It is important to remember that infection is not an either/or situation. We don’t look at a wound and decide whether it is “infected or not infected” — it is a spectrum.

An infection begins with contamination, where bacteria (or another pathogen) is present within the wound without causing any patient reaction, and the colonization of that bacteria progresses until it invades surrounding tissue and provokes a reaction from the patient.

All infections, regardless of the initiating pathogen, can run from mild to severe.

Determination of Wound Infections

Pain at the site of the wound is sometimes the only indication of infection that we see when treating an elderly patient, as the inflammatory changes one may expect may not accompany their infection. If pain is present, consider the possibility of infection even if other symptoms do not present.

Other classic signs that indicate infection include:

• Redness around the wound

• Swelling

• Increased temperature

• Pearlish or green discharge (pus) from the wound

• The wound is not healing

As MRSA is a growing concern due to our overuse of antibiotics and the resulting development of antibiotic-resistant strains, antibiotics should not be prescribed indiscriminately. An infection should be first confirmed and its cause determined. For example, an infection caused by a virus will need to run its course and will not be aided by an antibiotic.

Surface wound swabs are generally not reflective of true infection and are discouraged by the NPUAP. To obtain a sample, physicians should obtain pus from an abscess or do a tissue biopsy (the gold standard for evaluating wound infections).

Preventing Wound Infections

The ideal is to prevent infections before they start. To work towards this ideal, we should exercise universal precautions: treating all patients as though they are already infected and taking measures to not spread that infection to other patients or other wound sites.

That includes:

• Washing hands before and after all patient contact.

• Using clean gloves whenever evaluating a patient.

• Removing and changing dressings per facility protocol. Any dressings that are soaked in blood or bodily fluids should be red bagged.

• Moving from the least contaminated areas to the most contaminated areas — in many cases, this will mean starting at the lower extremities and moving upwards.

• Using hand gel will kill more bacteria than hand washing, but in highly contagious scenarios, a bleach solution is recommended.

• Disposing of all sharps at the point of care (within arm’s reach).

• Using disinfecting wipes to clean all non-disposable equipment and supplies.

• Using new instruments when proceeding to a new wound if the previous wound was infected.

• If transporting a computer from patient to patient, keeping it on a dedicated cart that nothing else is placed on, to prevent contamination.

• Not reaching into pockets with gloves on.

Physicians should strive to be leaders and teach infection care when they round with their wound care teams, and others shouldn’t hesitate to point out if they notice a physician straying from these guidelines. We can all learn from each other.