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Provide Local Wound Care


Figure 3: Intervention Algorithm


Signs and Symptoms of Wound Infection1 2

RNAO Evidence Levels:

LevelsA,B,C

Venous ulcers, like most chronic wounds, can become infected with superficial or spreading bacteria. The validated mnemonics “NERDS” and “STONEES” classify the signs and symptoms of localized infection (NERDS) and spreading infection (STONEES). Increased localized pain is a significant predictor of deep compartment infection.

Presence of Superficial Bacteria

  • N - Non-healing wound
  • E - Exudate increased
  • R - Red friable (fragile tissue that bleeds easily)
  • D - Debris (presence of necrotic tissue (eschar/slough)) in wound
  • S - Smell

Presence of Spreading Bacteria (<3 low bacteria count, >3 high bacteria count)

  • S - Size increasing
  • T - Temperature increased (>3 degrees F difference)
  • O - Os (probes to bone or bone is increased)
  • N - New areas of breakdown
  • E - Exudate present
  • E - Erythema and/or Edema
  • S - Smell

In addition to recognizing the signs and symptoms of infection in venous leg ulcers, it may be helpful to obtain a culture and sensitivity (C&S) using a validated method of sampling to quantify bacteria in wounds. Tissue biopsies are considered the gold standard but unfortunately are not practical in many settings. Fortunately, a linear relationship between quantitative tissue biopsy and swab for C&S taken using the Levine method of sampling (see below) has been validated and is recommended for assessing any open wound. Swabs for C&S are important in determining the type of bacteria and the appropriate antibiotics, but are not necessary to confirm the presence or absence of infection. The C&S results may not reflect the presence or absence of biofilm.

Levine Method for obtaining C&S laboratory swab3

  1. Cleanse wound thoroughly
  2. Place swab on granulation tissue
  3. Apply enough pressure to extract fluid
  4. Turn swab 360 degrees on fluid (avoid slough or debris)
  5. Place swab in transport medium

Signs and Symptoms of Lower Leg Cellulitis4

  • Cellulitis is a spreading bacterial infection of the dermis and subcutaneous tissues, where the edge of the erythema may be well-defined or more diffuse and typically spreads rapidly
  • Systemic upset with fever and malaise occurs in most cases, and may be present before the localising signs such as the local symptoms seen with STONEES5
  • Lower leg cellulitis can be extremely serious with long-term morbidity, including lower leg edema. It requires prompt recognition by health care providers and appropriate interventions
  • Note that lower leg cellulitis usually affects only one leg, not both. If both legs are affected, it is likely venous dermatitis or allergic contact dermatitis, but this does not mean that it could never be cellulitis in both legs6

Table 5 - Signs and Symptoms of Cellulitis of Lower Legs7

Signs and Symptoms of Cellulitis of Lower Legs Risk Factors

Symptoms:

  • May have fever
  • May have flu-like symptoms before cellulitis develops
  • Area very painful or tender
  • May not tolerate current compression esp. elastic types
Image of cellulitis of lower legs

Signs:

  • Appears as a diffuse, bright red, hot leg or may have streaking. This will spread if untreated. Mark with indelible marker to determine spread or resolution of infection. IF person has darker skin, this may be difficult to determine.
  • May have a clear demarcation line of pale skin against the darker red.
  • Clear serous or yellow exudate will “pour” out of the small openings, saturating the dressings quickly
  • May have small blisters or large bullae unrelated to venous disease
  • Rapid increase of edema up the lower leg… often starts at the foot but can start in the calf
  • Raised, swollen, tight shiny or glossy skin with a stretched appearance
  • Skin is hot to touch
  • Takes only a pin-point opening in the skin for bacteria to enter….. grazes, abrasions, cuts, puncture wounds
  • Maceration between toes in web space
  • Tinea Pedis (Athlete’s foot)
  • Diabetes
  • Liver disease with chronic hepatitis or cirrhosis
  • Lower leg edema of any etiology, especially lymphedema
  • Obesity with swollen limbs
  • Burns
  • Peripheral arterial disease
  • Recent surgery (especially vein harvesting for bypass grafting) and related infections
  • Osteomyelitis
  • Venous stasis dermatitis; eczema or psoriasis
  • Shingles or chickenpox
  • Severe acne
  • Any blunt trauma to the leg
  • Leg ulceration
  • White ethnicity
  • Insect, spider or animal bites
  • Immuno-suppression
  • Foreign objects in the skin (e.g. orthotic pins)
  • Open wounds or ulcerations

