized muscle is dark in color, soft, easily damaged and

does not contract when pinched.

- During debridement, excise only a very thin margin of skin from the

wound edge (Figure 5.1).

1. Systematically perform wound

toilet and surgical debridement,

initially to the superficial layers

of tissues and subsequently to

the deeper layers (Figures 5.2,

5.3).

2. After scrubbing the skin with

soap and irrigating the wound

with saline, prep the skin with antiseptic. Figure 5.2 Figure5.3

3. Do not use antiseptics within the wound.

4. Debride the wound meticulously to remove any loose foreign material

such as dirt, grass, wood, glass or clothing.

5. With a scalpel or dissecting scissors, remove all adherent foreign

material along with a thin margin of underlying tissue and then irrigate

the wound again.

6. Continue the cycle of surgical debridement and saline irrigation until the

wound is completely clean.

7. Leave the wound open after debridement to allow healing by secondary

intention.

8. Pack it lightly with damp saline gauze and cover the packed wound with

a dry dressing.

9. Change the packing and dressing daily or more often if the outer dressing

becomes damp with blood or other body fluids.

10. Large defects will require closure with flaps or skin grafts but may be

initially managed with saline packingWHO/EHT/CPR 2005,

formatted 2009 Best practice guidelines in disaster situations

https://
www.rch.org.au/rchcpg/hospital_clinical_guideline_index/
Wound_assessment_and_management/#AssessmentWound
Assessment
When conducting initial and ongoing wound assessments the following considerations should be taken
into account to allow for appropriate management in conjunction with the treating team:

 Type of wound- acute or chronic

 Aetiology- surgical, laceration, ulcer, burn, abrasion, traumatic, pressure injury, neoplastic
 Location and surrounding skin
 Tissue Loss
 Clinical appearance of the wound bed and stage of healing
 Measurement and dimensions
 Wound edge
 Exudate
 Presence of infection
 Pain
 Previous wound management

Wound Management
Guidelines for wound management: 

1. Promote a multidisciplinary approach to care.

2. Initial patient and wound assessment is important and whenever there is a change in condition.
3. Consider the psychological implications of a wound- especially relevant in the paediatric setting in
relation to developmental understanding and pain associated with the wound and dressing
changes.
4. Determine the goal of care and expected outcomes.
5. Respect the fragile wound environment.
6. Maintain bacterial balance- use aseptic technique when performing wound procedures.
7. Maintain a moist wound environment
8. Maintain a stable wound temperature. Avoid cold solutions or wound exposure.
9. Maintain an acidic or neutral pH.
10. Allow a heavily draining wound to drain freely.
11. Eliminate dead space but don’t pack a wound tightly.
12. Select appropriate dressings and techniques based on assessment and scientific evidence.
13. Instigate appropriate adjunctive wound therapies- e.g. compression, splinting and pressure
redistribution equipment, off-loading orthotics.
14. Follow the principles for managing acute and chronic wounds. 

Acute Wound Management

Wound cleansing
The goal of wound cleansing is to:

 Remove visible debris and devitalised tissue

 Remove dressing residue
 Remove excessive or dry crusting exudates
 Reduce contamination 

Principles of wound cleansing:

 Use Aseptic Technique procedure- a non-touch technique is used to protect key parts and key
sites. If a key part or key site is to be touched directly then sterile gloves must be worn. Note:
 when using a disinfectant on a key site (e.g. skin) or key part (e.g. injection port) it must be
allowed to dry. 
 Cleansing should be performed in a way that minimises trauma to the wound as new epithelial
cells and vessels are fragile.
 Irrigation is the preferred method for cleansing open wounds. This may be carried out utilising a
syringe in order to produce gentle pressure and loosen debris. Gauze swabs and cotton wool
should be used with caution.
 Wounds are best cleansed with sterile isotonic saline or water, warmed to body temperature.

Choice of dressing
A wound will require different management and treatment at various stages of healing. No dressing is
suitable for all wounds; therefore frequent assessment of the wound is required. 
Wound healing progresses most rapidly in an environment that is clean, moist (but not wet), protected
from heat loss, trauma and bacterial invasion.

 Much research has demonstrated that moisture control is a critical aspect of wound care.
 The appropriate dressing can have a significant effect on the rate and quality of healing.
 The appropriate dressing will help to minimize bacterial contamination and pain associated with
wound care.

