BACTERIOLOGY IN WOUND CARE

DR NURAHAN MANING CLINICAL MICROBIOLOGIST HRPZ II

Skin Flora

Moist Skin Area

Dry Skin Area

Staphylococcus aureus

Gram-negative bacteria

Staphylococcus epidermidis

Propionobacterium. Corynebacterium

Pathophysiology of wound infection

Normal function of skin: prevent colonization and invasion of underlying tissue by potential microbial pathogens Loss of skin integrity (wound) provides moist and nutritious environment for microbial proliferation Presence of foreign material and necrotic tissue facilitates microbial proliferation (dirty wound)

Foreign material - external fixator.

Predisposing factors for wound infection

Poor blood perfusion with hypoxia (pO2 < 20 mm Hg) inhibits granulation tissue response and wound repair Cell death and tissue necrosis due to hypoxia creates ideal growth conditions for wound microflora Hypoxia compromises oxygen radical dependent killing of bacteria by polymorphonuclear neutrophils

Contamination

Colonization

O2 O2 O2

pH

pH O2 pH pH

Critical colonization

Infection

Definition

Microbial colonization precedes wound infection

If tissue devitalized and/or host immunity compromised, conditions optimal for microbial growth and invasion follows colonization Source of microorganisms: exogenous (environmental), surrounding skin endogenous (mucous membranes of Systemic Local gastrointestinal ContaminationColonization Infection tract and genitourinaryInfection tract, oropharyngeal cavity)

 Exposed wound surfaces provides ideal

culture medium for a wide varieties of microorganisms to contaminate and colonized.

The abundance and diversity of bacteria in any wound depends on:

wound type depth Location quality of the tissues level of tissue perfusion host immune response.

Necrotic wounds

Common Pathogenic Bacteria Isolated from Different Types of Wound

Type of wound Probable aerobic bacteria Surgical wound infections S. aureus Enterococcus spp P. aeruginosa E. coli Enterobacter spp Probable anaerobic bacteria * contaminated wounds or dirty wounds may contain anaerobes especially those involving hollow viscus

Type of wound Automobile accident wounds infections

Probable aerobic bacteria S. aureus P. aeruginosa E. Coli / Klebsiella pneumoniae Streptococcus pyogenes

Probable anaerobic bacteria If contaminated with soil with decaying materials

Type of wound

Burn wound

Probable aerobic bacteria P. aeruginosa / S. aureus / E. Coli / klebsiella spp, Enterococcus spp

Probable anaerobic bacteria Peptostreptococcus / Bacteroides spp / Propionibacterium acne

Type of wound Bite wound (Polymicrobial)

Probable aerobic bacteria S. aureus Streptococcus spp Less common Pasturella multocida / Pasturella canis / Capnocytophaga canimorsus / B. Henselae / E. corrodens

Probable anaerobic bacteria Bacteroides spp Provotella spp Peptostreptococcus spp Clostridium perfringens

Type of wound Diabetic foot ulcer

Probable aerobic bacteria S. aureus / Strep. Algalactae (GBS) / P. aeruginosa / Enterococcus spp / coliforms

Probable anaerobic bacteria Peptostreptococcus / Bacteroides spp / provotella

Type of wound

Probable aerobic bacteria

Probable anaerobic bacteria

Decubitous ulcer

S. aureus / P. aeruginosa Peptostreptococcus / Bacteroides spp

Wound near anus contaminated with fecal materials

 HCAI wound MRSA ESBL

MRO: Acinetobacter spp

Pseudomonas aeruginosa

 Figure 2. Infection of the hand caused by methicillin-

resistant Staphylococcus aureus.

Gregory Moran, M.D., from the Center for Disease Control and Prevention.

Greenish pus

Wound infected with Pseudomonas aeruginosa

Microbial Analysis of Wounds

Wound culture should not be done routinely. 3 Situation where sampling is recommended: 1.Wounds that have clinical signs and symptoms of infection

New or increase swelling Local warmth Erythema or further extension of erythema New or increasing pain Purulent discharge or increase in the level of exudate Discoloration of surrounding skin Wound breakdown / dehiscence Lymphangitis Fever

2.Burns with skin graft rejection 3.Chronic wounds that have a long history of failure to heal

Clean wound

No need sampling for culture and sensitivity testing

 General Guidelines Quality of lab results proper collection and handling of the specimen as well as obtaining satisfactory material for examinations Actual infection site & minimum contamination from adjacent tissue, organs and secretions Sufficient quantity

Appropriate collection devices, specimen containers, & culture media must be used to ensure optimal recovery of microorganism

Basic principles of specimen collection

If possible, a culture specimen should be taken in the acute phase of the infection and before antibiotic are administered
Important to culture infecting agents while avoiding the normal flora Test results must always be compared with suspected diagnosis carefully

