Preparing the Wound Bed

Debridement, Bacterial
Balance, and Moisture Balance
R. Gary Sibbald, MD, FRCPC; Diane Williamson, MB, MRCP(UK); Heather L. Orsted, RN, BN, ET; Karen
Campbell, RN, MScN; David Keast, MD, CCFP; Diane Krasner, PhD, RN, CWOCN, CWS, FAAN; and Debra
Sibbald, BScPhm

ABSTRACT
Successful diagnosis and treatment of patients with chronic wounds
involve holistic care and a team approach. The integration of the
work of an interdisciplinary care team that includes doctors, nurses,
and allied health professionals with the patient, family, significant
others, and caregivers offers an optimal formula for achieving
wound resolution. Such an approach challenges practitioners and
everyone participating in wound care to integrate data and infor-
mation that arise from a number of sources and mitigating factors.
In this article, the authors define the changing paradigm that links
treatment of the cause and focuses on three components of local
wound care: debridement, wound-friendly moist interactive dress-
ings, and bacterial balance. The authors demonstrate that the
treatment of chronic wounds can be accomplished through a series
of recommendations and rationales based on the literature and
their experience. These recommendations lay the groundwork for
thorough assessment and evaluation of the wound.
Ostomy/Wound Management 2000;46(11):1435
kept pace with the evidence base. The chronic wound must
be directed back to this orderly nexus of events. Despite
treating the cause, providing appropriate local wound care,
and attending to patient-centered concerns, a certain per-
centage of wounds do not heal with best practices. Three
components involved in healing the wound that must be
considered by the healthcare professional include: treating
the cause, providing local wound care, and addressing
patient-centered concerns (see Figure 1). This paper focuses
on local wound care involving preparation of the wound.
The recommendations to follow can be used as a guide for
multidisciplinary teams to consider in order to obtain opti-
mal healing (see Table 1).
Recommendation 1
Assess the Patient for Adequate Blood Supply and
Host Factors for Healability
The local wound must be considered with underlying
causes, the patients physical condition, and related extenuat-
ing and mitigating circumstances. One important considera-
tion is to ensure that the wound has enough blood supply to

A
chronic wound is one in which the orderly
sequence of repair is disrupted at one or several
points of the inflammatory, proliferative, re-epithe-
lization, and remodeling stages.1 Key articles of Winter in
the 1960s23 demonstrated the benefits of moist interactive
healing. Unfortunately, clinical practices have not always
heal prior to initiating wound management.4 This is an
especially important principle for wounds of the lower
extremity. If a palpable dorsalis pedis or posterior tibial pulse
is present, the systolic pressure is approximately 80 mm Hg
or greater. The Doppler ankle brachial pressure index
(ABPI) is often used to diagnose arterial disease.5 A systolic

Dr. Sibbald is Associate Professor of Medicine at the University of Toronto. Ms. Williamson is a Fellow in Wound Care at the Womens College
Campus, Sunnybrook and Womens College Health Sciences Centre, Toronto. Ms. Orsted is a Clinical Specialist, Skin and Wound Management,
with Calgary Wound Care, Calgary, Alberta. Ms. Campbell is a Clinical Nurse Specialist at Parkwood Hospital, University of Western Ontario,
London, Ontario. Dr. Keast is a physician specializing in family medicine at Parkwood Hospital. Dr. Krasner is a Wound Care Consultant and
Adjunct Associate Professor, Johns Hopkins University School of Nursing, Baltimore, Md. Ms. Sibbald is Senior Lecturer, Faculty of Pharmacy,
University of Toronto. Address correspondence to: R. Gary Sibbald, MD, FRCPC, Womens College Campus, SWCHSC, 76 Grenville Street,
Toronto, Ontario, Canada.

14 OstomyWound Management
 This necrotic heel ulcer was caused by perioperative pressure. Autolytic debridement of a necrotic heel ulcer. Cross-hatching
Black eschar can be seen over the ulcer. A pulse is present the wound can be used to facilitate autolytic debridement
(> 80 mm Hg), indicating enough blood supply to heal. with moist interactive dressings.

For sharp surgical debridement, a scalpel and scissors have This leg ulcer has a base of loose slough and debris. The devi-
been used to lift the eschar, revealing the underlying healthy, talized tissue is an excellent bacterial culture media with the
viable tissue. green discoloration indicating the presence of pseudomonas.

In this unhealthy wound bed, fronds of bright red, friable In this wound, a healthy pink granulation base is surrounded
granulation tissue, increased wound exudate, and a white by a thin rim of a new purple epithelium.
macerated wound margin were all signs of an increased bacte-
rial burden.

