Infection/Wound & Dressings

Transcription

1 Infection/Wound & Dressings Wendy McInnes ; Vascular Nurse Practitioner The Lyell McEwin Hospital, Adelaide, South Australia wendy.mcinnes@sa,gov.au

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3 WIFi Foot Infection Clinical Manifestation of Infection PEDIS Grade Infection Severity No local or systemic signs of infection 0 Uninfected Infection present, as defined by the presence of at least 2 of the following: Local swelling or induration Erythema > 0.5 to < 2 cm around the ulcer Local tenderness or pain Local warmth or purulent discharge (thick, opaque to white or sanguineous secretion) 1 Mild Infection involving structures deeper than skin and subcutaneous tissues (e.g. bone, joint, tendon, muscle) or erythema > 2 cm around ulcer margin and NO altered infection parameters (see below) 2 Moderate Evidence of local infection with 2 or more of the following altered parameters: Temperature >38 or <36 C Heart Rate >90 beats/min Respiratory rate >20 breaths/min or PaCO 2 <32 mmhg White cell count < 4 or > 12 x 10 9 /L 3 Severe Foot Infection: IDSA/PEDIS System of Infection Severity

4 Infection Local swelling or Induration Purulent discharge Odour Friable tissue bleeds easily Abscess formation Delayed Healing

5 Infection Don t always show signs of infection

6 Infection

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8 Investigations Complete blood counts, HbA1c, liver function, serum creatinine C-reactive protein, erythrocyte sedimentation rate (ESR) (markedly high markers are suggestive of osteomyelitis) X ray for all patients with suspected non superficial Diabetic foot infection; particularly if ulcer present for over 2 weeks (assess deformity, bone destruction, soft tissue gas and foreign bodies) MRI if abscess, OM or Charcot is suspected especially if ulcer is chronic, deep or overlying bony prominence Bone scan or labelled white cell scan if MRI is contraindicated/not possible ABI/ Toe pressures CT angiogram or MR angiogram consider when ulcer doesn t heal in 6 weeks despite optimal management OR urgent imaging and revascularisation if ankle pressure, 50 mmhg/abi <0.5 Toe pressure <30mmHg Deep tissue histology and microscopy, culture and sensitivities punch biopsy or curette after cleaning/debridement aspirate purelent secretions with sterile needle/syringe Do not obtain repeat cultures unless evaluating non response or for infection control surveillance

9 Considerations Sepsis Perfusion Functionality / offloading Bone Involvement Age/Lifestyle Co-morbidities/ Risk factors Infection

10 Infection delayed closure

11 Infection Impiric Antibiotic Therapy according to severity of infection (CALHN) Likely pathogens - Methicillin sensitive Staphylococcus aureus & Beta-haemolytic streptococci High Risk MRSA add vancomycin and seek ID advice Severity of Infection (refer to Appendix 1 Table 3) for classification Ulceration (no infection) No Penicillin or Cephalosporin Allergy Penicillin Allergy (Delayed rash which is NOT urticarial or DRESS/SJS/TEN) For antibiotic allergies not listed above, consult ID for advice Antibiotics not recommended High Risk Penicillin / Cephalosporin allergy (e.g. anaphylaxis, urticaria, bronchospasm, angioedema, DRESS/SJS/TEN) High Risk Psueodomonas spp. Replace IV amoxicillin/clavulanic acid with Piperacillin/tazobactam 4.5g IV 6hrly Mild Infection Dicloxacillin 1 gram PO QID* If patient has received antibiotic therapy in the past month instead give Amoxicillin/ Clavulanate 875/125mg PO BD* (for additional Gram negative & anaerobic cover) Cefalexin 1 gram PO QID* Clindamycin 450 mg PO TDS Moderate Infection (if patient has received antibiotic therapy in past month treat as for severe infection below) Flucloxacillin 2 gram IV 6-hourly* PLUS Metronidazole 400 mg PO BD Followed by: Dicloxacillin 500mg PO QID* PLUS Metronidazole 400 mg PO BD Cefazolin 2 gram IV 8-hourly* PLUS Metronidazole 400 mg PO BD Followed by: Cefalexin 500mg PO QID* PLUS Metronidazole 400 mg PO BD Clindamycin 450 mg PO TDS Central Adelaide Local Health Network : Infectious Diseases 2017 Diabetic Foot Infection Assessment, Management & Treatment Guideline Severe Infection Amoxicillin / Clavulanic acid 1.2 g IV 8-hourly* Cefepime 2 gram IV 8-hourly* # PLUS Metronidazole 400mg PO BD Clindamycin 900 mg IV 8-hourly (slow infusion) PLUS Ciprofloxacin* # 400mg IV 12-hourly OR Ciprofloxacin* # 750 mg PO BD Once systemically improved, switch to oral therapy according sensitivity results (seek advice from ID)