Suggested Investigations:

  • High WBC, increased ESR and C-reactive protein.
  • Blood culture usually negative; swabs C&S usually negative unless necrotic tissue is swabbed (which is inappropriate)


Management of Lower Leg Cellulitis

  • Swabs for C&S not usually helpful if cellulitis is dry; if wet then should be done using LEVINE semi-quantitative method

    Levine Method for obtaining C&S laboratory swab8

    1. Cleanse wound thoroughly
    2. Place swab on granulation tissue
    3. Apply enough pressure to extract fluid
    4. Turn swab 360 degrees on fluid (avoid slough or debris)
    5. Place swab in transport medium
  • Mark line of demarcation on leg distally and proximally with soft-tip indelible marker (not pen) which helps caregivers and patient to visualize if the infection spreads beyond the point of first assessment
  • High compression, especially elastic systems, may be too painful to tolerate until the infection starts to respond to the antibiotic therapy. Do not stop compression entirely, because the edema will increase as a result of the cellulitis. May use appropriate lower mmHg compression such as two layers of tubular support bandage (e.g. Tubigrip)
  • Leg elevation is important
  • Treat any co-existing conditions such as venous ulcer, venous dermatitis or tinea pedis in addition to the systemic antibiotics
  • In some individuals, discomfort can be soothed using a compress of Burosol solution or Burrow’s solution x 15-20 minutes available from some compounding pharmacies
  • Polyhexamethylene Biguanide (PHMB –e.g. AMD) antimicrobial kerlix loose- woven (11.4 cm x 3.7 m) may be used. Wrap the affected leg from the base of the toe to below the knee, overlapping each turn by 50%. If exudate amount is large, cover with absorptive secondary dressing and kling wrap, covered by appropriate lower mmHg compression such as two layers of tubular support bandage (e.g. Tubigrip)
  • Another option if there is dermatitis along with the cellulitis and the individual is not allergic to sulpha or silver, is to obtain a prescription for Silver Sulfadiazine applied 3-5 mm thick to a combine (abdominal pad) roll with a non-metal device, place over the weeping areas, cover with high exudate absorptive dressing and kling. This must be done BID if the amount of exudate is high; once exudate diminishes it can be reduced to q 2-3 days
  • Combination systemic antibiotic therapy is needed for cellulitis (see table 6)
  • Once cellulitis is responding to systemic antibiotics and discomfort is resolving, resume previous level of higher compression.

Table 6 - Antibiotics for Cellulitis/Erysipelas in Lymphoedema9

Situation First-line antibiotics If allergic to penicillin Second-line antibiotics Comments
Community care Acute cellulitis Amoxicillin p.o. 500mg Q8h **(+/- flucloxacillin 500mg Q6h)** Clindamycin p.o. 300mg Q6h Clindamycin 300mg Q6h
If fails to resolve, convert to iv regimen as for hospital admission
Treat for at least 14 days or until signs of inflammation have resolved
Hospital care Acute cellulitis Amoxicillin iv 2g Q8h (or benzylpenicillin iv 1200-2400mg Q6h) plus gentamycin iv 5mg/kg daily Clindamycin iv 1.2g Q6h Clindamycin iv 1.2g Q6h (if poor or no response by 48 hours) Switch to Amoxicillin p.o. 500mg Q8h when:
  • temperature down for 48 hours
  • inflammation resolving
  • CRP <30mg/L
Prophylaxis to prevent recurrent cellulitis (≥ two attacks per year) Phenoxymethylpenicillin p.o. 500mg once daily (1g once daily if weight >75kg) Erythromycin p.o. 250mg once daily Clindamycin p.o. 150mg once daily or Clarithromycin p.o. 250mg once daily After one year, change dose of penicillin p.o. to 250mg once daily (500mg once daily if weight >75kg)