November 2000 Vol. 46 Issue 11 15


Chronic Wound
Diagnosis
Treat Cause Local Wound Care
Debridement Bacterial Balance
Non-healing Wound
Biological Agents
Growth Factors
Cells skin substitutes
Acellular matrix
Figure 1
This algorithm demonstrates an approach to the treatment of chronic wounds.
pressure ratio of 0.8 (eg, ankle systolic 80 mm Hg, brachial
systolic 100 mm Hg) and higher indicates the absence of
significant arterial disease, but a ratio below 0.5 suggests
severe arterial compromise and a low probability of healing.
The introduction of the handheld Doppler into clinics and
homecare settings has allowed practitioners to help identify
6
patients with arterial disease.
Patients with diabetes often have calcification of larger
vessels, which leads to their noncompressibility. This will
result in a falsely high ABPI value and healability should be
assessed with transcutaneous partial oxygen saturation of
>30% or toe arterial pressures (taken by photophlethysmog-
raphy) of >40 mm Hg. Patients with symptoms of intermit-
tent claudication at rest also should be assessed for surgery.
Not all patients are candidates for vascular pro-
cedures, and if extensive and diffuse distal dis-
ease is present, these procedures will not be ben- L
eficial. If nonhealability is established, then
moist interactive local wound care is contraindi-
cated. Topical antiseptics to dry the wound and
prevent proximal bacterial invasion of viable tis-
sue are recommended (see Recommendation 6).
Recommendation 2
Assess and Monitor the Wound History
and Physical Characteristics (location,
size, base, exudate, the condition of sur-
rounding skin, staging, and pain) 3
16 OstomyWound Management
Chronic wound care must
include ongoing, consistent doc-
umentation of wound character-
istics as part of continuous
monitoring for complications
Patient-Centered
Concerns and appropriate management.
Wound history. Patients
Moist Interactive should be asked about the dura-
Healing tion of the current ulcer and if
he or she has had an ulcer previ-
ously and what, if any, treat-
ment has been provided. The
more chronic an ulcer becomes,
the more difficult it is to heal. If
it is recurrent, issues of preven-
tion may not have been ade-
quately addressed.
Wound location and size.
The precise location of the
wound should be noted and can
often be outlined on a body map or diagram. Measuring the
length (usually the longest diameter) and the maximum
width at right angles to the diameter is important. This is
usually documented in centimeters.7 Wound circumference
can be traced onto a transparency or plastic page protector.
Use disposable plastic wrap next to the skin to avoid bacteri-
al contamination. A maximum depth should be measured
with a probe (sterile metal surgical instrument, sterile plastic
depth guide, or even a sterile cotton-tipped applicator or
sterile swab). Place the depth gauge in the deepest part of
the wound and use a gloved finger or a pen mark at the sur-
face to determine the depth that can be measured with a
ruler. The wound base also should be probed with caution
Ostomy/Wound Management 2000;46(11):1435
KEY POINTS
The provision of optimal local wound care involves a myriad of
patient and wound assessment variables, environmental considera-
tions, and treatment option decisions.
Using a holistic approach, the authors developed 13 general wound
care recommendations while providing sufficient background infor-
mation to tailor each of their recommendations to the needs of the
individual patient.
As the number of wound treatment choices continues to increase,
it is important to remember, and start with, the basic principles of
good wound care (debridement, bacterial balance, and moist
interacive healing).

