THE RATIONAL CLINICAL EXAMINATION

CLINICIANS CORNER

Does This Patient Have an Infection of a Chronic Wound?

Madhuri Reddy, MD, MSc Sudeep S. Gill, MD, MSc Wei Wu, MSc Sunila R. Kalkar, MD, MBBS Paula A. Rochon, MD, MPH CLINICAL SCENARIO An 89-year-old nursing home resident with dementia and limited mobility and no other medical illnesses presents with a stage III pressure ulcer in his coccyx region. The wound has been present for 3 months and has recently been increasingly painful. Appropriate support surfaces and transfer mechanisms have been initiated to ensure that pressure in the area has been significantly reduced. On examination, there is no fever, wound erythema, or purulent exudate. Swabs taken from the surface of the wound show moderate growth of mixed bacterial flora. Is this chronic wound infected? WHY IS THIS DIAGNOSIS IMPORTANT? Chronic wounds are those that have not undergone an orderly healing process.1 They are not always infected. A survey of clinicians in the United States who specialize in wound care found that most practitioners rely solely on the clinical examination to identify infection.2 Although the classic signs of infection (purulent exudate, heat, edema, and erythema) sometimes aid diagnosis, experts in chronic wounds argue
CME available online at www.jamaarchivescme.com and questions on p 621. Context Chronic wounds (those that have not undergone orderly healing) are commonly encountered, but determining whether wounds are infected is often difficult. The current reference standard for the diagnosis of infection of a chronic wound is a deep tissue biopsy culture, which is an invasive procedure. Objectives To determine the accuracy of clinical symptoms and signs to diagnose infection in chronic wounds and to determine whether there is a preferred noninvasive method for culturing chronic wounds. Data Sources We searched multiple databases from inception through November 18, 2011, to identify studies focusing on diagnosis of infection in a chronic wound. Study Selection Original studies were selected if they had extractable data describing historical features, symptoms, signs, or laboratory markers or were radiologic studies compared with a reference standard for diagnosing infection in patients with chronic wounds. Of 341 studies initially retrieved, 15 form the basis of this review. These studies include 985 participants with a total of 1056 chronic wounds. The summary prevalence of wound infection was 53%. Data Extraction Three authors independently assigned each study a quality grade, using previously published criteria. One author abstracted operating characteristic data. Data Synthesis An increase in the level of pain (likelihood ratio range, 11-20) made infection more likely, but its absence (negative likelihood ratio range, 0.64-0.88) did not rule out infection. Other items in the history and physical examination, in isolation or in combination, appeared to have limited utility when infection was diagnosed in chronic wounds. Routine laboratory studies had uncertain value in predicting infection of a chronic wound. Conclusions The presence of increasing pain may make infection of a chronic wound more likely. Further evidence is required to determine which, if any, type of quantitative swab culture is most diagnostic.
JAMA. 2012;307(6):605-611 www.jama.com

that these features may be absent.3 The current reference standard for diagnosis of infection is a deep tissue biopsy culture. Knowing the baseline prevalence of infection is crucial to understanding the incremental diagnostic value of various elements of the bedside examination and laboratory testing of wound swabs.4 Infected pressure ulcers are one of the leading causes of infections in long-term care facilities and can lead to sepsis.5,6 Patients with diabetes are prone to infection and have at least a 10-fold greater risk of being hospitalized for soft tissue and bone infections

of the foot than individuals without diabetes.7 Half of all diabetes-associated foot wounds become clinically infected during the course of hospitalAuthor Affiliations: Hebrew Rehabilitation Center, Boston, Massachusetts (Dr Reddy); Department of Medicine, Division of Geriatric Medicine, Queens University, Kingston, Canada (Dr Gill); Womens College Research Institute, Womens College Hospital, Toronto, Canada (Drs Kalkar and Rochon and Mr Wu); and Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada (Dr Rochon). Corresponding Author: Madhuri Reddy, MD, MSc, Hebrew Rehabilitation Center, 1200 Centre St, Boston, MA 02131 (madhurireddy@hsl.harvard.edu). The Rational Clinical Examination Section Editors: David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy Editor. JAMA, February 8, 2012Vol 307, No. 6 605

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DOES THIS PATIENT HAVE AN INFECTION OF A CHRONIC WOUND?

