Signs of Infection
Wound Assessment Signs of Infection
Signs and symptoms of wound infection include increased wound size/depth, increased exudate, erythema, malodour or other systemic signs of infection with or without increased neuropathic pain, muscle spasm or autonomic dysreflexia.
If infection can be excluded, re-assess mechanical contributing factors such as forces associated with unrelieved sitting and transferring. Also, consider issues such as the weakness of scar tissue, malnutrition and incontinence as contributing factors.
Assess both the superficial wound compartment, as well as deep and surrounding wound compartments for signs of infection (see also Red Flag: Deep Wound Infection).
The following tool can be used as a guide20:
3 or more = high bacterial population in superficial wound compartment
3 or more = high bacterial population in deep & surrounding wound compartments
Os probing to exposed bone
Red, friable granulation tissue
New or satellite wounds
Debris or dead cells on wound surface
Erythema / Oedema
Levine method swab culture32:
- Cleanse wound with normal saline.
- Remove/debride nonviable tissue.
- Wait 2-5 minutes.
- If ulcer is dry, moisten swab with sterile normal saline.
- Culture the healthiest looking tissue in the wound bed.
- Do not culture exudate, pus, eschar or heavy fibrous tissue.
- Rotate the end of the sterile alginate-tipped applicator over a 1cm2 area for 5 seconds.
- Apply sufficient pressure to swab to cause tissue fluid to be expressed.
- Use sterile technique to break tip of swab into collection device designed for quantitative cultures.
Consultation with tertiary Spinal Cord Injury services is strongly recommended for patients with suspected wound infection.
20. Woo and Sibbald 2009 as cited in Houghton et al 2013 p.157
32. NPUAP et al 2014 p.165
32. NPUAP et al 2014 p. 164