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Toolkit

Pressure Injury Toolkit For Spinal Cord Injury and Spina Bifida

Beyond the wound - Bringing best practice to the bedside

Signs of Infection

Wound Assessment Signs of Infection

Wound Location Stage Size Other Descriptors Signs of Infection Validated Tool
  • Evaluate the pressure injury for clinical signs of superficial or deep infection.
  • In circumstances where the wound is deteriorating or wound healing fails to progress in expected manner, investigate for osteomyelitis (bone infection).

Clinical Presentation

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.

Assessment

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

N

Non-Healing

S

Size increasing

E

Exudate Increasing

T

Temperature increasing

O

Os probing to exposed bone

R

Red, friable granulation tissue

N

New or satellite wounds

D

Debris or dead cells on wound surface

E

Erythema / Oedema

E

Exudate increasing

S

Smell

S

Smell

Investigations

Microscopy and Culture Wound Swab (MCS): “Consider diagnosis of infection if culture results indicate bacterial burden of >/= 105 CFU/g of tissue and/or presence of beta haemolytic streptococci”.32

Levine method swab culture32:

  1. Cleanse wound with normal saline.
  2. Remove/debride nonviable tissue.
  3. Wait 2-5 minutes.
  4. If ulcer is dry, moisten swab with sterile normal saline.
  5. Culture the healthiest looking tissue in the wound bed.
  6. Do not culture exudate, pus, eschar or heavy fibrous tissue.
  7. Rotate the end of the sterile alginate-tipped applicator over a 1cm2 area for 5 seconds.
  8. Apply sufficient pressure to swab to cause tissue fluid to be expressed.
  9. Use sterile technique to break tip of swab into collection device designed for quantitative cultures.

Referral

Consultation with tertiary Spinal Cord Injury services is strongly recommended for patients with suspected wound infection.

Reference

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