ization.8 More than 85% of spinal cord injured patients develop an infected pressure ulcer at least once in their life, and 70% have multiple infected pressure ulcers.9 Some clinicians have a low threshold to prescribe empirical antibiotic treatment and determine retrospectively that wounds were infected when they respond to antibiotics. However, this permissive strategy has not been evaluated and it may contribute to unnecessary costs, adverse drug effects, and the development of antibioticresistant bacteria.10 Individuals with diabetic foot ulcers who have previously used antibiotics have an increased risk of ulcer infection with methicillinresistant Staphylococcus aureus and a resultant increased risk of amputation.10 Many studies of grafts, flaps, and other surgical procedures for management of chronic wounds exclude infected wounds, but no standard objective criteria exist to define infection in clinical settings. In persons with spinal cord injury and pressure ulcers, ensuring that ulcers are not infected can help identify whether the wound is appropriate for surgical correction. Surgeons evaluating wounds preoperatively by visual inspection before flap closure are unable to reliably determine which wounds are infected,11 which is important because infected chronic wounds have significantly decreased flap survival.11 Thus, it is important to better characterize features of the history and physical examination and noninvasive tests such as swab cultures that might help in the diagnosis of infection of a chronic wound. Unfortunately, a standard technique for obtaining a swab culture does not exist and culture results are not systematically reported; different laboratories might report nonquantitative, semiquantitative, or quantitative culture results. Each type of result requires a specific form of swab and culture, some of which may not be widely available. This article addresses 2 pertinent clinical questions about chronic wounds: whether the chronic wound
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is infected and whether there is a preferred swab technique to use for culturing the wound. We will be referring to the diagnosis of infection in existing chronic wounds (for example, pressure ulcers, venous stasis ulcers, and diabetic foot ulcers). This article does not discuss the diagnosis of osteomyelitis because that was the subject of a previous JAMA Rational Clinical Examination article.12 METHODS
Search Strategy and Study Selection

tive surgical wounds, and burns) and osteomyelitis were excluded.

Reference Standards

We searched MEDLINE, EMBASE, and CINAHL databases through November 18, 2011, with a previously published search strategy used in all articles in the Rational Clinical Examination series.12 The strategy combines 9 exploded Medical Subject Headings (physical examination, medical history taking, professional competence, sensitivity and specificity, reproducibility of results, observer variation, routine diagnostic tests, decision support techniques, and Bayes theorem). We restricted our search to articles in English and humans. To select studies about infection of chronic wounds, we added as search terms the text words chronic wound and infection. For each study we identified, we reviewed the bibliography to find additional references. Articles were included if they were original studies describing historical features, physical examination maneuvers, or laboratory markers or were radiologic studies in the diagnosis of infection of chronic wounds among adult patients; if data could be extracted to construct 2 2 tables or the study reported operating characteristics of the diagnostic measure; and if the diagnostic test was compared with the reference standard test (deep tissue biopsy culture; see below) or other commonly used standards (clinical features, swab cultures, and laboratory markers). We included chronic wounds that were surgically debrided as part of the study. Studies of acute wounds (including traumatic wounds, postopera-

The reference standard for the diagnosis of infection of chronic wounds is a deep tissue biopsy culture. Microbial loads of greater than 105 of any organism per gram of wound tissue or the presence of any level of -hemolytic streptococcus is typically considered an indicator of infection of chronic wounds.11,13,14 Deep tissue biopsy can usually be performed in an outpatient setting but is an invasive procedure, often requires local anesthesia, may be contraindicated in patients with leg or foot ulcers from severe peripheral vascular disease, and, in specific situations, requires that the specimen be collected and processed appropriately for aerobic, anaerobic, fungal, and mycobacterial organisms.13,15 Other standards used for the diagnosis of infection of chronic wounds include wound swab cultures and laboratory markers. Because these standards are so commonly used in clinical practice and research reports, we evaluated the performance of clinical findings and procedures using these standards of uncertain validity for comparison with their accuracy against the reference standard of deep tissue biopsy culture.
Quality Review

One author (M.R.) identified potential studies by screening the retrieved studies. Three authors independently reviewed studies for quality (M.R., W.W., and S.R.K.) and 1 author (W.W.) extracted the operating characteristics of the diagnostic tests. Each study was rated with a topic-specific quality rating scale that used published principles,16 as well as a modified quality checklist specific to the Rational Clinical Examination series (BOX).17
Data Analysis

