Antimicrobial stewardship is a critical factor within effective wound care. It ensures that antimicrobials (including antibiotics and topical antimicrobial dressings) are used efficiently and appropriately, with the right product delivered to the right patient at the right time to support good clinical outcomes and avoid the spread of infection.
Dr. Kevin Woo, PhD, RN, NSWOC, WOCC(C)
Full Professor, Queen’s University
Education to deliver appropriate intervention
Education, effective tools and infection management (IM) pathways are crucial in supporting diagnosis of infection and delivering appropriate intervention with topical antimicrobial dressings, according to Dr Kevin Woo, Professor at Queen’s University, School of Nursing and School of Rehabilitation in Kingston, Canada.
A further challenge with diagnosis and treatment of local infection and biofilm is in differentiating inflammation – which may be due to trauma and underlying pathology – from infection.
Guidelines can help to deliver “the right product, right patient, right time approach” in wounds, but he stresses that the IM pathway was important as it can prompt “consistency in care and confidence in decision-making.”
As an evidence-based, clinically-oriented and user-friendly tool for translating knowledge to the bedside, the IM pathway has been validated and evaluated in practice and will help bedside clinicians to identify signs associated with local biofilm infection.
Dr Woo believes educating care teams and implementing the IM pathway in wound care is an important step and can be achieved with pocket-size tools to take to the bedside for wound assessment, supported by clinical expertise.
Dr Matthew Malone, PhD
Director of Research, South West Sydney Limb Preservation and Wound Research Academic Unit
Challenges in treating biofilms
Clinicians need to be aware of the challenges in treating biofilms; the importance of education to support diagnosis of infection and appropriate intervention; and the expertise for care of burn wounds, which are particularly prone to infection.
Biofilms, a cluster of microbial cells imbedded in a matrix, can be particularly difficult to treat as the wound microenvironment can play a large part in shaping bacterial behaviour.
However, Dr Matthew Malone, Director of Research at the South West Sydney Limb Preservation and Wound Research Academic Unit in Australia, warns that biofilms are not visible to the naked eye and are heterogeneously distributed in tissue, making it difficult to diagnose or target them.
Inappropriate antimicrobial treatment in a wound compromised by biofilm can lead to chronic infections.
“In some chronic biofilm infections, biofilm dispersal or social interactions may lead to acute infection flairs requiring more urgent interventions,” he adds. “Managing wound biofilms requires a multifaceted approach. This includes addressing underlying patient factors in addition to physically removing infected tissue through debridement. Antimicrobials also have a role to play, however clinicians must select agents which demonstrate anti-biofilm activity.”
“Only when clinicians understand that the problem in front of them is driven by biofilm can they make decisions on antimicrobials which are evidenced-based,” says Professor Malone.
Inappropriate antimicrobial treatment in a wound compromised by biofilm can lead to chronic infections.
Emma Woodmansey, PhD
Clinical Strategy Director, Advanced Wound Care, Clinical and Medical Affairs, Smith and Nephew
Reducing infection risk in wound care
Burn wounds are particularly prone to infection, primarily due to loss of the mechanical barrier of the skin and the immune-compromising consequences of burns.1
Dr Emma Woodmansey, Clinical Strategy Director, Advanced Wound Care at Smith and Nephew, says this can lead to significant morbidity and mortality, with up to 75% of burn victim deaths associated with wound infection.2
In addition, prolonged hospital stays also increase the risk of developing an infection caused by multi-drug resistant organisms.3
“This high risk of infection in burn wounds can lead to the use of antibiotics prophylactically to prevent infection developing,” she continues. “However, every time an antibiotic is used, the chance of resistant organisms developing is increased.”4,5
Antimicrobial dressings, such as silver dressings, can help prevent the spread of resistant bacteria from wounds to other patients in burn units.6
“Effective silver dressings have been shown to rapidly kill bacteria, even those resistant to many different antibiotics”, she adds. In daily practice in burn care silver dressings have been shown to decrease infections, antibiotic use, and length of stay, therefore minimising progression to systemic infection and sepsis, thus reducing the human and economic burden of burn wound management.6
[1] Church, D., Elsayed, S., Reid, O., Winston, B. & Lindsay, R. Burn wound infections. Clin. Microbiol. Rev. 19, 403–434 (2006)
[2] Ansermino, M. & Hemsley, C. Intensive care management and control of infection. BMJ 329, 220–3 (2004)
[3] Chen, Y. Y. et al. Trends in microbial profile of burn patients following an event of dust explosion at a tertiary medical center. BMC Infect. Dis. 20, 1–11 (2020)
[4] ISBI Practice Guidelines Committee, Steering Subcommittee & Advisory Subcommittee. ISBI Practice Guidelines for Burn Care. Burns 42, 953–1021 (2016)
[5] Palmieri, T. & ISBI Practice Guidelines Committee. ISBI Practice Guidelines for Burn Care, Part 2. Burns 1–90 (2018)
[6] Woodmansey, E. J. & Roberts, C. D. Appropriate use of dressings containing nanocrystalline silver to support antimicrobial stewardship in wounds. Int. Wound J. 15, 1025–1032 (2018).