There are a multitude of dressings available to select from. Effective dressing selection requires both
accurate wound assessment and current knowledge of available dressings (Ayello, Elizabeth A)

Wounds healing by Primary Intention

These wounds require little intervention other than protection and observation for complications.
Recommended dressings include:

 Dry non-adherants
 Island dressings
 Semi-permeable films
 Hydrocolloids
 Foams

Wounds healing by delayed primary intention

Occurs when the wound is contaminated or infection is suspected. These traumatic or surgical wounds
require intensive cleaning before healing can occur. Debridement using irrigation may be required.
Recommended dressings include:

 Normal saline compresses

 Amphorous hydrogels or hydrogel impregnated gauzes to assist with debridement
 Calcium alginate ropes or ribbons
 Hyrofibre ropes or ribbons
 Drainable wound/ostomy appliances when large amounts of exudate is present
 Foams

Absorbent or protective secondary dressings will be required for most wounds- it is important to ensure
that the surrounding skin is protected from maceration. A skin barrier wipe can be used.
Wounds healing by secondary intention
Acute surgical or traumatic wounds may be allowed to heal by secondary intention- for example a sinus,
drained abscess, wound dehiscence, skin tear or superficial laceration.
Dressing selection should be based on specific wound characteristics. Referral to Stomal Therapy should
be considered to promote optimal wound healing.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6225154/The treatment of skin wounds is a key
research domain owing to the important functional and aesthetic role of this tissue. When the skin is
impaired, bacteria can soon infiltrate into underlying tissues which can lead to life-threatening
infections. Consequently, effective treatments are necessary to deal with such pathological conditions.
Recently, wound dressings loaded with antimicrobial agents have emerged as viable options to reduce
wound bacterial colonization and infection, in order to improve the healing process. In this paper, we
present an overview of the most prominent antibiotic-embedded wound dressings, as well as the
limitations of their use. A promising, but still an underrated group of potential antibacterial agents that
can be integrated into wound dressings are natural products, especially essential oils. Some of the most
commonly used essential oils against multidrug-resistant microorganisms, such as tea tree, St. John’s
Wort, lavender and oregano, together with their incorporation into wound dressings are presented. In
addition, another natural product that exhibits encouraging antibacterial activity is honey. We highlight
recent results of several studies carried out by researchers from different regions of the world on wound
dressings impregnated with honey, with a special emphasis on Manuka honey. Finally, we highlight
recent advances in using nanoparticles as platforms to increase the effect of pharmaceutical
formulations aimed at wound healing. Silver, gold, and zinc nanoparticles alone or functionalized with
diverse antimicrobial compounds have been integrated into wound dressings and demonstrated
therapeutic effects on wounds.
A wound is a disruption of the normal structure and function of the skin and soft tissue
architecture [1]. An acute wound demonstrates normal physiology, and healing is anticipated to
progress through the expected stages of wound healing, whereas a chronic wound is defined as
one that is physiologically impairedhttps://www.uptodate.com/contents/basic-principles-of-
wound-managementTable 2. Signs and symptoms of wound infection

Classic signs of infection Additional signs of infection

Pyrexia Delayed healing

Pain Dark/discoloured granulation tissue

Oedema Fragile wound tissue

Increased exudate Malodour

Inflammation Cellulitis

Erythema Pocketing at base of wound

Abscess formation

Painful/altered sensation around wound bedDiagnosing infectionTable 3. Wound dressing

options

Antimicrobial Formulation Examples

Silver Cream, impregnated dressing, ionic

silver, nanocrystalline silver

Flamazine, Aquacell Ag, Silvercell,

Acticoat

Honey Impregnated dressing, neat for direct

application

Algivon, Mesitran, Activon

Polyhexamethylene biguanide (PHMB) Impregnated dressings Kendal AMD, Suprasorb X = +

PHMB

Inadine Cream, ointment, spray, impregnated

dressings, paste

Betadine, Iodoflex, Iodosorb

Chlorhexide Solution, impregnated dressings Chlorhexitulle

From: Joint Formulary Committee, 2011.

discharge, delayed healing

(compared with the normal

rate of healing for the site and

condition), discolouration,

friable granulation tissue that

bleeds easily, unexpected pain

and tenderness, pocketing at

the base of the wound,

bridging of the epithelium or

soft tissue, abnormal smell

and wound breakdown.

Investigation: swabs

When there are signs of wound

infection, a wound swab

should be taken to identify the

pathogens involved. It is

essential that the swab results

are interpreted in light of the

clinical signs and symptoms.

However, it is important to

know that there is little clinical

evidence to support the role of

wound swabs in identifying

wound infection. The use of a

wound swab may identify

some or all of the bacteria

within the wound, but may not

always indicate the clinically

significant species (Wounds

UK, 2010).

Despite the limitations of

wound swabs, they will

remain part of clinical

practice until more advanced

techniques are developed and

validated (Wounds UK, 2010).

The identification of the

infecting microbe helps clarify

correct management and is

essential for highlighting

antibiotic sensitivity.

Identifying patients at

greater risk of infection

Individuals at greater risk of

wound infections include

those who are

immunologically

compromised, neonates and

the elderly (White, 2009).

A patient’s individual

immune response influences

the effect of the bacteria

within the wound. The

immune response can be

affected by many factors

including nutritional status,

the health of the circulatory

system, metabolic disorders

such as diabetes, concurrent

infections, and medication,

e.g. steroid therapy.