Likelihood ratios (LRs) predicting the presence of infection, given a positive test result (sensitivity/1specificity) and a negative test result (1 sensitivity/

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DOES THIS PATIENT HAVE AN INFECTION OF A CHRONIC WOUND?

specificity), were calculated for each outcome of interest with published raw data and then rounded off. We calculated 95% CIs by using the method described by Simel et al.18 When any 2 2 table included a value of 0, we added 0.5 to each cell of the 2 2 matrix to calculate the 95% CIs for the LRs. A random-effects summary estimate of prevalence was obtained with the derSimonian-Laird approach and heterogeneity was assessed with the I2 statistic. All the included studies reported the number of wounds and the number of patients. Only 2 studies19,20 included patients who had more than 1 wound. We therefore calculated our results according to the number of wounds in each study, not the number of patients. RESULTS
Study Characteristics

chronic wounds in the level 4 to 5 studies was higher (summary prevalence, 59%; 95% CI, 40%-76%; I 2 = 97%; P .001 for heterogeneity). The prevalence of infection of chronic wounds in all 15 studies was 53% (95% CI, 40%67%; I2 = 95%; P .001 for heterogeneity).
Accuracy of Symptoms and Signs for Infection of Chronic Wounds

Box. Criteria for Level of Evidence in Diagnostic Studiesa Level 1: independent, blind comparison of test (ie, sign, symptom, or investigation) results with a reference standard of anatomy, physiology, diagnosis, or prognosis among a large number of consecutive patients ( 75) Level 2: independent, blind comparison of test results with a reference standard among a small number of consecutive patients Level 3: independent, blind comparison of test results with a reference standard among nonconsecutive patients with suspected target condition Level 4: nonindependent comparison of test results with a reference standard among a grab sample of patients who obviously have the target condition (and perhaps healthy individuals) Level 5: nonindependent comparison of test results with a standard of uncertain validity (which may incorporate the test results in its definition) among grab samples of patients (and perhaps healthy individuals)
a

The search strategy identified 341 abstracts, from which 15 relevant studies were selected (eFigure, available at http://www.jama.com).19-33 TABLE 1 provides details about the 6 quality level 1 to 3 studies (see eTable 1 for details of the 9 quality level 4-5 studies). The initial agreement between the 3 raters for the level of evidence was 80%, although all differences were resolved with consensus. The 15 studies included 985 patients with a total of 1056 chronic wounds. Eight studies prospectively evaluated the accuracy of findings compared with a reference standard test, although none assessed their interobserver variability.20,22,24,26,27,29,31,32 Because most of these studies combined wounds arising from multiple etiologies, we could not evaluate the prevalence and accuracy of the various diagnostic features according to patient characteristics or wound type.
Prior Probability of Infection of Chronic Wounds

The prior probability of infection in a chronic wound can be inferred from the prevalence of infection of chronic wounds in the level 1 to 3 studies (summary prevalence, 45%; 95% CI, 32%58%; I2 = 82%; P .001 for heterogeneity). The prevalence of infection of

No symptom or sign was evaluated in more than 2 studies, so the LRs from individual studies with their 95% CIs or LR ranges were used to summarize the results. Symptoms. Two studies (both quality level 2) from the same investigator showed that the likelihood of infection increases when an ulcer causes increasing pain (LR range, 11-20).21,25 The absence of increasing pain (LR range, 0.64-0.88) was not as useful as its presence. Signs. Purulent exudate, erythema, heat, and edema (the classic signs of wound infection) were not helpful in diagnosing infection of chronic wounds, with LR ranges including values less than 1.0.21,25 Wounds that had no serous exudates (LR range, 0.57-0.62) or those that were healing rapidly (LR range, 0.29-0.96) were less likely to be infected. Foul odor, which is often considered a sign of infection, did not significantly predict the diagnosis of infection. Combinations of Findings. Gardner et al21 examined the validity of a combination of signs recommended by the Infectious Diseases Society of America for identifying diabetic foot ulcer infections. The societys guidelines recommend using the presence of a purulent exudate or 2 or more indicators of inflammation (pain, erythema, induration, heat, or edema).34 Gardner et al21 found that this combination of symptoms and signs has only 52% sensitivity and 46% sensitivity, which yields a positive LR of0.96 (95% CI, 0.60-1.6) and negative LR of 1.0 (95% CI, 0.61-1.8). Thus, the combination of findings recommended by a panel of experts may not be helpful,

Based on Simel.17

pointing out the difficulty in clinically identifying infection of chronic wounds.

