Venous leg ulcers (VLUs) are the most common type of chronic leg wound, and can be challenging to manage.¹ VLUs account for up to 90% of all chronic leg ulcers.¹ Proper diagnosis and treatment planning are key to wound healing outcomes. This fact is particularly true for older adults, who have an annual VLU prevalence of 1.7%.²

Infection Risks

Billions of dollars are spent annually to treat patients with VLUs as a result of wound chronicity, recurrence, and susceptibility to microbial invasion and infection.² With the presence of infection, many other complications can arise and present a greater danger to the patient, such as delayed healing, cellulitis, enlargement of the wound, and debilitating pain. Deep infections can also cause systemic illness.²

Delayed healing: In addition to infection, other risk factors for delayed healing in VLUs include increased wound surface area, a history of previous ulceration, the presence of venous abnormalities (particularly deep vein pathophysiology), and the lack of high compression. Decreased mobility, advanced age, and poor nutrition are also associated with delayed healing. Because the presence of VLUs can have a profound effect on patients' everyday lives, their emotions, and their quality of life, the longer a VLU is present, the greater the impact on the patient's psychosocial well-being will be.³

Cellulitis: Cellulitis is a specific type of infection generally caused by group A Streptococcus and Staphylococcus aureus. It frequently requires antibiotic treatment to eradicate the responsible bacteria. Often, patients must adhere to the medication regimen while getting plenty of rest for 10 to 14 days. Signs of inflammation may be observed, although they can reflect the patient's response to the bacterial exotoxin or the infection itself.⁴

Wound enlargement: Wound enlargement is a common complication of chronic wounds, such as infected VLUs.² Given that the measurement of wound surface area is a reliable indicator of prognosis and healing, the depth, width, and length of the infected ulcer are critical components of wound assessment. As wound size increases, healing often takes longer, and patients have a poorer prognosis with larger wounds.⁵

Pain: With non-healing leg ulcers, the wound is stuck in a "continuous inflammation cycle" that is impacted by local factors, such as infection and underlying disorders such as any peripheral vascular disease or neuropathy. The presence of any these factors can cause an immense amount of pain, which is further compounded by treatment, such as wound cleansing, debridement, and dressing changes. Pain, along with other symptoms felt by patients with an infected VLU, serves to restrict mobility and affect patients' quality of sleep. Pain may also negatively impact all aspects of daily life and be a source of depression, anxiety, and social isolation.⁶

Systemic illness: Deep infections in chronic non-healing wounds can often be masked by neuropathy; however, if patients report pain or flu-like symptoms, a systemic infection may be suspected. With this diagnosis, the infected VLU must be treated aggressively through debridement and targeted antimicrobial therapy. In some extreme cases of osteomyelitis, surgery may be necessary to treat the recalcitrant infection.⁷ It is also important to assess for spreading of infection to include sepsis.

Infection Prevention

Preventing infection is key to successful treatment of VLUs and to obtain conditions conducive to healing. Controlling bacteria and reducing the presence of endotoxins are critical in managing chronic wounds and preventing infection. Preventing infection in patients with VLUs is a crucial strategy that is promoted through wound care best practices, including the following recommendations⁸:

• Avoid direct contact with the wound bed.
• Use single-use disposable or sterilized equipment.
• Ensure proper cleaning of equipment, disposal of equipment, and disposal of soiled dressings.
• Follow proper hand hygiene protocol according to policy and procedure.
• Wear personal protective equipment when clinically indicated or according to policy and procedure.

Conclusion

VLUs occur in approximately 1% of the Western population, and these lesions have wound healing times of 3-12 months. During this time, quality of life is generally negatively impacted.⁹ Infection can often worsen a patient's prognosis by introducing other complications. The optimal treatment modality ensures that all measures are taken to prevent infection whenever possible. This goal is crucial to improve patients' prognoses and limit unnecessary antimicrobial use.

References

1. NHS Inform. Venous leg ulcer. National Health Service (Scotland); updated July 2019. https://www.nhsinform.scot/illnesses-and-conditions/skin-hair-and-nails…. Accessed January 2, 2020.

2. Pugliese DJ. Infection in venous leg ulcers: considerations for optimal management in the elderly. Drugs Aging. 2016;33(2):87-96.

3. Parker CN, Finlayson KJ, Shuter PE, Edwards HE. Risk factors for delayed healing in venous leg ulcers: a review of the literature. Int J Clin Pract. 2015;69(9):967-977.

4. Davis JS, Mackrow C, Binks P, et al. A double-blind randomized controlled trial of ibuprofen compared to placebo for uncomplicated cellulitis of the upper or lower limb. Clin Microbiol Infect. 2017;23(4):242-246.

5. Vasudevan B. Venous leg ulcers: pathophysiology and classification. Indian Dermatol Online J. 2014;5(3):366-370.

6. Catanzano O, Docking R, Schofield P, Boateng J. Advanced multi-targeted composite biomaterial dressing for pain and infection control in chronic leg ulcers. Carbohydr Polym. 2017;172(15):40-48.

7. Frykberg RG, Banks J. Challenges in the treatment of chronic wounds. Adv Wound Care. 2015;4(9):560-582.

8. Minnesota Department of Health. Wound care infection prevention recommendations for long-term care facilities. 2018. https://www.health.state.mn.us/facilities/patientsafety/infectioncontro…. Accessed January 12, 2020.

9. Meulendijks AM, de Vries FMC, van Dooren AA, Schuurmans MJ, Neumann HAM. A systematic review on risk factors in developing a first-time venous leg ulcer. J Eur Acad Dermatol Venereol. 2018;33(7):1241-1248.