TABLE 1
QUICK REFERENCE GUIDE TO THE 13
RECOMMENDATIONS FOR PRACTICE:
PREPARING THE WOUND BED
1. Assess the patient for adequate blood supply and host fac-
tors for healability.
2. Assess and monitor the wound history and physical charac-
teristics (location, size, base, exudate, the surrounding skin,
staging, and pain).
3. Correct treatable causes of tissue damage.
4. Provide education and support for patient-centered care to
increase compliance.
5. Debride healable wounds, removing necrotic and nonviable
tissue.
6. Assess the wound for bacterial balance and infection.
7. Cleanse wounds with normal saline or water.The use of
topical antiseptics should be reserved for wounds that are
nonhealable or those in which the local bacterial burden is a
greater concern than the stimulation of healing.
8. If MRSA is present, assess the patient for colonization or
infection. Select appropriate topical and/or systemic agent
for treatment.
9. Use only nonsensitizing topical antibacterial agents for local
symptoms and signs of infection or increased bacterial burden.
10. Use systemic antibiotics if symptoms or signs of infection
extend beyond wound margin or the ulcer probes to bone.
11. Select appropriate dressings for local moisture balance to
stimulate granulation tissue and re-epithelialization.
12. Evaluate expected rate of wound healing to determine if
treatment is optimal.
13. Use biological agents when other factors have been correct-
ed and healing does not progress at the expected rate.
for bone, sinuses, or undermining. One of the best ways to
document wound characteristics is to use a flow chart. In
the future, digital photography with color printouts may
become the norm in everyday practice.
Wound base. It is helpful to think of the wound in four
major colors: black (necrotic), yellow (fibrous), red-pink
(granulation tissue), pink-purple (re-epithelialization), or a
combination of these colors. Black eschar represents devital-
ized tissue that may be soft or firm. If healability has been
established, then eschar needs to be removed to promote
healing. A yellow fibrous base may be firm or sloughy. A
firm, yellow base represents underlying deep structures such
as fascia or subcutaneous fat or the fibrin base for subse-
quent granulation tissue and does not need to be removed.
Soft sloughy yellow material may indicate infection or
degraded fibrin that needs to be removed.
Granulation tissue is usually a salmon red-pink
color, firm and moist. With increased bacterial
load, this granulation tissue may become dark-
er, exuberant, friable, and malodorous. Hyper-
granulation should be documented because it
may require removal to facilitate re-epithelial-
ization. Newly formed epithelialization is a
pink-purple color that usually appears at the
flush edges of the wound, but may occur in
the center around the underlying hair follicle
structures.
Exudate. Exudate is usually described by its
quantity (scant, moderate, and copious); char-
acteristics (serous-serum, sanguinous-blood,
purulent-infection, or a combination of these);
and odor (presence or absence). In general,
heavy exudates, even when clear fluid, should
alert clinicians to problems related to the
underlying cause (uncontrolled edema) or an
early sign that there may be increased bacterial
burden or infection.
Wound margin and surrounding skin.
The wound margin should be checked for cal-
lus formation, excess moisture in the form of
maceration, edema, or erythema.
Hyperkeratotic (thick) callus, especially in per-
sons with diabetes on the plantar aspect of the
foot, can lead to increased local pressure.8
Removing this type of callus is important. If
the callus continues to form, pressure offload-
ing is not optimal and the patient will require
reassessment. Maceration of the surrounding skin usually
presents with white hyperkeratosis and a wet surface. This
indicates increased hydration of the keratin, and may be a
reflection of a local dressing that is keeping the ulcer too
moist or not absorbing exudate, an uncorrected cause (eg,
limb edema or uncorrected pressure), or a sign of infection.
The presence of erythema locally is a sign of inflammation
or infection. If this erythema is warm, hot, and tender,
infection is most likely. Discreet erythema with well demar-
cated margins that follow the outlines of applied dressings or
topical treatments may indicate a contact allergic dermatitis.
Common allergens, such as neomycin, lanolin, and per-
fumes must be avoided at all times. Chronic wounds allow
optimal penetration of these substances and systemic pro-
cessing by the immune system.
November 2000 Vol. 46 Issue 11 17
 TABLE 2
AN APPROACH TO PAIN MANAGEMENT
Type of Pain/Symptoms
Nociceptive Pain Mild
(normal nerve
function) Moderate
Aching, throbbing, Severe
sharp, easily localized
Neuropathic pain Nerve irritation
(burning)
Shooting, stabbing Nerve damage
(shooting, stabbing)
Contact irritant dermatitis also can occur and is less spe-
cific. There is an absence of the clear outline at the edges of
the irritation, although erythema, scaling, and some macera-
tion may also occur. Chronic irritant dermatitis is best treat-
ed with protectants such as petrolatum, zinc oxide oint-
ment, or commercial barrier preparations around the wound
margins. Thick materials often can be applied with a tongue
depressor to decrease frictional resistance.
Staging of the wound. General and disease-specific tools
can be used to grade or stage chronic wounds. However, all
wounds can be classified as partial or full thickness.9 The
National Pressure Ulcer Advisory Panel/Agency for Health
Care Policy and Research (NPUAP/AHCPR) has a four-
stage system for pressure ulcers,9 and alternative systems
should be used for leg and other ulcers. In general, this sys-
tem applies to Stage I for persistent erythema but intact
skin. Stage II represents an erosion (epidermal base) or
superficial ulceration (dermal base). Stage III wounds have a
subcutaneous fat base, and Stage IV wounds have a deeper
muscle, tendon, bone, or joint base. Staging an ulcer and
documenting the initial assessment of wounding is impor-
tant. Other descriptors have been recommended for the
healing process10 (see Recommendation 8 of Best Practices for
the Prevention and Treatment of Pressure Ulcers by Dolynchuk
et al on page 45). For diabetic foot ulcers, the University of
Texas treatment based classification system addresses neu-
ropathy, deformity, vascularity and infection.11,12 (See
Recommendation 4 of Best Practices for the Prevention,
Diagnosis, and Treatment of Diabetic Foot Ulcers by Inlow et
al on page 59.)
18 OstomyWound Management
Treatment
Acetominophen, aspirin or nonsteroidal anti-inflammato-
ry, plus a co-analgesic
Codeine, oxycodone, or other mild opiod plus
acetominophen or aspirin plus co-analgesic
Morphine, hydromorphone, fentanyl, diacetyl morphine
plus co-analgesic
Tricyclic antidepressants, gabapentin