Accuracy of Noninvasive Techniques for Identifying Infection of Chronic Wounds

Comparisons With Reference Standard. Four studies evaluated the utility of noninvasive techniques (ie, swab cultures or laboratory markers) compared with the reference standard (deep tissue biopsy culture) for the diagnosis of infection of chronic wounds. The 4 studies included a total of 198 patients.23,24,26,27 One of the 2 studies that examined the utility of swab cultures was of quality level 1 and showed that a quantitative swab conducted with Levine techJAMA, February 8, 2012Vol 307, No. 6 607

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DOES THIS PATIENT HAVE AN INFECTION OF A CHRONIC WOUND?

nique (wherein a swab is rotated over a 1 1-cm area for 5 seconds with sufficient pressure to extract fluid from within the wound tissue) was helpful in predicting wound infection (positive LR, 6.3; 95% CI, 2.5-15).21 This same study demonstrated that a negative swab culture result makes wound infection less likely (LR, 0.47; 95% CI, 0.31-0.73). Cultures of wound exudates or swabs performed with the Ztechnique, in which a swab is applied in a zigzag manner covering the entire wound surface while the swab is rotated between the thumb and forefinger, neither predicted nor excluded wound infection, with the CI including 1.0 for positive or negative results (TABLE 2).21 A lower-quality study (level 2) demonstrated that quantitative swab cultures conducted with Levine technique did not predict the likelihood of

wound infection, whereas a negative swab culture result predicted the absence of wound infection (LR, 0.35; 95% CI, 0.15-0.85).26 Another study of quality level 2 demonstrated that laboratory inflammatory marker IL-6 in wound fluid did not predict the presence or absence of wound infection.24 Comparisons With Nonreference Standards. Studies that used a standard (eg, semiquantitative swab culture) other than the reference standard (deep tissue biopsy culture) for diagnosing infection of chronic wounds were automatically deemed to be quality level 5. Eight studies used nonreference standards.19,20,28-33 There were mixed results regarding the utility of physical examination findings (see eTable 2 for LRs).28,32 Semiquantitative swab cultures were as predictive as quantitative swab cultures, superficial

drainage fluid swab cultures were as predictive as deep wound swab cultures obtained after debridement,19,20,31 and elevated white blood cell count or elevated erythrocyte sedimentation rate was as predictive as clinical features.30 Similarly, the absence of the laboratory marker C-reactive protein was as predictive as clinical features in ruling out infection.29,30 A handheld infrared thermometer to assess periwound skin temperature may be of use in diagnosing infection of chronic wounds but needs further study. LIMITATIONS OF THE LITERATURE Only 6 of the 15 studies we identified attained a level 1 to 3 quality rating. The majority of studies compared individual clinical findings with standards of uncertain validity, and none of the findings have been evaluated in multiple

Table 1. Quality Level 1-3 Studies Addressing Diagnosis of Infection of Chronic Wounds, Ordered by Quality Level and Numbers of Patients a
Study Assessment Demographic Details No. of Patients/ No. of Wounds 83/83 Age, Mean (SD), y 57 (12) Duration of Wounds at Study Onset Mean 83 wk

Source Level 1 Gardner et al,23 2006 Level 2 Gardner et al,21 2009 Serena et al,22 2008

Reason Study Not Level 1

Study Type Cross-sectional

Setting Acute care

Female, No. (%) 15 (18)

Type of Chronic Wound Nonarterial ulcers b Nonarterial diabetic foot ulcers

75 Consecutive patients 75 Consecutive patients

Cross-sectional

Acute care

64/64

55 (11)

15 (23)

Mean 34 wk

Ambrosch et al,24 2008

75 Consecutive patients

Randomized controlled trial comparing cellulose antimicrobial matrix and standard care Prospective

