Wounds in Long-term Care Facilities: Microbiology and Management Christina Lin; Jonathan Zenilman, MD; Geeta Sood, MD; Denise King, RN; Edmund Duthie, MD Medical College of Wisconsin and Zablocki VA Medical Center, Milwaukee, WI;

MSTAR Program at Johns Hopkins Bayview Medical Center, Baltimore, MD

Introduction

Objectives

Methods Results Conclusion

References

Funding Source: MSTAR, American Federation for Aging Research (AFAR)

Ø  To show whether the appearance of the wounds correlated with what was found in the cell cultures of the wounds.

Ø  To determine whether the presence of polymorphonuclear leukocytes (PMNs) in the wounds correlated with infection.

Ø  To analyze the types of wound microorganisms and whether they are harmful to the patient.

Ø  To discover how effective the wound dressings are in preventing infection and to determine the preventive properties.

Ø  To find ways to better protect older patients residing in LTC facilities who have open wounds.

Ø From the microbiology culture reports, the microorganisms of interest were Staphylococcus aureus- MRSA (n = 10), Pseudomonas aeruginosa (n=11), Staphylococcus sp. coagulase negative (n = 7), and Klebsiella pneumoniae (n = 3). Ø Although there were microorganisms found in the wounds, they were not causing the patients any complications. Ø There were PMNs found in all the wounds. Ø Only 1 out of the 77 wounds clinically appeared infected to the wound nurses, so the appearance of the wound could be used for diagnostic. Ø Microbiology showed which microorganisms were in the wounds but not to the level of causing infection. Ø Wound dressings with calcium alginate and silver (n = 21) were used the most. Iodosorb (n= 12) and Hydrofera Blue (n=1) were the others. Ø Antimicrobial wound dressings were used in over half of the wounds showing the importance of protecting against and containing infection. Summary The risk of infection from an open wound is a major health concern. Local management was effective in controlling infection in this point prevalence review. Microbiology and clinical judgment can be used in conjunction to figure out the best treatment plan for each wound patient.

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Stage of Pressure Sores

Figure 2. Number of each stage of pressure sores found from the patients

Figure 1. Pressure Ulcer Category/Staging Illustrations by the National Pressure Ulcer Advisory Panel (NPAUP). Retrieved from the NPAUP website http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-categorystaging-illustrations/. Permission granted for educational purposes.

Ø A one-month prospective prevalence study at the John R. Burton Pavilion LTC facility.

Ø  32 out of the 86 patients had wounds. Ø  Total count of wounds was 77, and they were

categorized as pressure (49), surgical (24), or other (4) wounds.

Ø Document the types of wound dressings being used and how effective in preventing the occurrence of infection.

Ø  Prospective rounds with the wound nurses to see: o  the wound nurses’ evaluation of the wounds o  whether the wounds were infected o  the dressings used for each wound

Ø Through the hospital’s Electronic Patient Record (EPR), obtain the microbiology culture reports to see which microorganisms were present in the wounds.

Infection is a prominent area of concern in long-term care (LTC) facilities, and it can make proper wound management difficult. Patients in LTC facilities have a high risk of developing chronic wounds such as pressure ulcers or they are already admitted with existing wounds. Long-term stays in hospitals and care facilities are a concern especially among the geriatric population because aging is accompanied by a steady decline in resistance to infectious diseases. This study investigates the role wound dressings play in preventing, managing, and containing infections in LTC patients with wounds.

Table 2. Microorganisms present in the wounds ---------------------------------------------------------------Staphylococcus aureus- MRSA 10 Staphylococcus sp. coagulase neg 7 Klebsiella pneumoniae 3 Enterococcus faecium- VRE 1 Pseudomonas aeruginosa 11 Citrobacter freundii 2 Citrobacter koseri 1 Serratia marcescens 1 Corynebacterium species 1 Enterobacter aerogenes 1 Enterococcus faecalis 1 Hafnia alvei 1 Proteus mirabilis 1 Stenotrophomonas maltophilia 1 Candida glabrata 1 Escherichia coli 3 Morganella morganii 1

Iodosorb 35%

Calcium Alginate-

Ag 62%

Hydrofera Blue 3%

Figure 3. Types of antimicrobial wound dressings used

Table 3. Antimicrobial properties of above dressings ----------------------------------------------------------------- Calcium Alginate-Ag: The silver makes it effective against a broad-spectrum of microorganisms, including fungi, MRSA, and VRE. Iodosorb: The iodine makes it effective against a broad range of bacteria including MRSA. Hydrofera Blue: The polyvinyl alcohol sponge complexed with two organic pigments (Methylene Blue and Gentian Violet) provides broad-spectrum bacteriostatic protection.

1.  Cencetti C, Bellini D, Pavesio A, Senigaglia D, Passariello C, Virga A, Matricardi P. Preparation and characterization of antimicrobial wound dressings based on silver, gellan, PVA and borax. Carbohydr Polym. 2012 Oct 15;90(3):1362-70.

2.  Storm-Versloot MN, Vos CG, Ubbink DT, Vermeulen H. Topical silver for preventing wound infection. Cochrane Database System Rev. 2010 Mar 17;(3).

3.  Yu-Hsin Lin, Jui-Hsiang Lin, Shih-Hao Wang, Tse-Hao Ko, Guan-Chin Tseng. Evaluation of silver-containing activated carbon fiber for wound healing study: In vitro and in vivo. J Biomed Mater Res B Appl Biomater. 2012 Sep 15.

4.  Percival SL, Slone W, Linton S, Okel T, Corum L, Thomas JG. The antimicrobial efficacy of a silver alginate dressing against a broad spectrum of clinically relevant wound isolates. Int Wound J. 2011 Jun;8(3):237-43.