Gabapentin
Pain. Pain also may be an important indicator of untreat-
ed disease. Krasners13 model of chronic wound pain divides
stimuli into incident pain, recurrent episodic pain, and con-
tinuous pain. Incident pain occurs with debridement or
major trauma. This type of pain can be relieved with topical
analgesia, interlesional analgesia, or presedation with agents
following the World Health Organization pain ladder.14
Episodic pain often can occur with dressing changes. Pain
control, both local and systemic, should be instituted at
appropriate time periods before dressing changes for com-
fort (see Table 2). Continuous pain may reflect the lack of
treatment of the underlying cause, local wound irritation, or
infection. Careful assessment of continuous pain must be
made to determine if its origin is in the local wound or the
surrounding anatomical region.
Wound pain should be routinely assessed and document-
ed using the patients self report. The 10-cm visual analog
scale is the gold standard for quantitative pain assessment.
Using this scale, patients grade their pain by placing a mark
on the 10-cm line where 0 indicates no pain and 10 indi-
cates the worst pain ever experienced. The presence of new
or increasing pain in the chronic wound patient often sig-
nals complications such as infection, a Charcot arthopathy,
or vascular compromise.
Recommendation 3
Correct Treatable Causes of Tissue Damage
It is important to always treat the underlying cause of a
wound. In other articles in this series, the literature addresses
the importance of correcting factors associated with venous
leg ulcers, pressure ulcers, and foot ulcers (diabetic and oth-
ers). Regarding venous leg ulcers, Fletcher et al15 reviewed six
studies that compared compression versus local ulcer treat-
ment alone without compression (eg, hydrocolloid,16
polyurethane foam,17 and film dressing18). A higher propor-
tion of patients demonstrated healing in the six studies using
compression compared to local treatments alone, and five of
these studies revealed statistical significance.
Nutrition. In addition to ulcer-specific causes, the
patient as a whole must be examined. One factor the practi-
tioner must consider is to determine that nutrition is ade-
quate to produce sufficient protein to support the manufac-
ture of granulation tissue. The patients weight is a good
starting point. Being over- or underweight can impinge on
wound healing. Patients should be as close to ideal body
weight as possible. In addition to weight, protein intake also
must be considered. A good intake screen for recent (the
past few weeks) protein consumption is pre-albumin, and
for more long-term protein consumption, serum albumin.
An albumin of higher than 3.0 g/L is normal, but albumin
levels between 2.0 g/L and 3.0 g/L may cause some delay in
healing. Below 2.0 g/L, patients are malnourished and will
have difficulty healing.
Medications, including medical history. Another factor
that cannot be overemphasized is the importance of the gen-
eral medical history, including a medication record. A num-
ber of medications may interfere with wound healing,
including systemic steroids, immunosuppressive drugs, and
nonsteroidal anti-inflammatories. The presence of a major
illness or systemic disease also is detrimental to healing.
Rheumatoid arthritis and other autoimmune diseases such
as systemic lupus, uncontrolled vasculitis, or pyoderma gan-
grenosum can all deter the wound healing process. In these
disorders, the paradox of using systemic steroids or
immunosuppressive agents to control the underlying process
is absolutely essential before optimal local wound healing
can occur. These patients have stimulated immune systems
that react against their own skin, and this response must be
curtailed so that an orderly process of healing can occur.
Recommendation 4
Provide Education and Support for Patient-
Centered Care to Increase Compliance/Adherence
Wound care must be a partnership between healthcare
professionals, patients, families, and caregivers. Patients must
understand decisions that are being made about their care,
and they must be part of the decisions as well. The more the
patient understands the principles involved in treatment, the
more likely he/she is to be compliant. Compliance should
include compression bandaging for healing in patients with
venous ulcers, followed by support stockings for life; the
patient should comprehend why this is necessary. A neu-
rotropic foot ulcer or pressure ulcer patient who requires
pressure offloading with regular monitoring and under-
stands why this enhances rather than interferes with quality
of life will have a far better approach to his/her care.
Another component of compliance includes selecting a
treatment program that is reasonable and affordable and will
facilitate an acceptable quality of life. The integration of the
interdisciplinary team with the patient, family, significant
others, and caregivers creates an optimal formula for success.
Recommendation 5
Debride Healable Wounds, Removing Necrotic and
Nonviable Tissue
Debridement involves the removal of dead, devitalized, or
contaminated tissue and foreign material from a wound. In
chronic wounds, slough and eschar often accumulate and
impair healing. Natural mechanisms exist to facilitate
debridement; however, studies have shown that if this
process is accelerated, more rapid wound healing occurs.19
Debridement reduces wound contamination as well as
removes wound debris; thereby, potentially reducing tissue
destruction. Any loculated dead spaces that might otherwise
harbor bacteria and provoke frank infection need to be
exposed during debridement.
Several modes of debridement exist: surgical, autolytic,
enzymatic, and mechanical (see Figure 2). Once a decision
has been made to debride, several factors influence the
choice of debridement method. The use of more than one
debridement method may be appropriate as outlined below
(see Table 3).
Surgical debridement. Surgical debridement is the
fastest and most effective way to remove debris and necrotic
tissue. It is highly suitable in wounds with large areas of
necrosis, high degrees of contamination, or frank infection.
Therefore, the majority of surgical debridement tends to be
performed in diabetic foot ulcers and pressure ulcers where
these criteria are commonly fulfilled. All wounds should be
appropriately cleansed before debridement. Sharp, sterile
surgical debridement to a bleeding base has been demon-
strated by Steed et al19 to increase the healing rate of diabetic
neurotropic foot ulcers (DNFUs). This procedure not only
converts a chronic, nonhealing wound into an acute wound,
November 2000 Vol. 46 Issue 11 19
 Non-Healable Wounds
Active debridement and No Patient/wound assessment
moist interactive healing healability General medical status
contraindicated Healability of wound, etc.