Ambulatory care

49/49

Not stated

Not stated Clinically noninfected venous stasis ulcers

1 but mo

18

Acute care

45/45

72 (4)

Bill et al,26 2001

75 Consecutive patients

Prospective

Ambulatory care

38/38

Not stated

Gardner et al,25 2001

75 Consecutive patients

Cross-sectional

Acute care

36/36

65.1 (13)

Venous stasis ulcers, mixed arterial and venous stasis ulcers Not stated Pressure ulcers, diabetic ulcers on lower extremity, venous stasis ulcers, arterial ulcers Not stated Nonarterial chronic wounds b

33 (73)

Mean 24 mo

6 mo

Mean 88 wk

a See eTable 1 for quality level 4 to 5 studies. Deep tissue biopsy culture was the standard used for diagnosis in all studies listed here. b Including pressure ulcers, venous stasis ulcers, and chronic ulcers from surgical incisions, trauma, or peripheral neuropathy.

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DOES THIS PATIENT HAVE AN INFECTION OF A CHRONIC WOUND?

studies. Most of the clinical signs to diagnose infection of chronic wounds (eg, foul odor, friable or discolored granulation tissue) are highly subjective and

may have poor interrater reliability. With so few studies, we cannot be certain that the symptoms and signs lack utility or whether they might perform

better when evaluated in combination with multiple findings. Although wound care experts might value changes in chronic wounds as impor-

Table 2. Diagnostic Accuracy of Reference Standard for Infection of Chronic Wounds a

Prevalence of Wound Definition of Wound Infection, Sensitivity Infection No. (%) Wound Assessment (95% CI) Clinical Symptoms and Signs Increasing pain 0.13 (0.05-0.31) 0.38 (0.16-0.65) Foul odor 0.20 (0.09-0.39) 0.36 (0.15-0.65) Discolored granulation 0.28 (0.14-0.48) tissue 0.64 (0.35-0.85) Erythema 0.32 (0.17-0.52) 0.55 (0.28-0.79) 106 Organisms/g of 25 (39) Serous exudate 0.88 (0.70-0.96) tissue21 0.55 (0.28-0.79) Delayed healing 0.48 (0.30-0.67) 0.81 (0.52-0.95) IDSA combination c,21 0.52 (0.33-0.70) 105 Organisms/g of 11 (31) Edema 0.20 (0.09-0.39) tissue or wounds 0.64 (0.35-0.85) contained any amount Heat 0.12 (0.04-0.30) of -hemolytic 0.18 (0.05-0.48) streptococci25 Wound breakdown 0.02 (0.01-0.16) 0.46 (0.22-0.71) Sanguinous exudate21 0.83 (0.65-0.94) Purulent exudate 0.26 (0.12-0.43) 0.18 (0.05-0.48) Pocketing21 0.04 (0.01-0.19) Friable granulation 0.02 (0.01-0.16) tissue 0.82 (0.52-0.95) 105 Organisms/g of 14 (28) Clinically noninfected 0.03 (0.01-0.25) tissue or wound wounds contained any amount of -hemolytic streptococci Quantitative Swab Culture 30 (36) Levine technique 0.57 (0.39-0.73) 106 Organisms/g of viable tissue Positive Negative Likelihood Likelihood Ratio (95% CI) Ratio (95% CI)

Source

Specificity (95% CI)