12 Infection Antimicrobial Stewardship Oral antibiotics IV antibiotics May require long term antibiotics PICC /24 hr infusion Antimicrobials

13 Wagner Wound Ulcer Classifications ulcer depth, gangrene, loss of perfusion 6 grades does not take into account infection& ischaemia University of Texas Two part score, grade & stage WIFi Wound, Ischaemia, Foot infection World Union of Wound Healing Societies 2016 Local Management of Diabetic Foot Ulcers A position Document Wounds International

14 WIFi Wound Grading Classification Grade Ulcer Gangrene 0 None No 1 - Small shallow ulcer, no bone exposure unless limited to distal phalanx - Minor tissue loss, salvageable with 1-2 digital amputations 2 - Deeper with bone exposure not involving heel /shallow heel ulcer, without calcaneal involvement - Major tissue loss, salvageable with > 3 digital amputations/standard TMA 3 - Extensive deep ulcer involving forefoot and/or midfoot/ deep full thickness heel +/- calcaneal involvement - Extensive tissue loss, salvageable only with complex foot reconstruction/nontraditional proximal TMA/flap coverage or complex wound management needed for soft tissue defect No Digits only Extensive/Heal Wound Grading Classification *TMA, Trans-metatarsal amputation

15 The Wound T: tissue viability Location I: infection / inflammation Pain M: moisture imbalance Odour E: edge of wound Education

16 Debridement Reduce Bioburden and biofilm reformation Reduce Callous PERFUSION? Promote eschar IS IT SAFE????

17 Moisture Balance Low Exudate Wound Management May require increased moisture if perfusion ok May require slough removal Consider gel (PHMB/ Superoxidized ) High exudate Slough & high levels of exudate Maceration Excoriation

18 Wound Management Dry Necrotic Tissue Keep Dry can paint with betadine Prevent Infection (always cover even in shower) Low adherent dressing or gauze between toes Keep covered so as not to induce infection demarcated areas can allow bacteria in Oedema Management Risk of skin damage from adhesives Venous insufficiency, cardiac, renal issues Consider compression if perfusion intact

19 Normal saline or sterile water Antiseptic Solutions Cleansing Povidone Iodine (promotes eschar dry gangrene) PHMB (surfactant lifts debri) Super-oxidised solutions (disrupts biofim & planktonic bacteria) Note antimicrobial effect on biofilm increases with exposure time washes/soaks for smaller time periods may not see the same effects as studies reporting 24 hour exposure time International Wound Infection Institute 2016 Wound Infection in Clinical Practice International consensus update 2016 Edwards-Jones, V 2017 Wound Biofilms: What makes them stick? Wound Essentials, Vol 12, No.1 Bjarnsholt T, Eberlein T, Malone M, &Schultz G 2017 Management of Biofilm Made Easy Wounds International, May 2017

20 NO EVIDENCE Wound Management Absorb excess exudate Maintain moist environment Protect surrounding skin Barrier to bacterial contamination Cost effective Not require frequent changes Gas and water vapour permeable no films Comfortable Not too bulky added pressure - footwear

21 Wound Hydration/ Debridement Never debride legs or feet if decreased blood supply Protect the Skin Offload Pressure Odour Control Moisture Retentive Exudate Management Hydrogels Films Foams/Absorbent pads Extra Absorbent Pads Gel sheets Hydrocolloids Absorbent Films Hydrofibre Non adherent nets/dressings Alginates Negative Pressure Dry Moist Exuding Heavily Exuding Infected Heavily Colonised Silver Iodine based dressings Disinfectant Solutions/Gels Antimicrobials

22 Povidone Iodine Betadine (promote gangrene) Inadine (decrease bacterial load) First Aid Kit Gel - consider PHMB or Super-oxidized Solution Absorbent reflect exudate level Foam expensive option Absorbent pads (cheap option) some better than others Calcium Alginates (stop bleeding) Fibre dressings (+/- silver) Non adherent contact layers (some much more expensive than others Primary/secondary dressing (not films) Tubular compression oedema reduction if perfusion ok

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