Yes

Debridement not
Healable No necessary
Yes + neuropathic
Wound Moist interactive
Debridement healing
(especially in diabetic feet)
Yes/No Maintain bacterial
balance
Color of wound
(Black or loose, Yes
yellow) or friable
Type of debridement
Surgical
Level of expertise/setting
Autolytic
Institution/home No Enzymatic
Mechanical
Yes Cost
Speed
Allergy
Availability
Pain
Reassess at regular
Surgical preferred intervals Not healing

Continued healing
Yes/No

Figure 2
Healed
Debriding a wound - feedback loop for improved outcomes.

but also decreases the surface bacterial burden. Before
debridement, pain control may be achieved with topical,
intralesional, oral, or intravenous agents. Topical EMLA20,21
(Astra-Zeneca, Wayne, Pa) can be applied in a thick coat
(like icing a cake) and occluded with a transparent film
dressing for 30 to 60 minutes prior to the procedure
(EMLA is approved for this indication in Canada, but not
in the United States). Intralesional xylocaine (with adrena-
line to stop bleeding, except on distal extremities) can be
placed around the periphery of the lesion if EMLA is not
available or if deeper anesthetic is required. However,
surgery cannot be employed in all patients, nor can it be
used in all settings (see Table 4). Blood clotting must be
normal and in non-neuropathic wounds, anesthetic is often
required. These factors almost dictate that significant surgi-
cal debridement, other than removal of devitalized tissue
should be performed by a trained individual, often in a hos-
pital or clinic setting, where facilities for achieving home-

20 OstomyWound Management

TABLE 3
KEY FACTORS IN DECIDING
METHOD OF DEBRIDEMENT
Surgical Enzymatic Autolytic Mechanical
Speed 1* 2 4
Tissue selectivity 2 1
Painful wound 4 2
Exudate 1 4
Infection 1 3
Cost 4 2
* 1 is usually most desirable, and 4 is usually least desirable.
ostasis are available. Removal of devitalized tissue may only
be performed by trained healthcare professionals in
approved care settings.
Autolytic debridement. Moist interactive dressings
especially hydrogels, hydrocolloids, transparent films, and
alginates can provide autolytic debridement. These dress-
ings create an environment capable of liquifying slough and
promoting granulation tissue at the same time. If tissue 22,23
autolysis is not apparent in 24 to 72 hours, another form of
debridement should be used. The eschar surface can be
scored with a scalpal blade, making superficial parallel
grooves on the hard eschar surface in a grid pattern. The
grooves are not intended to penetrate viable tissue, and
bleeding should be minimal or absent.
Enzymatic debridement. The most selective mode of
debridement enzymatic debridement relies on
naturally occurring enzymes applied exogenously to
the wound surface to degrade debris. In Canada, the
only licensed enzymatic product is collagenase, isolat-
ed from Clostridium histolyticum. Collagenase exists in
wounds naturally as a matrix metalloproteinase, where
it has been shown to degrade immature collagen in
the wound matrix. Early debridement is promoted
because collagenase acts as the rate-determining
enzyme in collagen degradation, catalyzing cleavage of
glycine in the native collagen triple helix. It is highly
specific for collagen and is thought to promote
debridement by digesting collagen bundles that bind
nonviable tissue to the wound bed. Some small trials
report faster debridement with collagenase compared
to placebo.24,25 Future trials are needed to confirm if
this agent has a role promoting later stages to stimu-
late granulation tissue and re-epithelialization.26
22 OstomyWound Management
Collagenase is inactivated by heavy metals
(silver, zinc) and detergents. In the Unites
States, papain and papain-urea products
are also available.27
Enzymatic debridement appears to be
most useful in the removal of eschar from
3 large wounds when surgical techniques
3 4
cannot be utilized. Debridement can be
1 3
3 2 facilitated by cross-hatching or scoring
4 2 hard eschar prior to application of the
1 3 enzyme. Problems arising from enzymatic
debridement relate to the production of
excessive amounts of exudate with these
agents, local irritation to surrounding
skin, and possible infection.
Mechanical debridement. Mechanical debridement
physically removes debris from the wound. It may be used
in the management of surgical wounds along with pressure,
ischemic, and venous leg ulcers. The simplest form of
mechanical debridement is wet-to-dry gauze, but this tech-
nique is nursing time-intensive and costly. This often causes
bleeding and pain with removal, leading to nonselective
trauma to the wound. Other methods include irrigation,
pulsatile lavage, and whirlpool therapy.27,28 In the whirlpool
or other foot-soaking procedures, the entire foot is
immersed, causing the maceration and bacterial seeding
(bacterial soup) of susceptible areas such as the toe webs,
nail folds, and tiny cracks in the skin (fissures). (See
Recommendation 9 of Best Practices for the Prevention and
Treatment of Pressure Ulcers by Dolynchuk et al on page 46.)
TABLE 4
CONTRAINDICATIONS FOR SURGICAL
DEBRIDEMENT OF VIABLE TISSUE
Absolute Contraindications
Lack of expertise in procedure
Nonhealable ulcer (ie, insufficient vascular supply to
allow healing)
Septicemia in the absence of systemic antibacterial
coverage
Medically unfit patient
Relative Contraindications
Patient on anticoagulants (dependent on INR [interna-
tional normal ratio]/PTT [activated partial prothrom-