Patients who smoke are

also at increased risk of

developing wound infections

(Kean, 2010). Increased

susceptibility to wound

infection is thought to be due

to delayed epithelialization as

a result of reduced white cell

response and downgraded

inflammatory response, both

of which lead to a higher

bacterial count in the wound

bed (Kean, 2010).

Kean (2010) also suggested

that wound dehiscence rates

may rise in smokers as a

result of abnormal fibroblast

morphology, cell adhesion and

migration, or from a lack of

collagen being deposited and

remodelled in the wound bed,

leading to poor tensile

strength.

The healthier the patient

the more likely that a wound

will remain harmlessly

contaminated or colonized

with microorganisms and the

less likely infection is to

develop (Patel, 2007). It is

important to understand the

relationship between a

patient’s immune response

and the risk of infection in

order to accurately assess

individual vulnerability to

infection, plan measures to

reduce the risks of infection

(if possible) and provide the

patient with the appropriate

and accurate information

needed to take measures to

reduce the risk.

Wound healing in people

with conditions such as

diabetes is also impaired.

Many factors contribute to

wound healing deficiencies in

people with diabetes, including

decreased or impaired growth

factor production, delayed

angiogenic response and

altered macrophage function.

As a result people with

diabetic foot ulceration have a

high risk of hospitalization,

lower limb amputation, and

high mortality rates (Falanga,

2005) (Figure 3).

An awareness of local

referral pathways is needed to

ensure that such patients are

seen in a timely manner by a

specialist in the management

ofManagement

Correction of the bacterial

burden reduces inflammation

in the wound bed and

therefore promotes healing.

The use of a topical

antimicrobial dressing can

help control bacterial burden.

Antimicrobial dressings are

designed to reduce the

number of pathogens on the

wound bed to a level that no

longer impairs wound healing.

There are many

antimicrobial dressings on the

market. These include silver,

honey, polyhexamethylene

biguanide (PHMB), inadine

and chlorhexide (Table 3).

All these dressing have

different physical properties

and currently there is no clear

evidence or guidance to

indicate which product is

better suited to which type of

wound or tissue type.

However, Wounds UK (2010) has produced a best practice

statement on the use of

topical antiseptic/antimicrobial

agents designed to

provide guidance for health

practitioners on when to

start—and equally

important—when to stop

using topical antimicrobial

agents.

Wounds UK (2010)

recommends that in locally

infected wounds where there

are no signs of the infection

spreading, topical antiseptic

or antimicrobial agents should

be used. If the signs of

infection subside and the

patient shows no signs of

systemic infection, the

antiseptic/antimicrobial agent

should be discontinued. In a

health service that has to

account for the costeffectiveness

of wound

dressings it is important to

observe that, although

antimicrobial dressings may

appear to be expensive they

may be more cost-effective in

the long term.

In an audit of 133 562

individuals, McDermott-

Scales et al (2009) found that

66.7% of patients who

received wound-related

antibiotics had more than one

course. Therefore the use of

antimicrobial dressings may

be clinically and cost-effective

when used appropriately.

Systemic antibiotics may

not be the most appropriate

way to reduce bacterial

burden in wounds,

particularly with an increase

in bacteria resistant to

antibiotics. Indeed Howell-

Jones et al (2006) reported

that general practices

prescribed more antibiotics

for patients with chronic

wounds than for those who

did not have a chronic

wound.

Consideration should be

given to other methods of

reducing the bacterial burden

including tissue debridement,

wound cleansing, and

increased frequency of

dressing changes. This should

be done in combination with

methods to enhance patients’

resistance to infection and

reducing risk factors by

ensuring underlying vascular

disease has been addressed,

nutritional intake is

optimized, oedema controlled,

encouraging smoking

cessation, and supporting

optimum control of blood

sugar levels in people with

diabetes.

Conclusions

The diagnosis of infection and

critical colonization in

wounds remains a process of

recognition and interpretation

of clinical signs and

symptoms. Practitioners need

to have an understanding of

this process and the

treatments available, as

wound infection continues to

be a challenge and has a

significant impact in terms of

quality of life and NHS

financial burden. Early

recognition of infection along

with prompt and effective

treatment improves the

quality of patients’ care. It

also reduces cost; in the

current economic climate

providing cost effective care is

the responsibility of every

NHS practitioneWound infection is a result

of the dynamic interaction

that takes place between

the host and the pathogen

➤➤Infection occurs when

microorganisms grow,

multiply and invade host

tissue provoking a systemic

immunological reaction

➤➤Wound infection is a

common surgical

complication—surgical site

infections are associated

with substantial morbidity

➤➤A topical antimicrobial

dressing can help control

bacterial burden by reducing

the number of pathogens

on the wound bed

➤➤Wound infection can delay

healing and impair patients’

quality of life