0.99 (0.89-0.99) 11 (0.58-200) 0.88 (0.75-1.0)) 0.98 (0.84-0.99) 20 (1.1-334) 0.64 (0.41-0.99)) 0.87 (0.73-0.94) 1.5 (0.50-4.8) 0.92 (0.73-1.2) 0.88 (0.70-0.96) 3.1 (0.81-11) 0.73 (0.45-1.2) 0.85 (0.70-0.93) 1.9 (0.69-4.8) 0.85 (0.64-1.1) 0.56 (0.37-0.73) 0.77 (0.62-0.87) 0.68 (0.48-0.83) 0.21 (0.11-0.35) 0.72 (0.52-0.86) 0.54 (0.39-0.68) 0.64 (0.45-0.80) 0.46 (0.32-0.61) 0.77 (0.62-0.87) 0.72 (0.52-0.86) 0.85 (0.70-0.93) 0.84 (0.65-0.94) 0.97 (0.85-0.99) 0.98 (0.84-0.99) 0.09 (0.03-0.20) 0.65 (0.48-0.77) 0.64 (0.45-0.80) 0.92 (0.80-0.97) 0.77 (0.61-0.87) 1.4 (0.77-2.7) 1.4 (0.62-3.1) 1.7 (0.78-3.7) 1.1 (0.89-1.4) 1.9 (0.9-4.5) 1.0 (0.61-1.8) 2.3 (1.3-4.1) 0.96 (0.60-1.6) 0.87 (0.33-2.3) 2.3 (1.1-4.9) 0.80 (0.21-2.8) 1.1 (0.24-5.3) 0.51 (0.02-12) 24 (1.4-397) 0.91 (0.75-1.1) 0.74 (0.29-1.5) 0.50 (0.13-2.0) 0.50 (0.06-4.7) 0.08 (0.01-1.3) 0.64 (0.28-1.5) 0.88 (0.64-1.2) 0.66 (0.33-1.3) 0.57 (0.17-2.0) 0.62 (0.32-1.3) 0.96 (0.60-1.6) 0.29 (0.08-1.0) 1.0 (0.61-1.8) 1.0 (0.80-1.4) 0.51 (0.22-1.1) 1.0 (0.85-1.3) 0.98 (0.70-1.4) 1.0 (0.94-1.1) 0.55 (0.33-0.93) 1.9 (0.51-8.5) 1.1 (0.86-1.6) 1.3 (0.85-1.9) 1.0 (0.92-1.2) 1.3 (1.1-1.5)

Gardner et al,21 2009 (deep tissue biopsy culture vs clinical signs) Gardner et al25 2001 (deep tissue biopsy vs clinical signs) b

Serena et al,22 2008 (deep tissue biopsy culture vs clinical diagnosis)

0.76 (0.57-0.89) 3.4 (1.6-7.2) 0.24 (0.07-0.85) 0.99 (0.88-0.99) 2.4 (0.05-115) 0.98 (0.89-1.1)

Gardner et al,23 2006 (deep tissue biopsy culture vs quantitative swab culture)

0.91 (0.80-0.96)

6.3 (2.5-15)

0.47 (0.31-0.73)

Ambrosch et al,24 2008 (deep tissue biopsy culture vs IL-6 in wound fluid) Bill et al,26 2001 (deep tissue biopsy culture vs quantitative swab culture)

105 Organisms/mL

28 (62)

Wound exudate 0.43 (0.27-0.61) 0.75 (0.62-0.85) 1.7 (0.95-3.3) Z-technique 0.63 (0.45-0.78) 0.53 (0.40-0.66) 1.3 (0.91-2.0) Inflammatory marker 0.62 (0.42-0.76) 0.57 (0.33-0.79) 1.4 (0.72-2.8) IL-6 in wound fluid

0.76 (0.53-1.1) 0.69 (0.41-1.2) 0.69 (0.36-1.3)

105 Organisms/mL

28 (74)

Quantitative swab culture with Levine technique

0.79 (0.60-0.90) 0.60 (0.31-0.83) 2.0 (0.90-4.3) 0.36 (0.15-0.85)

Abbreviation: IDSA, Infectious Diseases Society of America. a See eTable 2 for quality level 4 to 5 studies. b For findings reported by these authors in 2 separate studies, the data on the first line represent the more recent study,21 whereas the data on the second line represent the earlier study.25 c Defined by the IDSA as purulent exudates or 2 or more signs of inflammation (ie, pain, erythema, heat, or edema).18,21

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DOES THIS PATIENT HAVE AN INFECTION OF A CHRONIC WOUND?

