Treat Wound Infection Using Best Practices in Antimicrobial Stewardship

Infected wounds can have significant consequences for health, quality of life, survival, healthcare utilization, and costs of care. Antimicrobial medications can play a crucial role in the management of these wounds. However, research shows that antibiotics are overused in wound care, often without proper clinical justification.

Overuse of antimicrobial agents is leading to antimicrobial resistance, an urgent threat to public health. According to the Centers for Disease Control and Prevention, more than 2.8 million antimicrobial-resistant infections occur in the United States each year, and those infections are associated with 35,000 deaths annually.

Healthcare providers in all roles and settings have a responsibility to find a balance between proactively treating the patient in the room and being good stewards of antimicrobial medications to protect public health.

Colonization versus infection

Bacteria are everywhere, and all wounds are colonized. If you were to take a culture from any intact, healthy skin, that culture would contain bacteria. But colonization does not equal infection.

An infection requires that bacteria are present and that the host is reacting to their presence. These reactions include clinical signs of infection, including:

  • Elevated white blood cells
  • Fever of any grade
  • Malaise or general sense of illness
  • Rapid heart rate
  • Red or purplish skin on or near the wound

Mere presence of bacteria and even odor emanating from a wound are not confirmation of infection. And although a stalled wound may be due to a higher level of bacteria, that is not necessarily an infection either.

The overwhelming majority of wounds do not require antibiotics. However, it can be difficult to advocate for antimicrobial stewardship to patients who have stalled wounds that they believe might be infected. The information can be contrary to what they think they know. Some may request or even demand a prescription for an antibiotic. In the moment, it may be easier to write that prescription rather than use valuable time to educate about the natural presence of bacteria and the dangers of antimicrobial resistance.

Complicating the issue is that wounds often occur in people with comorbid conditions that suppress the immune system. A patient with cancer or poorly controlled diabetes might not be able to mount an effective immune response to an infected wound. So healthcare providers may want to initiate early antimicrobial intervention to prevent sepsis.

Consensus guidelines and best practices

In 2022, the International Wound Infection Institute Committee published a consensus statement titled “Wound Infection in Clinical Practice: Principles of Best Practice.” The international, multidisciplinary group’s work can help clinicians make treatment decisions based on expert opinion and the evidence to date.

The publication includes a continuum of microbial burden that places wounds into stages of leading up to and including infection:

  • Contamination: no proliferation, no host reaction, and no stalled healing
  • Colonization: limited proliferation, but no host reaction or delayed healing
  • Local infection (covert or subtle): granulation, bleeding, exudate, and unexpected delayed healing
  • Local infection (overt or classic): several infectious symptoms, such as erythema, warmth, swelling, discharge, wound breakdown, and pain
  • Spreading infection: thickening and hardening of soft tissues, worse erythema, further wound breakdown perhaps with additional lesions, and inflammation in the lymphatic system
  • Systemic infection: Significant symptoms of infection, including lethargy, loss of appetite, and fever

Antimicrobial therapy is generally necessary only in the later stages of the continuum. But the clinician should also consider the following factors to determine whether to begin antibiotics:

  • The strength of the patient’s immune system and its ability to fight infection
  • The number of microbes in the wound
  • The species of microorganism(s), as well as potentially synergistic combinations of microorganisms

Referring a suspected infection to a wound care specialist

These decisions are nuanced and difficult to make during a short office visit. Before you give an antibiotic for a possible infection or delayed healing, consider referral to a wound care center. However, try not to prescribe an antibiotic before referral, unless it is absolutely necessary. If the patient is already on an antibiotic, that can complicate diagnosis and treatment.

Wound care specialists can implement several effective treatments prior to initiating antimicrobial medications, as supported by the consensus guidelines. This often includes debridement, topical antiseptics, and special dressings.

Some centers are implementing a new technology called MolecuLight. This handheld, noncontact fluorescence camera can image wounds at the point of care, detecting the presence and location of microbial loads. Healogics and others are studying whether clinicians using MolecuLight debride more often and use antibiotics less.

For resources about wound care, visit Healogics’ Wound Care Awareness library.

By William J. Ennis

William J. Ennis, DO, MBA, MMM, CPE, is chief medical officer of Healogics, the nation’s leading provider of advanced wound care. He also serves as the Catherine and Francis Burzik Professor of Wound Healing and Tissue Repair and chief of the Section of Wound Healing at the University of Illinois at Chicago’s Division of Vascular Surgery.