Fighting Germs to Heal Pressure Injuries

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Anyone who has ever treated a patient with a pressure injury could tell you - the best medicine is always in the area of prevention. Any sore that's stopped before it happens is one less painful wound to the patient and one less opportunity for germs to gravitate and cause an infection.

Infections, unfortunately, are a significant risk when it comes to any wound that leaves the skin open and vulnerable. But pressure injuries compound that risk with other factors. The wounds can be chronic, which means that they stay open for an extended period of time. That gives bacteria plenty of opportunities to colonize.

Pressure injuries also tend to show up when there is decreased blood flow to the area and a low amount of oxygen - additional factors that contribute to a creating a bacteria-friendly environment.

This type of bacterial build-up is often too intense for the patient's immune system to deal with on its own. It can be dangerous and require immediate attention.

Professor Dr. Hilde Beele, a dermatologist and professor at Ghent University, offers strong advice on how to spot an infection and what to do when it has started.

Looking for Clear Signs

Identifying the clinical signs of an infection as early as possible can make it easier to treat. Otherwise, the infection could spread. Some of the more common signs are increased pain in the area, heat coming from the area, change of color, and exuding liquids.

Remember, a wound could be contaminated and even colonized by bacteria but may not get infected. When the area reaches a point where it is critically colonized and starts to replicate, however, the amount of bacteria can be overwhelming and may then require antibiotics.

Getting a proper reading, however, can be tricky. A potentially infected area needs to be cleaned as quickly and thoroughly as possible in order to prevent new germs from taking advantage of the vulnerable space. But getting a proper diagnosis also requires a test sample, so the doctors know exactly what they are fighting.

Therefore, is it better to clean the infected area, and then get the sample? Yes and no, according to Prof. Beele. The correct answer is to take the sample after the area is cleaned but before an antiseptic has been applied.

Techniques for Taking Samples

1. Swab - Taking a surface reading of the area could be sufficient when the germs are at a critical point. But since a swab only tests the very top of the wound, it's hard to know if the germs you capture are responsible for the infection.
Advantage: Non-invasive
Disadvantage: Inconclusive

2. Biopsy - If a significant sample is required to determine which antibiotics to use, doctors may need to remove a bit of the tissue. This can be done a few different ways, but each one carries some level of risk for the patient. It could even make the infection worse because it means creating a new wound in the same area.
Advantage: Thorough reading of the infection
Disadvantage: Invasive and risky

3. Irrigation/Aspiration: This method is non-invasive but still effective in getting a substantial sample of the infected area. It consists of taking a syringe with saline and putting it on the wound (irrigation), giving it time to mix with the wound tissue, then picking it up again into the syringe (aspiration). You will probably need to pour out 1 cc of saline to pick up .25 cc for the sample.
Advantage: Non-Invasive
Disadvantage: Provides a good idea of the germs but not as thorough as biopsy

Treating the Infection

Bacteria can have the status of plankton or biofilm. The biofilm status is more difficult to treat because it’s harder to penetrate the layer of film. When it comes to pressure injuries, that bacteria layer can extend the period of inflammation and stunt general healing.

So an antibacterial treatment is necessary as quickly as possible. Often topical solutions can be effective in clearing the infection. Instead of topical antibiotics, Prof. Beele suggests four other techniques:

1. Wet Dressings - A wet cloth or sponge towel can be placed on the infected area. It can help with cleaning and debridement, removing the dead tissue that needs to be cleared out to let new tissue develop. The towel must be moist throughout the day and replaced daily.
2. Topical Antiseptic - Cleaning the infected area may require applying some local antiseptic. Some of the best are Povidone iodine (for example Isobetadine ®, Braunol ®, – Chloorhexidin (eg. Diaseptyl ®).
3. Silver Dressing - A wound with significant contamination could benefit from a foam or absorbent dressing made with silver. This type of dressing has a greater antibacterial effect than a regular wet dressing, but it is also more expensive.
4. Sugar, Sugar Pasta, and Honey - Sugar and pure honey, which can be prepared into a paste with additions such as iodine, can help extract exudate from a wound.

A systemic antibiotic can also help clear an infection over a period of two weeks. More serious infections, such as those that reach the bone or joint, will require more substantial treatment, including intravenous medication.

Focus Treatment on the Person

With pressure injuries, infections happen. Handling them more effectively can speed up healing, reduce pain, and prevent other complications.

No matter which sort of treatment you administer, remember that you are always treating the person, not the lab results. That means that the treatment must be coordinated with all of the patient's other medical considerations.

It also means that there must be awareness that the person being treated is not only a patient but a human being as well. That awareness will not only help guide the direction of the treatment but also improve the quality of care.