Wound care clinicians stress infection control

Patients can serve as VRE, MRSA reservoir

Wound care clinicians are emphasizing stringent infection control practices and proper antibiotic use in a draft position statement by the Miami-based American Subacute Care Association’s Wound Care Alliance. The multidisciplinary committee addresses issues of infection control and increasing drug resistant pathogens in new recommendations for infection control in wound care.

The recommendations incorporate aspects of recommendations for wound care by the federal Agency for Health Care Policy and Research in Rockville, MD, which has issued a clinical advisory that outlines the preferred pathway for managing ulcer colonization and local and systemic infection. The issue of resistant pathogens is among the top concerns of the committee, says chairwoman Samantha Morgan, RN, CRRN, CCM, ET, director of rehabilitation services for Tendercare in Bloomfield Hills, MI.

’The committee itself is fairly new, but that is one of the first items on the agenda that we are looking at,” she says. ’One of the things I know we are going to emphasize goes back to the very basics — handwashing, handwashing, handwashing. A lot of these infections are induced by the practitioners themselves and spread by them inadvertently.”

The committee has taken the position that immediately administering antibiotics when wounds become inflamed is counterproductive and only contributes to the aforementioned pressures that select out for resistance.

’There is a profound difference between inflammation and infection,” she says.

If a wound becomes infected, preventing cross-transmission to other patients is critical in settings like hospitals and subacute facilities where wound patients may be in close proximity.

’As a wound care specialist, my strongest recommendation is to contain the drainage,” Morgan says.

To do that, Morgan advocates wound ’pouching,” containing the wound site in a plastic pouch that is changed every two or three days. Pouching systems are preferable to frequent wound handling and dressing changes, particularly given the ability of drug resistant pathogens to spread on the hands of health care workers, she emphasizes.

’The fewer times you can touch dressings and mess with the wound, the fewer times you have the likelihood of passing that organism onto someone else,” she says.

Methicillin-resistant Staphylococcus aureus (MRSA) has long been a problematic wound care pathogen, but now there is increasing concern about vancomycin-resistant enterococci (VRE).

VRE can cause serious infections in hospitalized wound patients, but more often they are likely to be only colonized, says Karen Green, RN, CIC, infection control coordinator at Mount Sinai Hospital in Toronto. However, the pathogen appears to have a greater ability to survive on environmental surfaces than MRSA, making it more likely to be spread around the hospital once introduced, she notes.

’That is often the case with decubitus ulcers,” Green says. ’They sometimes become infected, but more often than not they become colonized with a whole myriad of bacteria.”

In such situations, colonized patients can serve as a VRE ’reservoir” from which the organisms can eventually reach severely immunocompromised patients who may quickly develop serious systemic infections. The likelihood of transmission is also increased because patients with chronic wounds often require more intensive hands-on care, Green adds.

’The type of care that you have to provide to them is such that it’s easy to take bacteria from one patient to another,” she says. ’So a debilitative group of patients like this can set up a relatively unrecognized [VRE] reservoir.”

A possible vehicle for transmission is contamination of wound care products and containers, particularly if they are designated for use on several patients, she notes. Wound cleaning solutions, ointments, and creams should be used between patients as little as possible to avoid contamination of such items with VRE.

’A lot of patients with complicated wounds may be geographically close together,” Green says. ’We think of things that we take from patient to patient like thermometers and blood pressure cuffs as being potential reservoirs for spreading VRE. But you can carry this bacteria on any type of shared product, whether it’s a bottle of solution or a package of dressing material.’

In such cases involving colonized patients, infection control is paramount because there is no clearly effective decolonization protocol for VRE.