tant indicators of infection (eg, increases in size or amount of exudate), no studies evaluated the diagnostic accuracy of serial assessments. The lack of multiple studies across a broad range of patients is important because the presence or absence of clinical findings might depend on the comorbidities of the patients and the type of chronic wound (eg, pressure ulcer vs venous stasis ulcer) and not just on whether infection is present. Thus, the context in which a wound occurs may have an important influence on the diagnostic accuracy of symptoms and signs that has not been adequately explored in studies of high quality. SCENARIO RESOLUTION The patient has a pressure ulcer and increase in the level of pain, with the absence of erythema or purulent exudate. With a prevalence of 45% infection in the studies of quality level 1 through 3, using the lower end of the LR range (11) for increasing pain increases the posttest probability to 90%. An absence of erythema and purulent exudate does not rule out infection. We are unsure from the information given what technique was used to perform the swab. Evidence from single studies suggests that the swab culture provides no information (LR CI crosses 1.0), unless Levine technique is used. If the physician assesses the probability of infection as 90% because of the presence of pain, a negative swab result with Levine technique (LR, 0.47) still confers a probability of 81% for infection. Because infection is so likely despite the negative swab result, the need for subsequent diagnostic tests depends on the need for isolating bacteria. This would be important if it would affect the choice of antimicrobial therapy. CLINICAL BOTTOM LINE Despite heterogeneity, the CI for the prevalence of chronic infection in studies of quality level 1 through 3 of 32% to 58% creates a reasonable range for estimating the probability of infection in individual patients. An increase in the
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level of pain might be a useful symptom for identifying infected ulcers, but the absence of pain (in a patient who can perceive pain) should not reassure the clinician that a wound is sterile. This finding needs to be confirmed in future studies by comparing the results to deep tissue biopsy culture because the CIs from the individual findings in our study were broad. Furthermore, the underlying cause of the ulcer and comorbidities of the patient will affect the presence or absence of pain independent of infection. Classic signs of wound infection, evaluated in isolation from the clinical context and other findings, are not particularly helpful in diagnosing infection in a chronic wound (LR range, 0.8-2.3). The lack of utility of the classic findings for infection is perplexing, as is the finding that the positive LR range of a serous exudate (range, 1.1-1.9) suggests more usefulness than a purulent exudate (range, 0.500.74). Overall, the available studies suggest that the character of wound fluid exudates (categorized as serous vs purulent) is most likely not useful as a predictor of infection when the reference standard is a deep tissue biopsy culture. The apparent lack of utility of a combination of findings identified by infectious disease experts (Infectious Diseases Society of America criteria) as useful for diabetic foot infection21 is both surprising and disappointing but highlights the difficulty in making the diagnosis. When there is a clinical suspicion of infection (the presence of increasing pain is most useful), a quantitative swab should be performed. A quantitative swab culture performed with Levine technique has the highest-quality evidence of any noninvasive diagnostic test of infection of chronic wounds. An infection of chronic wounds is more likely (LR, 6.3) when a quantitative swab culture result with Levine technique is positive, whereas a negative swab culture result decreases the likelihood (LR, 0.47). Further research with use of an appropriate reference standard (ie, deep tissue biopsy culture) is needed to de-

termine whether wound fluid cultures (obtained with an irrigation-aspiration technique), semiquantitative swab cultures, and laboratory tests such as C-reactive protein level, erythrocyte sedimentation rate, white blood cell count, or procalcitonin level are useful for diagnosing infection in chronic wounds. More specifically, comparative effectiveness studies of treatment guided by clinical diagnosis and Levine technique swab results vs treatment guided by deep tissue biopsy culture would be the most useful data to help physicians in the care of patients with chronic wounds. Despite our rigorous search, the available literature we found was limited; thus, we have put forth the best evidence possible for identifying infection of a chronic wound. There were no studies identified that addressed the precision of symptoms, signs, or investigations in the diagnosis of chronic wounds. For information regarding the management of infection of chronic wounds, clinical guidelines are available through the Wound Healing Society (http://onlinelibrary.wiley.com /doi/10.1111/wrr.2006.14.issue-6 /issuetoc).13,35-37 In summary, the presence of increasing pain, along with a quantitative swab culture, might help physicians estimate the probability of infection. Further evidence is required to determine which, if any, type of quantitative swab is most diagnostic.
Author Contributions: Dr Reddy had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Reddy, Gill, Rochon. Acquisition of data: Reddy, Wu, Kalkar. Analysis and interpretation of data: Reddy, Gill, Wu, Kalkar. Drafting of the manuscript: Reddy. Critical revision of the manuscript for important intellectual content: Gill, Wu, Kalkar, Rochon. Statistical analysis: Reddy, Wu. Administrative, technical, or material support: Wu, Kalkar, Rochon. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Funding/Support: This work was supported by an Interdisciplinary Capacity Enhancement grant (HOA80075) from the Canadian Institutes of Health Research (CIHR) Institute of Gender and Health and the CIHR Institute of Aging.

