Managing challenging wounds has long been a hard test for many long-term care providers. And when wounds become infected with multi-drug resistant organisms, caregivers may find it's a bit like adding insult to injury.
With the increasing prevalence of MDROs across all healthcare settings — not to mention the comorbidities that make seniors more prone to wounds and hard-to-treat infections — it's a problem that's likely here to stay.
“Nosocomial infections are one of the greatest costs in healthcare and a big contributor to morbidity and mortality. These are important in the context of wounds because every wound contains bacterial colonization, says James Spahn, M.D., founder of EHOB Inc., He's also a head and neck surgeon who specializes in soft tissue survival and pressure ulcer prevention and treatment.
“There's always a concern of infection and cross-contamination,” Spahn says.
While sound infection prevention strategies, such as meticulous handwashing, are undoubtedly essential, even the most conscientious caregivers can attest that wound infections can and do still surface. There is no doubt that tackling these infections requires adherence to tried-and-true wound care strategies.
“The discussion of antibiotic-resistant infections highlights the importance of accurate wound assessment and documentation, and consistent monitoring of wound progress,” notes Patricia Burns, RN, MSN, WOCN, vice president of clinical affairs for Smith & Nephew.
Sleuth the source
Treating infected wounds properly relies heavily on caregivers' ability to differentiate a non-infected wound from one that's reached critical colonization.
As one wound care nurse explained, a wound with full-blown infection will usually be pale in color, as opposed to the more typical “beefy red” seen on other healing wounds, and granulation will stall. There may be increased drainage.
“These visual cues are important because the elderly may not show any outward signs of infection or mount a big inflammatory response, such as a spiking fever,” says Carolyn Watts, RN, MSN, CWON, senior associate in surgery at Nashville's Vanderbilt University Medical Center. Watts, who serves on the board of directors for the Wound Ostomy Continence Nurses Society.
For a suspected wound infection, caregivers must assess whether the infection is contained or spreading into surrounding tissue. If the infection is contained in the wound, the most appropriate course of action may be topical treatment. If cellulitis or purulent drainage is present, however, both systemic and topical treatment may be prudent, explains Watts.
Relying on wound cultures to determine the precise infection-causing organism also is wise.
“Many long-term care facilities are choosing broad spectrum antimicrobial agents rather than culturing to determine the specific organisms,” says David W. Brett, Smith & Nephew's science and technology manager.
Proper use of broad-spectrum topical antimicrobial products can reduce cross-contamination in residents because they provide a barrier that protects in both directions. “Antimicrobial barrier dressings protect residents from exposure to environmental contaminants and they help protect the environment from infected residents,” says Burns. “The best practice may be to apply a broad-spectrum topical therapy that has demonstrated efficacy for multiple kinds of bacteria.”
When it comes to the increasingly common pathogen Methicillin-resistant Staphylococcus aureus, mupirocin ointment has shown real promise. This treatment has been approved for adult subjects and healthcare workers as part of a comprehensive infection control program to reduce the risk of MRSA infection during institutional infection outbreaks with this pathogen.
“If someone is colonized, you can get one infection cleared up and then another one may appear. Oral antibiotics are frequently indicated and in some extreme cases, even IV antibiotics may be considered,” says Watts. “We frequently use mupirocin ointment on nasal swabs to eradicate nasal colonization of MRSA.”
Handle with care
Proper wound cleaning is a first line of defense against microorganism proliferation. While normal saline may suffice for clean, granulating wounds, commercial-grade cleansers might be a better choice when the wound has debris and bacteria, says Jackie Todd, RN, CWCN, DAPWCA, clinical education specialist for Medline's Advanced Wound Care division.
These solutions use gentle surfactants to reduce surface tension between the wound bed and debris, Todd says. What's more, the delivery PSI of the solution should be between four and 15 – a number that's safe for granulation tissue. “This helps loosen drainage and debris for ease of cleaning,” she explains.
Don't underestimate the power of debridement for removing infection-causing microorganisms, either. Although sharp debridement is the quickest way to clear the wound bed of necrotic tissues and debris, not everyone is a candidate, Todd warns. Depending on the resident's immediate need and physical condition, and the facility's resources and capabilities, other debridement options, such as mechanical, chemical, biological and autolytic, may be more appropriate.
“Numerous types of dressings are available to assist with debridement, providing both clinical and cost-effective solutions,” she says, noting that any dressing that maintains a moist wound healing environment will promote autolytic debridement.
Studies show that silver-containing products, such as dressings, films, hydrogels and foams, may be worth their weight in gold.
“Silver products have antibacterial clearance by the FDA and have been shown to be effective against several drug-resistant organisms,” explains Holly Korzendorfer, PT, Ph.D., CWS, FACCWS, vice president of business and clinical development for DermaRite.
Low-frequency ultrasound, ultraviolet or electrical stimulation also can be effective against challenging infectious bioburden, Korzendorfer says. Still, because these devices may come with specific wound management settings and instructions, she recommends collaborating with rehab staff when giving these treatments.
Keep it contained
Most wound infections are spread via contact, which means caregivers must follow clean technique and universal precautions.
Using the no-touch technique for dressing removal helps contain organisms during dressing changes, assures Todd. Staffers do this by wearing gloves for dressing removal and holding the dressing in one hand, then pulling the glove off over the dressing to “bag” it. Removing the second glove and pulling it over the first glove that contains the soiled dressing offers additional protection. “When completed, it's like double-bagging a soiled dressing,” she says.
Watts offers this advice: Avoid sharing supplies and equipment, and leave the supply cart in the hallway. “Take only what you need into the resident's room. If you forget something on the cart after you've already washed your hands and put on clean gloves, you can't just go back out to the cart and grab it with your gloves on or you'll risk cross-contamination. You'll need to start over again by rewashing hands and regloving.” Gowns also must be changed between residents.
Containing infections relies heavily on the proper dressing. This is determined by the microbial control needed, drainage level and the wound's healing status. “Can the dressing absorb and contain the drainage, thereby containing the microorganisms? Is it waterproof? Is there a barrier film to keep out external microorganisms?” asks Todd. When used with universal precautions, absorbent dressings that decrease the frequency of dressing changes can decrease the potential spread of microorganisms, she says.
Draping and disinfecting equipment is also vital, adds Korzendorfer, as is “designating items for single-resident use to avoid cross-contamination as much as possible.”
Don't overlook infection risks from off-loading devices, either, stresses Spahn. A simple pillow, or any item used for pressure offloading that has come in contact with an infected wound, could potentially contaminate someone else.
“If you can't be sure it's fully clean, don't reuse it,” he says. “Yes, that will cost more money, but it'll be a drop in the bucket compared to the costs of treating infections.”
Caregivers are often so focused on the wound and infection that they fail to see the bigger picture.
“Wounds are so complicated that if we want to prevent and treat them effectively, we need to really know our residents and their physiological status,” Spahn says. “If a person is having gastrointestinal problems, for example, don't wait. Get the GI professional and dietitian on board.”
Wounds require an interdisciplinary, focused approach, he says.
“With these more challenging wounds and drug-resistant infections we're seeing, the team approach is becoming even more important,” Spahn asserts. He adds, “Don't be afraid to call in the experts for help. The sooner you get on the right track, the better the outcomes will be.”