The Risk of Infection and Indication of Systemic Antibiotics in Chronic Wounds

Rachel L. Reitan, DNP, FNP-C, MSNeD, CWS; Robert M. McBroom, MD; Richard E. Gilder, MS, RN

Disclosures

Wounds. 2020;32(7):186-194. 

In This Article

Abstract and Introduction

Abstract

Background: No definitive guidelines exist to assist clinicians in determining when a chronic wound is infected or at risk for infection, nor do guidelines exist to aid in determining the indication or duration of systemic antibiotics. The lack of widely accepted guidelines can lead to excessive and improper use of systemic antibiotics, which can contribute to adverse drug events and the rise of multidrug-resistant organisms. Implementing a simple tool to measure the risk of infection in patients with chronic wounds could help clinicians determine the indication and appropriate use of systemic antibiotics as well as potentially reduce the use of systemic antibiotics.

Objective: This evidence-based practice project aims to identify both chronic wounds at risk for infection and the risk factors associated with chronic wound infection, evaluate the use of systemic antibiotics in patients with chronic wounds, and reduce the use of systemic antibiotics in chronic wounds that are not infected or at risk for infection by implementing a Wounds at Risk (WAR) score for all patients admitted with chronic wounds.

Materials and Methods: In this pre- and post-observational study, a convenience sample of all patients admitted with chronic wounds over a 6-week period were given a WAR score based on electronic medical record observations. Data were collected on the use and indication of systemic antibiotics and were compared with the same data of a control group of patients admitted with chronic wounds during a 6-week period before project implementation. Other clinical, microbiological, and demographic data also were collected and compared between the 2 groups.

Results: Though not significant, the overall use of systemic antibiotics was decreased in the post-intervention group. A significant reduction was seen in wound-related indications for antibiotics, most notably in the "infected ulcer" category. Diabetic foot ulcers were at highest risk for infection, and pathogen or microbiological burden did not play a significant role in infection risk.

Conclusions: The WAR score can help guide clinicians in determining the need for antibiotics, thus helping to reduce unnecessary antibiotic exposure, which can reduce the incidence of adverse drug events and multidrug-resistant organisms.

Introduction

Up to 2% of the US population has a chronic wound, including diabetic foot ulcers (DFUs), venous leg ulcers (VLUs), arterial ulcers, nonhealing surgical wounds, and pressure ulcers/injuries (PU/Is).[1,2] Chronic wounds are associated with a significant increase in health care utilization and health care costs,[3] increased morbidity and mortality,[4] and decreased quality of life.[5] In addition, patients with chronic wounds have more exposure to systemic antibiotics compared with patients without chronic wounds, putting them at a higher risk for developing multidrug-resistant organisms (MDROs) and other adverse events.[6] Because of this, it is vital for health care providers to identify when a chronic wound is at risk for infection to avoid both the overuse and underuse of systemic antibiotics. Despite this, no widely accepted guidelines exist to assist clinicians in determining when a chronic wound is infected or at risk for infection, nor do definitive guidelines exist to aid the clinician in determining the indication or duration of systemic antibiotics.[7,8] This ambiguity can lead to excessive and improper use of systemic antibiotics, which then contributes to adverse drug events (ADEs) and the development of MDROs in not only the patient but also in the community.[8] The Wounds at Risk (WAR) score is a tool used to assess the risk of infection in patients by scoring a number of host factors that can contribute to an increased risk for infection in wounds. Implementing this simple tool could help clinicians determine the indication and appropriate use of systemic antibiotics and potentially reduce the use of systemic antibiotics in this patient population.

Economic, Health, and Social Burden of Multidrug Resistant Organisms

Each year, 23 000 deaths and more than 2 million illnesses are caused by MDROs.[9] The number one risk factor for developing an MDRO is previous exposure to antibiotics.[8] Up to 60% of patients with chronic wounds are treated with at least 1 systemic antibiotic within a 6-month period despite a lack of evidence to support the benefits or efficacy of systemic antibiotics for chronic wound healing rates.[10] A direct relationship exists between the overuse of antibiotics and the rise of MDROs, making routine and even "last resort" antibiotics ineffective.[8] Contamination of normal skin flora and colonization of bacteria, including MDROs, is a natural occurrence in wounds and especially in chronic wounds.[11–13]

Antibiotics can be harmful. Even when prescribed and taken properly, antibiotics can cause ADEs, including super infections like Clostridioides difficile colitis and severe—and sometimes fatal—reactions like Stevens-Johnson syndrome and anaphylaxis.[8,9] In the United States, antibiotics are responsible for nearly 1 out of every 5 ADEs seen in emergency departments and each year, the United States sees 250 000 cases of C difficile, resulting in 14 000 deaths annually.[9]

Varied Risk Factors for Infection

The Infectious Diseases Society of America (IDSA), the British Society for Antimicrobial Chemotherapy, and the European Wound Management Association all concur that no universally accepted diagnosis criteria for an infected chronic wound exists.[7,8,14] They also agree that the traditional signs and symptoms of infection include redness (erythema/rubor), warmth (calor), purulence, swelling or induration (tumor), and tenderness and pain are not always present in infected chronic wounds.[8,14] In fact, in the IDSA's guidelines for the diagnosis and treatment of diabetic foot infections, the presence of at least 2 of these symptoms is enough to both diagnose a diabetic foot infection and treat with systemic antibiotics, but the authors of the guidelines warn that these diagnostic criteria are based solely on expert opinions and not evidence.[14]

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