bin time] etc.)
Home care setting
Recommendation 6
Assess the Wound for Bacterial Balance and
Infection
The presence of wound-associated bacteria alone does not
indicate infection or impaired wound healing. Indeed, some
authors have suggested that a small amount of a certain bac-
teria species in a chronic wound facilitates healing.29,30 In
clinical practice, assessing when a wound has moved from a
symbiotic bacterial load that does not cause tissue damage to
an increased bioburden causing impairment of wound heal-
ing can be difficult. The following equation demonstrates
that although bacterial quantity and virulence are significant
in assessing a wound for infection, host factors are of over-
riding importance.
Risk of wound infection31 = Bacterial dose x virulence
Host resistance
Factors such as immunosuppression, diabetes, and med-
ication all can influence whether any bacteria present will
impair wound healing. Furthermore, these factors can act to
mask classical signs of infection such as erythema, increased
temperature, pain, and edema.
Swab technique is important to obtain meaningful
results.32 The wound should be cleansed with saline or water
and all debris should be removed. The healthy appearing
granulation is swabbed in a zigzag pattern, gently rotating
the tip of the swab (swabs are only recommended if clinical-
ly indicated). If the wound is relatively dry, the swab may be
moistened with the transport media prior to swabbing. A
semiquantitative swab is then inoculated on standard media
in the lab and streaked in four quadrants. Results will indi-
cate no growth to 1 to 4+ growth of an organism, depend-
ing on the number of streaked quadrants that support bacte-
rial growth. These swabs are quick and inexpensive. The
semiquantitative swab correlates well to the gold standard
quantitative biopsy results,33 but there is some loss of speci-
ficity. Despite the fact this is the procedure of choice in
most centers, inadequate wound bed preparation will result
in an excess number of confusing, nonsignificant wound
surface colonies appearing on the agar plates in the lab. The
clinical assessment of wound bioburden and the choice and
route of antibacterial agents should be based on host and
wound factors in association with wound swab results.
The concepts of bacterial contamination, colonization,
critical colonization, and local and systemic infection lend
themselves to guidance with regard to when to use antimi-
crobial agents in wound care (see Table 5).
Most wounds are contaminated and contain nonreplicat-
24 OstomyWound Management
ing organisms. Colonization occurs when organisms are
replicating but not causing host injury. Skin commensals
such as Staphylococcus epidermidis and Corynebacterium
species are the most common colonizers. Neither contami-
nated nor colonized wounds show signs of infection, and
impairment of wound healing is unlikely. The concept of
critical colonization (increased bacterial burden) has recently
been introduced to describe wounds moving between the
spectrums of colonization (where the host is unaffected) and
local infection (in which host injury occurs). It has been
suggested that during critical colonization, subtle clinical
signs of infection such as increasing pain/tenderness, increas-
ing serous exudate and friable granulation tissue, or failure
to heal may be present prior to the classical signs of foul
odor, frank pus, surrounding erythema, increased tempera-
ture, pain, and swelling associated with infection.34 It is
important to emphasize that many people with chronic
wounds, in particular people with diabetes, have an
impaired host response. These patients may therefore exhibit
only subtle signs, or even have a complete absence of signs
of infection (ie, no elevation in temperature) when bacteria
are damaging the skin and delaying healing.35 A semiquanti-
tative swab with 4+ growth of a significant pathogen or a
quantitative biopsy with 1.0 x 106 cfu/g (cfu = colony
forming unit) of tissue in the presence of nonhealing may be
an indication for systemic antibacterial therapy. Therefore,
host monitoring is a vital part of assessment, with factors
such as raised blood sugar levels in people with diabetes
often being a helpful indicator of local or systemic infection.
Recommendation 7
Cleanse Wounds with Normal Saline or Water. The
Use of Topical Antiseptics Should be Reserved for
Wounds that are Nonhealable or the Local Bacterial
Burden is a Greater Concern than the Stimulation
of Healing
Cleansing and irrigation are used to eliminate exudate
and surface debris from wounds. Not only does this process
facilitate healing, but it also decreases bacterial burden by
removing heavily contaminated surface slough and debris.
Saline or sterile water are agents of choice for most
wounds. Tap water should not be used for immunosup-
pressed patients and the water source should be reliably
clean before advocating it as treatment in other chronic
wounds.36
Rodeheaver28 studied wound cleansers in vitro to assess
cellular toxicity. He concluded that nonionic agents are best,
 TABLE 5
ASSESSMENT OF AND INTENTION TO TREAT INFECTION
IN CHRONIC WOUNDS
Bacterial burden Contaminated Colonized Critically colonized Local infection Systemic infection
Wound clinical symptoms Wound +/- early signs of No/subtle signs and Local signs and Constitutional signs
and signs progressing local infection symptoms of symptoms of and symptoms of
Host stable infection infection infection

