My name is Dot Weir. I'm a nurse of many, many years and a wound care nurse into my well into my fourth decade as a wound care nurse. So I've practiced in all sites of care. I started out my practice in Orlando, Florida. In 2017, I moved up to the state of New York and practiced there until 2000, well until just last October, and I just recently relocated, my husband and I did, over to Holland, Michigan and I'm actually going to be working for the hospital here but not until January.

Well, obviously, someone who has a wound infection, that can only go south if it's not treated. So we always want to recognize it early and get treatment started as early as possible, so maybe we can avoid actual systemic antibiotics. But obviously the end risk is that they could become septic from their wound. So something that we're evaluating each and every time we change a dressing is to see if there's any kind of changes to the wound that would indicate that there is an increasing level of bacteria growing on the wound.

Well cardinal signs are what we were all taught in our basic training, no matter what our background is. You look for erythema or redness, swelling, firmness or induration in the tissue, warmth, change in the appearance of the drainage, like going from a clear drainage to maybe having some white cells in it, looking more perular, like pus, and certainly any increase in the odor to the exudate. And then I think a critically important one is that the patient begins to have pain that they didn't have before. The tissues many times will be more friable and, I mean, sometimes it can just be some subtle things up front, and that's what we want to look for before it gets any worse.

The best tool that we have is a clinical observation. The first thing we have to do is do a good assessment of the wound, and so we look for those signs and symptoms that we just talked about. And so a lot of people think, oh, we need to culture, that's how we diagnose infection. If we've decided that a patient has a wound infection, then we, the provider will, unless there's some good reason not to, the provider will usually start that patient on empiric antibiotics, either based on the appearance of the exudate, the odor associated with the wound, maybe something that the patient's been infected with before. So they'll start them on antibiotics, and then we do a good culture to confirm that the antibiotics that they've started on are the correct ones. But earlier, what would be ideal is if you can see these subtle changes coming sooner, then you would have already started using maybe a topical antimicrobial in order to reduce the bacterial load on the surface. So it's our eyes and our nose really that tell us the first cues that something may be going awry with the bacterial load in the wound, listening to the patient as I said. 

So culture is one way we confirm what organism is growing there. We have some other things at our disposal and that would be like fluorescence imaging, which we have one of those devices, and it doesn't diagnose infection at all, but it does show us where bacteria is sitting, both on the wound itself as well as on the periwound. And I think the periwound is something that many times is not addressed properly, because there is so much bacteria that sits on the skin that doing good wound cleansing of not only the wound but the periwound also can help prevent cross-contamination over into the wound.

Well, I probably got ahead of myself on that, so when you decide is when you start to see changes. Now, there is an exception. If you have a patient who is immunocompromised in any way, sometimes people with diabetes, won't manifest signs and symptoms of infection like someone who otherwise has a better and a more intact immune system. So just subtle things like maybe the wound was closing and it stopped. So looking for subtle things, especially the healing that slows down, could be also an early sign to look for, because you don't want, someone could have a full-blown infection in a very a period of time because they didn't exhibit the subtle signs and symptoms that we look for. 

So we have fluorescence imaging which can illuminate—there’s a couple of different ones that are on the market—illuminate the bacteria usually with a red color is most gram negatives and gram positive bacteria and then a cyan or a hot white indicates usually pseudomonas.

So past that, doing a good culture either the textbook way to do a culture is to do a quantitative tissue biopsy, and that's the gold standard but not necessarily the standard of care. What we do have to do, though, is if we're going to culture a wound, is that we do it appropriately, that we do a good one cleansing. If we've used an antimicrobial cleanser, do a rinse and then do a good Levine technique, which is where we're trying to actually get the exudate off the surface of the wound, but we don't want to culture something that we just took a dressing off that's been on for 3 days or 5 days or 7 days. So good, exquisitely good, culturing technique can net you the most accurate results so that your treatment is going to be most accurate. And again, we would always like to try to use topical antimicrobial agents to reduce that bacterial load so that we don't have to go on to systemic agents.

Just, too, I am part of the International Wound Infection Institute. It's woundinfection-institute.com. I encourage everyone to join. You have access to our clinical guidelines. We are going to be coming out with a new cleansing document in March. That's underway right as we speak. So that's woundinfection-institute.com, or just Google "International Wounded Infection Institute," and join because you get the newsletters. It costs nothing to join, but you have a lot, you can reap a lot of rewards. So I wanted to definitely put a plug in for that.

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