Venous Dermatitis: Signs, Symptoms, Prevention and Treatment

Table 7 - Venous Stasis Dermatitis: Signs, Symptoms, Prevention and Treatment10

Description Treatment
Image of venous stasis dermatitis

Venous Stasis dermatitis (also known as “Venous dermatitis”, “Gravitational dermatitis” or “Venous, stasis eczema”) describes the red, itchy rash on the lower legs which can be dry and scaly or can weep and form crusts commonly seen in people with chronic venous insufficiency. The skin may appear brown or purple in colour and the lower legs become increasingly edematous. It may be associated with acute contact dermatitis, which appears as itching, burning red areas on the lower leg corresponding to an area where a topical product has been used.
  • Avoid the use of known sensitizers in individuals with venous disease (perfume, latex, dyes, lanolin or wool alcohols, balsam of peru, cetylsterol alcohol, parabens, colophony propylene glycol, neomycin, rubber, some adhesives, framycetin or gentamycin) (Sibbald et al. 2007).
  • Limit baths and showers to 15 minutes in warm not hot water.
  • Avoid harsh soaps
  • Avoid vigorous use of a washcloth or towel. Blot or pat areas dry so there is still some moisture left on the skin.
  • Use moisturizers immediately after bathing such as Glaxal Base (ask pharmacist if not on shelf), Cliniderm, Eucerin or Moisturel lotions (not cream) or plain Vaseline petrolatum ointment to keep the skin healthy and free of dry scales.
  • Any products containing petrolatum or alcohol should be stopped if severely dry scaly skin develops.
  • For severely dry, scaly skin (Xerosis) use products containing Urea such as Uremol 20% or Attractain (contains 10% urea and 4% AHA), Eucerin 10% Urea Lotion, Lac-Hydrin 12%.
  • Urea works by enhancing the water-binding capacity of the stratum corneum. Long-term treatment with urea has been demonstrated to decrease transepidermal water loss. Urea also is a potent skin humidifier and descaling agent, particularly in 10% concentration.
  • Lactic acid (in the form of an alpha hydroxy acid) can accelerate softening of the skin, dissolving or peeling the outer layer of the skin to help maintain its capability to hold moisture. Lactic acid in concentrations of 2.5% to 12% is the most common alpha hydroxy acid used for moderate to severe xerosis.
  • Use creams and lotions as directed, and stop if any signs of dermatitis occur.
  • Only use topical corticosterioid preparations for two weeks at a time (if being applied more frequently than 2 x/ week) because they cause skin to break down or develop a rebound dermatitis
  • If dermatitis occurs and patient is using compression stockings, there is a risk that the lotions or creams will cause accelerated deterioration of the stocking material. In this case, it is best to only apply the topical products at bedtime when the stockings are removed.
  • If the dermatitis is severe, there may be a need to switch to compression bandaging with a medicated wrap containing zinc or other products.
  • Systemic antibiotic therapy is not needed for acute contact dermatitis, unless cellulitis has developed
  • Referral to dermatologist for allergy patch testing is indicated if dermatitis does not respond to treatment


Dressing Choices for Venous Stasis Dermatitis (Eczema)11

  • Itching and burning can be soothed using a compress of Burosol solution or Burrow’s solution x 15-20 minutes (product is no longer available over the counter (OTC) but can be obtained in powdered sachets from some compounding pharmacies)
  • Apply prescribed steroidal cream to all affected areas- with added Menthol ¼% to ½% will aid in soothing and anti-itch effect, and cream can be kept in refrigerator
  • Apply Unna’s boot using a medicated zinc paste bandage (e.g. Viscopaste) wrapped in a spiral wrap using fan-fold pleats to prevent constriction

Determining Goals for Local Treatment for Venous Leg Ulcers12

RNAO Evidence Levels:

LevelsA,B,C


Healable Wounds

  • Have sufficient vascular supply, underlying cause can be corrected, & health can be optimized

Goal: Principles of wound bed preparation and moist wound healing: debridement, bacterial balance, exudate control, protect peri-wound skin

Maintenance Wounds

  • Have healing potential, but various patient factors are compromising wound healing at this time

