The detection of a wound at risk of infection (W.A.R.) is apparently a rather complicated logical procedure that must take into account a number of factors concerning both the organism as a whole that the wound in the fundamental features, both the operator antisepsis measures and the hygienic conditions of the social environment in which the patient lives . W.A.R. are an defined and precise entity and their classification can not depend on a rough clinical approach characterized by improper wound assessment (misinterpretation of the color of the perilesional skin or the bottom of the lesion diagnosing nonexistent infectious conditions) by improper anamnesis and by the absence of olistic evaluation of the patient. The Wound Specialist facing a wound from characters of doubt, must remember all the conditions of endogenous and exogenous risks including immunological defects that might favor a local infection. The main endogenous factor are:
- Advanced age
- Young age (premature infants, babies)
- Underlying ilness
- Immunosoppressive medication
- Congenital and acquired immune defects
- The range of the exogenous situations, predisposing to infective complication, is quite wide and is represented mainly by:
- Heavy contamined wounds (combat, bite, traumatic)
- Presence of foreign bodies
- Postsurgical wounds (procedures with high microbial contamination)
- Risk due to location (perineal surgery, etc)
- Specific pathogenicity and virulence of the pathogen
- Enviromental risks (occupational and lifestyle risk)
Smoking In particular, cardiac and abdominal surgery, or orthopedic surgery of the lower limbs have a high risk of infective evolution of the wounds; surgical complications that are most frequently associated with infection are primary and secondary (re-operation) wound dehiscence, the “Skin Breakdown” as spot skin necrosis or blisters, skin fistulas of subdermal or subcutaneous haematoma or seroma. The anatomical district that most affect negatively the healing process of injuries with a high incidence of local infection are definitely the perineum, foot, abdomen, sternal region, the facial area and the anus praeter.
The presence of pre-existing medical devices as tracheas cannulas, catheters, probe , or bone external fixator amplifies the risk of infective involution, regardless of anatomic location. Another important factor is the pathogenicity of the microbial agent found in the swab or biopsy culture on the bottom or in the depths of the wound: in microbiology the infection risk corresponds to the result of a fraction which has in the numerator the pathogen burden (number of pathogens x virulence) while the denominator is the patient’s immune competence. We can’t therefore forget the special treatment that should be reserved to the five emerging and super resistant bacterial species that can distinguish a wound at risk of infection: 1.MRSA (Methicillin-resistant Staph . Aureus) 2.VRSA (Vancomycin-resistant Staph . Aureus) 3.ESBL (Extended Spectrum Beta-Lactamase) 4.VRE (Vancomycin-resistant Enterococcus) 5.MRAB (Multidrug-resistant Acinetobacter Baumannii).
A panel of experts shared the need to achieve a scale of measurement of the level of infection risk of a wound, giving a score to each individual predisposing condition: the simultaneous presence of one or more exogenous and /or endogenous naturally increase the level of risk (see tables I, II , and III). tabetaTA Tabella I Tabella II Tabella III
When the W.A.R. score is greater than 3, it configures a serious risk of local infection and will need to prepare a specific and appropriate local treatment to prevent or fight the infection status. The therapeutic management of a wound at high risk of infection (WAR Score > 3 points) will therefore follow the operational steps required and comply with the requirements of antisepsis and exudate control; the basic steps of the approach to a wound with high WAR score are the following: Cleanse the wound with an antiseptic solution –avoid saline or tap water- Use non adherent dressing with antimicrobial agent Select absorbency capacity of dressing based on exudate level Leave dressing on for maximum time to avoid disturbing the healing process, monitoring for signs and symptoms of infection Reassess at each dressing change (consider systemic use of antibiotic for speading infection).
The persistence of the signs of local infection or the appearance of a changement towards a form of insidious infection (Biofilm) should advise the Wound Care Specialist to complete the described therapeutic strategy with a series of weekly debridements (mechanical or surgical), in order to avoid the bacterial reorganization on the bottom of the wound.