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DOES THIS PATIENT HAVE AN INFECTION OF A CHRONIC WOUND?

Role of the Sponsors: The funding organizations did not participate in the design or conduct of the study; in the collection, analysis, or interpretation of the data; or in the preparation, review, or approval of the manuscript. Online-Only Material: eTables 1 and 2 and the eFigure are available at http://www.jama.com. Additional Contributions: We thank Karen Catignani, MD, PhD (Ohio State Medical Center), Sheri Keitz, MD, PhD (University of Miami), Rambi Cardones, MD, PhD (Duke University), and Debra MillerCox, MD, PhD (Spartanburg Regional Wound Healing Services), for their review of the manuscript. No one received financial compensation for his or her contributions. E, Boulton AJ. Methicillin-resistant Staphylococcus aureus in diabetic foot infections. Drugs. 2010;70 (14):1785-1797. 11. Robson MC, Heggers JP. Bacterial quantification of open wounds. Mil Med. 1969;134(1):19-24. 12. Butalia S, Palda VA, Sargeant RJ, Detsky AS, Mourad O. Does this patient with diabetes have osteomyelitis of the lower extremity? JAMA. 2008; 299(7):806-813. 13. Steed DL, Attinger C, Colaizzi T, et al. Guidelines for the treatment of diabetic ulcers. Wound Repair Regen. 2006;14(6):680-692. 14. Schraibman IG. The significance of betahaemolytic streptococci in chronic leg ulcers. Ann R Coll Surg Engl. 1990;72(2):123-124. 15. Heggers JP. Variations on a theme. In: Heggers JP, Robson MC, eds. Quantitative Bacteriology: Its Role in the Armamentarium of the Surgeon. Boca Raton, FL: CRC Press; 1991:15-23. 16. Jaeschke R, Guyatt G, Sackett DL; EvidenceBased Medicine Working Group. Users guides to the medical literature, III: how to use an article about a diagnostic test, A: are the results of the study valid? JAMA. 1994;271(5):389-391. 17. Simel DL. Update: primer on precision and accuracy. In: Simel DL, Rennie D, eds. The Rational Clinical Examination. New York, NY: McGraw Hill Medical; 2009. 18. Simel DL, Samsa GP, Matchar DB. 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A cross-sectional validation study of using NERDS and STONEES to assess bacterial burden. Ostomy Wound Manage. 2009; 55(8):40-48. 29. Jeandrot A, Richard JL, Combescure C, et al. Serum procalcitonin and C-reactive protein concentrations to distinguish mildly infected from noninfected diabetic foot ulcers: a pilot study. Diabetologia. 2008;51(2):347-352. 30. Uzun G, Solmazgul E, Curuksulu H, et al. Procalcitonin as a diagnostic aid in diabetic foot infections. Tohoku J Exp Med. 2007;213(4):305-312. 31. Ratliff CR, Rodeheaver GT. Correlation of semiquantitative swab cultures to quantitative swab cultures from chronic wounds. Wounds. 2002;14 (9):329-333. 32. Schmidt K, Debus ES, Jessberger ST, Ziegler U, Thiede A. Bacterial population of chronic crural ulcers: is there a difference between the diabetic, the venous, and the arterial ulcer? Vasa. 2000;29(1): 62-70. 33. Fierheller M, Sibbald RG. A clinical investigation into the relationship between increased periwound skin temperature and local wound infection in patients with chronic leg ulcers. Adv Skin Wound Care. 2010; 23(8):369-379, quiz 380-381. 34. Lipsky BA, Berendt AR, Deery HG, et al; Infectious Diseases Society of America. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2004; 39(7):885-910. 35. Robson MC, Cooper DM, Aslam R, et al. Guidelines for the treatment of venous ulcers. Wound Repair Regen. 2006;14(6):649-662. 36. Whitney J, Phillips L, Aslam R, et al. Guidelines for the treatment of pressure ulcers. Wound Repair Regen. 2006;14(6):663-679. 37. Hopf HW, Ueno C, Aslam R, et al. Guidelines for the treatment of arterial insufficiency ulcers. Wound Repair Regen. 2006;14(6):693-710.

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