Goal: Principles of wound bed preparation and moist wound healing: debridement, bacterial balance, exudate control and protect periwound skin. Avoid higher cost advanced wound treatments until factors compromising wound healing are resolved. Focus on quality of life issues, exudate and odour management

Non-healable/Palliative Wounds

  • Have no ability to heal due to untreatable causes such as terminal disease or end-of-life

Goal: Avoid higher cost advanced wound treatment and focus on exudate and odour management, quality of life issues


Calculating Current Percentage of Healing Since Admission

Surface Area (admission) – Surface Area (current)  × 100 = _______% reduction
Surface Area (admission)  
*Surface area = length x width


Utilize Product Picker from Canadian Association of Wound Care (CAWC)

Product Picker for Classification of Dressing Products

Each organization may use the PDF Fillable CAWC Product Picker to list the products available within their organization (see Toolkit Item #14)


South West Regional Wound Care Program Tables



Table 8 - Wound Assessment13

Wound Assessment
Clean Epithelializing Wound Clean Granulating Wound, Decreasing in Surface Area 20-30% in 3-4 Weeks* Clean Granulating Wound NOT Decreasing in Size 20-30% in 3-4 Necrotic Healable Wound (Debridement is Appropriate) Necrotic Non-Healable Wound (Debridement is NOT Appropriate)
Irrigate with ≤ 7 PSI pressure, or pour solution over the wound bed.

Use at least 100cc’s of solution, at room or body temperature.

Cleanse the periwound skin of debris, exudates.

No antimicrobial solutions.
Irrigate with ≤ 7 PSI pressure, or pour solution over the wound bed.

Use at least 100cc’s of solution, at room or body temperature.

Cleanse the periwound skin of debris, exudates.

No antimicrobial solutions.
Irrigate with 7-15 PSI pressure.

Use at least 150cc’s of solution, at room or body temperature.

Cleanse the periwound skin of debris, exudates.

* Granulating wounds not decreasing in size may have a localized infection.
Irrigate with 7-15 PSI pressure.

Use at least 150cc’s of solution, at room or body temperature.

Cleanse the periwound skin of debris, exudates.
Do not irrigate or cleanse the wound itself (the intent is to allow the necrotic tissue to dry out and stabilize).

If there is exudate present on the periwound skin, gently cleanse it and pat dry.

Topical application of proviodine-iodine solution or Chlorhexadine to the wound surface is appropriate, i.e. paint with Proviodine.
Malignant Wounds Wound with Debris or Contamination/ Superficial & Partial Thickness Burn Wound with Debris or Contamination/ Superficial & Partial Thickness Burn * Localized And/Or Spreading Infection Maintenance Wounds
Irrigate with 7-15 PSI pressure, if tolerated. Reduce pressure as needed to minimize pain and damage to friable tumor tissue.

Use at least 150cc’s of solution, at room or body temperature.

Cleanse the periwound skin of debris, exudates.

Foul odor indicates presence of anaerobes - use an antimicrobial solution, and/or topical Metronidazole.
Irrigate with 7-15 PSI pressure.

Use at least 150cc’s of solution, at room or body temperature.

Cleanse the periwound skin of debris, exudates.

May cleanse small burns with lukewarm tap water and mild soap.
Irrigate into tunneled/undermined area using a 5Fr catheter or “soft-cath” with a 30cc syringe

Use at least 150cc’s of solution, at room or body temperature. Irrigate until returns are clear

Gently palpate over undermined or tunneled areas to express any irrigation solution that is retained

Do not force irrigation when resistance is detected.

Cleanse the periwound skin of debris, exudates.
Irrigate with 7-15 PSI pressure.

Use at least 150cc’s of antimicrobial solution, at room or body temperature.

Cleanse the periwound skin of debris, exudates.

Two week challenge: May use a 10 – 14 day cleansing regime with an antimicrobial solution to address bacterial burden.
Cleansing will be dependent on characteristics of wound bed and goal of treatment.

If goal is to prevent wound from deteriorating, cleanse as per a Necrotic Non-Healable Wound.