 Specimen collected before the commencement of antibiotic therapy Specimen container must be properly labeled, place in the biohazard plastic bag and accompanied laboratory request form Specimen are best transported immediately to the laboratory

Triggers For Suspecting Wound Infection In Acute Wounds 1. New or increase 1.Discoloration of swelling surrounding skin 2. Local warmth 2.Wound breakdown / 3. Erythema or further dehiscence extension of erythema 4. New or increasing pain 3.Lymphangitis 5. Purulent discharge or 4.Fever increase in the level of exudate

Extensive burn wound (> 20%) Burns with skin graft rejection Chronic non-healing wounds

1. Wound swabbing Test request: Wound swab for culture and sensitivity Suitable for superficial wounds Requirements:

Specimen Collection

Procedure For Taking Wound Swab

1. Prepare the required equipments as above 2. Perform hand hygiene and wear PPE 3. Clean the wound using sterile water or saline. Irrigate the wound surface using syringe and needle to flush out contaminating and colonizing bacteria 4. Moist the sterile swab (if the wound surface is dry) with normal saline 5. Use a zig-zag motion whilst simultaneously rotating the swab stick between the fingers

Procedure For Taking Wound Swab

1. Sample the whole wound surface 2. Place the specimen straight into the transport medium

and lable the container Complete the request form( Per Pat 301). clinical information should be provided (e.g., type and site of wound, associated malodor, signs of infection, antibiotic therapy) in order to ensure that meaningful results can be provided in as short a time as possible 1. Place the specimen and request form into the Biohazard bag and sent straight to the laboratory 2. Wound swabs should be stored at room temperature

Tissue sampling
Test request : Tissue for culture and sensitivity and

gram stain

Should be performed aseptically after initial

debridement and cleansing (with sterile saline or distilled water) of the wound The most useful method for determining the presence of invasive pathogens. Taken after initial debridement and cleansing of superficial debris and should be taken aseptically.

Procedure for Taking Tissue Sampling

Obtain tissue sample

from the deep part of the wound or base of the lesion/wound/ulcer and placed into a sterile screw capped container with few drops of saline to keep it moist

Fluid sampling
Suitable

for wound with copious volume of fluid present either beneath the scab or any superficial debris. be done aseptically and try to avoid endogenous contamination. cavity wounds such as pressure sores, irrigation with saline and gentle massaging may be required to provide fluid for sampling.

Should

In

Fluid sampling
Test request: Fluids for C&S and gram stain Suitable for wound with cavity, sinus or pockets.

Should be done aseptically after cleansing (with sterile saline or distilled water)

For Taking Fluid Sampling

1. Placed about 5 ml of aspirate in a sterile screw capped bottle 2. If the pus is very little, use a sterile swab to collect a sample from the cavity or sinus and immerse the swab in the transport medium 3. Sent the specimen immediately to the lab 4. Sample should be taken from deep cavity or sinus

Wounds that are likely to contain anaerobic bacterias:

Wounds that are in close proximity to the mucosal

areas. Wounds that are deep and contains devitalized tissues. Chronic nonhealing wounds with poor blood perfusion.

Anaerobic infection

Anaerobic Culture Collection

Test request: Tissues or fluids for culture and

sensitivity and gram stain Should be done aseptically Samples must be either aspirates or tissues only. Swabs are not suitable for anaerobic culture For large pieces of tissues ( 1 cm), sample can be placed in a screw capped bottle because the bigger the tissue, the higher is the yield for anaerobic culture. Smaller pieces should be placed in an aerobic transport media or Robertson cooked meat medium.

Anaerobic culture
Collection: 1. Abscess Clean site by wiping with sterile saline or water Aspirates the area containing fluid, pus or exudates by needle and syringe, expel air from the syringe and cap it or send in a screw capped bottle and send to the laboratory immediately

Storage and Transportation of Wound Specimens for anaerobic culture 1.Specimens should be sent immediately to the laboratory for processing 2.In hospitals where the laboratory does not accept specimens after office time or over the weekends, the specimen should be kept at room temperature and sent immediately on the next working day.

1. Blood cultures should be performed for a patient with a severe infection, especially if the patient is systemically ill.

Antibiotic Treatment
Antibiotics should only be given when there are

evidence of wound infection

Should follow the antibiotic guideline
Empirical treatment should cover the possible

organisms as stated in the table above and should be changed according to the culture results

Sample for culture should never be send in Formalin & should not be left dry in the container

Formalin

Saline

Sterile water

Summary
Sample should be taken when indicated Correct sampling technique is pertinent for optimal yield Correct Transport material & container may determine

whether the bacteria is able to grow Never send samples in FORMALIN Bacteria isolated from any wound does not indicate infection clinical correlation is crucial No growth does not exclude infection Consider anaerobic infection in deep seated infection or when there is abundant of devitalized tissues Antibiotic treatment only when indicated and follow guideline