Bacterial C & S* No +/-C & S wound C & S wound C & S wound C & S wound
Blood culture
Topical No +/- Yes Yes Yes
antibiotic/antibacterial
Systemic No No +/- +/- Yes
antibiotic/antibacterial
Enzymatic No +/- +/- No No
debridement
Surgical debridement +/- +/- +/- Yes Yes

* Culture and sensitivity

but their toxicity index is still greater than saline. There are
four main methods of cleansing. Healthcare practitioners
who cleanse wounds can a) use a saline moist gauze to soak
or compress a wound; b) gently pour a solution over a
wound; c) irrigate the wound with a piston or bulb syringe
5 to 8 pounds per square inch (psi) for cleansing with a
bulb syringe or 5 to 15 psi to remove slough or eschar with
an 18- to 20-gauge angiocath (venous access device) and 30-
cc syringe held 4 to 6 inches from the wound; and d) use an
appropriate commercially prepared spray cleanser with pre-
determined average psi. When higher pressures are used,
splash back commonly occurs and healthcare providers
should take appropriate precautions.
Antiseptic agents are used primarily to decrease bacterial
growth on inanimate objects. When they are used in
wounds, they have antibacterial properties, but they also
inhibit healing (cytotoxic properties. See Table 6).
If a wound does not have enough blood supply to heal, a
patient is immunosuppressed, or in negative protein bal-
ance, the prime objective may be to reduce bacterial burden.
Tissue toxicity is not the prime concern. Antiseptics would
then be indicated with the precautions outlined in Table 6.
Providone/iodine or chlorhexidine would be the agent of
first choice for most nonhealing wounds (to dry the surface,
decrease surface bacteria).
Recommendation 8
If Methicillin Resistant Staphylococcus Aureus is
Present, Assess the Patient for Colonization or
Infection. Select Appropriate Topical and/or Systemic
Agents for Treatment
With the development of increasing bacterial resis-
tance, it is important to restrict the use of antibiotics to
situations where they are definitely indicated and fur-
thermore, to use the narrowest spectrum of antibiotic
possible.
Methicillan-resistant Staphylococcus aureus (MRSA) is a
very common cause of hospital-acquired infections.
Unfortunately, these bacteria can commonly develop
resistance to antibiotics. The most important of these is
MRSA. Bacteria develop resistance to methicillin and to
other families of antibiotics. Some strains of MRSA can
spread from patient to patient very readily and have been
labeled epidemic MRSA.
Methicillan-resistant Staphylococcus aureus is commonly
found in ulcers, and although its presence in wounds rarely
causes death, cross infection into immunocompromised
hosts can be fatal. It is therefore the responsibility of health-
care professionals to try to minimize the risk of the develop-
ment of resistant microorganisms and their subsequent
spread.

November 2000 Vol. 46 Issue 11 25

 TABLE 6
WOUND ANTISEPTIC AGENTS ALL TOXIC TO HEALTHY
GRANULATION TISSUE
Hypochlorite solution
Hydrogen peroxide
Proflavine, mercuric chloride/crystal
violet plus other analine dyes
Cetrimide (quaternary ammonium)
Chlorhexidine (plus cetrimide =
SavalonTM [Astra-Zeneca,Wayne,
Pa])
Acetic acid 0.5% 5.0%
Providone/iodine (Agent of choice in
most nonhealing wounds)
The pathogenicity of MRSA may not be significantly dif-
ferent from traditional S. aureus infections, but these infec-
tions may be difficult to control. The incidence of MRSA is
on the increase in many countries. Unfortunately, healthcare
providers, through direct contact with patients, may spread
MRSA from nasal colonization (20% of people are persis-
tent carriers, 60% intermittent carriers, and the remainder
often never carry the organism). The treatment of MRSA
may vary, depending upon whether it has colonized or
infected the wound. For topical colonization, mupirocin has
been the traditional agent of choice. However, with overuse
of mupirocin, resistance in some centers has been docu-
mented.37 The use of mupirocin should be limited and
reserved predominantly for the treatment of MRSA. As
alternatives to mupirocin in healable wounds, cadexomer
iodine and new ionized silver technologies have been very
successful in eliminating colonization. These nonantibiotic
alternatives are effective against MRSA and can be used to
minimize the risk of provoking resistance. Ionized silver and
cadexomer iodine depend on three separate antibacterial
actions (cell membrane, cytoplasmic organelles, nucleic
acid); therefore, resistance is highly unlikely to develop.
Colonization also can be eliminated by the use of
systemic antibiotics in combination. One protocol calls
26 OstomyWound Management
Irritating to skin due to high pH. Buffered prepara-
tions - Dakins/ Eusol often select out Gram
negatives
De-sloughing agent when effervescent (few sec-
onds). It can harm healthy granulation and may
form air emboli if packed in deep, closed spaces
Bacteriostatic agents against Gram positives only
Gram-positive and negative organisms detergent
effect but high tissue toxicity
Gram-positive and negative action with residual
effect on tissue
Low pH effective vs pseudomonas but may select out
S. aureus
Broad spectrum of activity (Gram-positive, Gram-
negative, anaerobes, yeast), but this is decreased
in the presence of pus or wound exudate. Iodine
toxicity reported if use prolonged or over large
areas
for the use of rifampin with either minocycline or clot-
rimoxazole. Infection may require intravenous treat-
ment with vancomycin. Depending on individual sensi-
tivities, other antibiotic combinations may work on
some patients. Because MRSA is stored in the gut,
recurrences are common, and it is important to monitor
these patients at regular intervals. The nosocomial
spread of MRSA has been well documented in one
authors unit, and the use of double barriers such as
handwashing and soapless cleansers should be encour-
aged for staff moving between patients with wounds.
Documentation of MRSA on tape-measuring guides
and other instruments that move from patient to
patient also illustrates the importance of decontaminat-
ing the environment as well as implementing a rigorous
handwashing routine.
Patients with MRSA should have cultures from three
sites (nares, rectum, and the wound). These cultures
should be repeated at regular intervals until they are
negative on three occasions, then long-term monitoring
is indicated. A modified protocol from the Peel
Interdisciplinary Wound Healing Committee has been
reproduced with the permission of Caremark (see
Figure 3).
 MRSA Isolated Through Culture

Infected Colonized

Infectious diseases consult Consider decolonization therapy

(individual decision)

Mupirocin (Bactroban) ointment

Serious infection consult
Hospitalization
Treatment based on sensitivity
results: may include IV vancomycin
Less serious infection
Treatment options based on sensi-
tivity results:
Oral fusidic acid and rifampin
Rifampin and one of minocycline
or clotrimoxazole
to anterior nares/wounds and
oral/topical agents for other sites if
appropriate (see Table 7)
2% chlorhexidine soap for all
washing/bathing x 710 days
Repeat culture of anterior nares,
perianal and open wounds 48
hours after treatment completed

Mupirocin anterior nares if positive.