Table 9 - Dressing Selection and Cleansing Enabler - Healable Wounds14


Table 10 - Dressing Selection and Cleansing Enabler - Maintenance/Non-Healing Wounds15

Note:


Patient Education on Skin Care16

Skin care is a vital element to promote wound healing and prevent recurrence of venous leg ulcers.

The following information is provided to clients as recommended practices:

  • Shower before wrapping of compression bandages.
  • Avoid harsh soaps or highly perfumed soaps.
  • Soothe any local skin irritation with a moisturizing cream.
  • Avoid creams with perfumes, aloe and lanolin, as these products increase the risk of dermatitis.
  • Monitor skin for potential reactions, and if present, contact your care provider.
  • Discuss long-term use of steroids with your care provider.
  • Avoid the use of adhesive products due to increased sensitivity of people with venous disease

Adjunctive Therapies17 18

Consider Multi-disciplinary referrals for adjunctive therapy.

Adjunctive therapy refers to additional treatment used together with the primary treatment to achieve the outcome of the primary treatment.

There are many types of adjunctive therapies for wound management. The ones contained in this resource include only those that have been verified by rigorous research standards and are included in the RNAO/CAWC best practice guidelines.

Electrical Stimulation Therapy (EST)

RNAO Evidence Level:

Level B

  • refers to the application of a low level electrical current to the base of a wound or peri-wound using conductive electrodes to induce cellular activity to facilitate wound healing.

Therapeutic Ultrasound (TU)

RNAO Evidence Level:

Level A

  • refers to the therapeutic application of ultrasound waves to the base of a wound or peri-wound to induce cellular activity to facilitate wound healing.

Provide Organizational Support
  1. Krasner DL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 4th Ed. Malvern, PA. HMP Communications; 2007
  2. Sibbald R.G, Woo K, Ayello E. Increased bacterial burden and infection: The story of NERDS and STONES Adv Skin Wound Care 2006; 19 (8): 447-461
  3. Sibbald R.G, Woo K, Ayello E. Increased bacterial burden and infection: The story of NERDS and STONES Adv Skin Wound Care 2006; 19 (8): 447-461
  4. Wellington Waterloo CarePartners, Kitchener Ontario
  5. Fulton R. et al. Guidelines on the management of cellulitis in adults. CREST. 2005. http://www.acutemed.co.uk/docs/Cellulitis%20guidelines,%20CREST,%2005.pdf
  6. Eagle M. Understanding cellulitis of the lower limb. Wound Essentials. 2007. 2:34-44
  7. Photo courtesy of Dr. Stephan Landis: Cellulitis with blisters and bullae
  8. Levine NS, Lindberg RB, Mason AD, Pruitt BA Jr. The quantitative swab culture and smear: a quick, simple method for determining the number of viable aerobic bacteria in open wounds. J Trauma. 1976;16(2):89-94
  9. http://ewma.org/fileadmin/user_upload/EWMA/Wound_Guidelines/Lymphoedema_Framework_Best_Practice_for_the_Management_of_Lymphoedema.pdf
  10. Wellington Waterloo CarePartners, Kitchener Ontario
  11. Wellington Waterloo CarePartners, Kitchener Ontario
  12. Despatis,M.,Shapera,L.,Parslow,N.Woo,K.(2008) Complex Wounds Wound Care Canada 8(2):24‐25
  13. South West Region Wound Care Program. http://swrwoundcareprogram.ca/Uploads/ContentDocuments/WoundCleansingAlgorithm.pdf
  14. South West Region Wound Care Program. http://swrwoundcareprogram.ca/Uploads/ContentDocuments/DressingSelectionPoster(Healable)-CommunityVersion.pdf
  15. South West Region Wound Care Program. http://swrwoundcareprogram.ca/Uploads/ContentDocuments/DressingSelectionPosterCommunity(Maintenance).pdf
  16. Registered Nurses Association of Ontario. Learning Package: Assessment and Management of Venous Leg Ulcers. June 2006
  17. Registered Nurses Association of Ontario. Nursing Best Practice Guideline: Assessment and Management of Venous Leg Ulcers. March 2004
  18. Registered Nurses Association of Ontario. Nursing Best Practice Guideline Supplement: Assessment and Management of Venous Leg Ulcers. March 2007

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