Guideline Summary – Wound Infection

Clinical Signs and Symptoms (S&S) of Wound Infection

Two(2) or more of the below S&S are sufficient for a clinical diagnosis of potential or actual wound infection.
One(1) or more of the below S&S is sufficient in the case of a client with a Diabetic Ulcer or Arterial Wound.
Continuum Signs and Symptoms Interventions
Contamination  There are no signs of infection, erythema, pain, or excess wound exudate.  Hand hygiene protocols and Personal Protective Vigilance
Microorganisms  The wound progresses to closure in a timely manner. Equipment (PPE) use with staff. Required
are transient,  Hand hygiene and PPE teaching with client/family.
wound closure  Education with client/family about prevention and signs
Colonization  There are no signs of infection, erythema, pain, or excess exudate. & symptoms of wound infection.
Microorganisms  The wound progresses to closure.  Education with client about personal hygiene.
present usually  If microbial colonization increases, there may be subtle changes in the  Aseptic dressing technique (sterile, no-touch, clean).
without impeding wound healing progression.  Cleanse wound bed with normal saline, potable water, Increasing
wound healing  Biofilm may develop, interfering with the wound healing progression by sterile water, or wound cleaner. Clinical
contributing to chronic inflammation and may lead to a localized infection.  Assess, measure wound, and monitor for changes. Concern(s)
 Assess for wound pain.
 Monitor wound for local infection. Intervention
Local Infection  Increased and/or new onset of wound pain, or increasing pain. The above interventions PLUS Required
Microorganisms  Poor healing and/or wound enlargement; less than 10% change in wound  Use topical antimicrobial dressing.
invade leading to measurements after 1 week of care or less than 30% healing in 3 weeks.  Manage biofilm with wound cleansing, irrigation and use
healing  Friable granulation / hypergranulation / bright red granulation tissue in of most appropriate wound debridement approach.
impairment. wound bed.  Monitor frequently for wound improvement or spreading
Subtle S&S of  Bridging and pocketing in granulation tissue. infection, and/or additional changes.
infection may  Increase in exudate and/or change in exudate characteristic e.g., purulent.  If not improved in 7-14 days after initiating antimicrobial
evolve into more  Onset of, or increased malodour after wound cleansing. dressing collaborate with Wound Clinician or
classic S&S of  Peri-wound erythema, local warmth, and edema. Physician/NP. Consider use of an antibiotic and/or a
infection. different antimicrobial dressing.
 Monitor for spreading infection.
Spreading  Increased wound size; & the presence of satellite, or new satellite wounds. The above interventions PLUS
Infection  Periwound warmth 2 cm or greater and/or 2-3°F change in periwound skin  Notify the Physician/NP for consideration of culture and
Microorganisms temperature using an infrared thermometer. susceptibility (C&S) swab and systemic antibiotics.
invade with  Periwound erythema extending and induration of 2 cm or greater.  Monitor and notify Physician/NP if no improvement in
classic signs &  Mild to moderate periwound swelling/edema. Wound crepitus. 72 hours after initiating systemic antibiotics.
symptoms of  Increasing malodour after wound cleansing.  Report new probe to bone to Physician/NP immediately.
wound infection  Changes or increased blood glucose in those with diabetes mellitus.  Consider use of a different antibiotic and/or
 Lymphangitis, general malaise/lethargy. antimicrobial dressing; reassess very 2 weeks.
 Monitor for systemic infection (sepsis, bacteremia).
Systemic  Increasing general malaise/lethargy.  As wound heals and S&S of infection subside, consider
Infection  Fever, rigor and/or chills. discontinuation of antimicrobial dressing. Some high
Microorganisms  Change in behaviour or cognition e.g., delirium. risk clients may benefit from ongoing use of
invade with  Change in blood glucose levels e.g., clients with diabetes mellitus. antimicrobial dressings.
classic signs &  Autonomic Dysreflexia in clients with T6 spinal cord injuries or above.
symptoms of  Elevated heart rate and respirations. Definitions:
systemic  Elevated white blood cell (WBC) count. Note: ≥ means greater than or equal to.
infection
 Severe sepsis / septic shock leading to multi-organ failure and/or death.

January 2017
 Source: WUWHS, (2008); Swanson et al. (2015). Increasing clinical problems & increased intervention is required to prevent wound deterioration & facilitate healing Wound International, 6(2), 22-27;
Carpenter et al. (2016). Expert recommendations for optimizing outcomes in the management of biofilm to promote healing of chronic wounds. Wounds, (June). IWII (2016, Nov 11). International
Consensus Update: Wound infection in clinical practice.

January 2017