Topical treatment or systemic treatment Positive culture Negative culture
to other sites
2% chlorhexidine soap for all
washing/bathing for duration of Treatment options based on Repeat cultures
treatment sensitivity results: weekly x 3 before
Oral fusidic acid and rifampin labeling cleared
Rifampin and one of
minocycline or clotrimoxazole
Culture anterior nares, perianal
and open wounds within 48 Hospital: repeat cultures
hours of completed treatment once a month.
Positive: Negative: Nursing homes and
(Consider) infectious Repeat cultures community: repeat every
Repeat cultures weekly x 3 disease consult weekly x 3 before 3 to 6 months
before labeling cleared Treatment options as labeling cleared
per sensitivity results

Figure 3.
Wound management for patients infected or colonized with MRSA.Copyright 1998, Caremark Ltd. Adapted with permission.

Recommendation 9 One other factor to consider when applying topical

Use Only Nonsensitizing Topical Antimicrobial
Agents for Local Symptoms and Signs of Infection or
Increased Bacterial Burden
Once the decision to use topical antimicrobial agents has
been made, the healthcare provider is faced with choosing
an antimicrobial agent. The aim is to reduce bioburden, and
the principle factor influencing choice is the offending
organism (see Table 7). This information is usually gained
from bacteriology results; however, clinical judgment can
often detect the presence of some organisms such as
Pseudomonas. These can be recognized by their distinctive
odor and a greenish tinge. Anaerobes can be assumed to be
present in a wound with an accompanying putrid odor or a
wound duration of longer than 1 month.38
agents to an ulcer is the propensity to induce sensitization
that can elicit an allergic contact dermatitis. Neomycin,
lanolin, and perfumes, which can be present in topical
antimicrobial vehicles, are common sensitizers and should
be avoided.39 Similarly, ointments rather than creams should
be used to reduce exposure to preservatives that can also act
as sensitizers.
Two products listed in Table 7 combine antibacterial
properties with moist interactive healing. Cadexomer iodine
(Iodosorb, Iodoflex; Healthpoint, Fort Worth, Tex./Smith
and Nephew, Hall, U.K.) is composed of microspheres of
starch crosslinked with ether bridges and iodine. This prod-
uct absorbs moisture up to seven times its weight in water
and slowly releases iodine for antibacterial action that is not

November 2000 Vol. 46 Issue 11 27

 TABLE 7
CHOOSING APPROPRIATE ANTIMICROBIALS
Staphylococcus MRSA Streptococcus Pseudomonas Anaerobes Comments
aureus
Cadexomer iodine + + + + + Good autolytic debridement;
limited potential for bacteri-
Safe and Effective

al resistance. Caution with

thyroid disease
Ionized silver + + + + + Use with water, not saline.
Limited potential for bacte-
rial resistance
Silver sulphadiazine + + + + + Not for use in sulfasensitive
patients
Polymyxin B sul- + + + + +
phate Bacitracin
zinc + Reserve for MRSA and other
Selected Use

Mupirocin resistant Gram-positive

organisms
+ Reserve for anaerobes and
Metronidazole odor control
Weak Weak Weak Weak For use on large wounds. Can
Benzoyl peroxide cause irritation/allergies
+ + + Reserve for oral/IV use
Gentamicin + +
Caution

Fucidin Ointment contains lanolin,

which can sensitize to cause
+ + + + + allergic contact dermatitis
Polymyxin B sul- Contains neomycin, which
phate Bacitracin causes an allergic contact
zinc neomycin dermatitis, may cross sensi-
tize to aminoglycosides
+ = effective against bacteria

strong enough for cytoxicity. It should be used with caution
in patients with thyroid disease and iodine allergy. If cadex-
omer iodine is used on large areas or for long periods, moni-
toring of thyroid function is advised.
Ionized silver dressing (Acticoat; Westaim Biomedical,
Exeter, NH, Fort Saskatchewan, Alberta, Canada) has a slow
release of silver, combined with an absorptive polyester pad.
The silver has a broad spectrum of antibacterial coverage
and can be used very successfully to decrease friable exuda-
tive tissue on the wound surface. Acticoat must be used
with sterile water because the chloride in saline precipitates
the silver to inactive silver chloride. Acticoat contains no
sulfa, which may be present in other silver preparations.
Topical antibacterials will only treat the wound surface
and not deeper infection. Their use should be re-evaluated
after 2 weeks or if symptoms or signs of deeper infection
occur.40
Recommendation 10
Use Systemic Antibiotics if Symptoms or Signs of
Infection Extend Beyond Wound Margin or the
Ulcer Probes to Bone
Systemic antibiotics should be used if infection extends
beyond the ulcer margin. Ulcers of less than 1-month dura-
tion require primary Gram-positive coverage primarily for at
least 2 weeks or until clinical symptoms and signs resolve. If
immunosuppression is an issue, broad spectrum agents,
including Gram-negatives and anaerobes, should be includ-
ed. A semiquantitative swab is often helpful when patients
fail to respond to the initial therapy. In complex cases, an
infectious disease consult is advised.
If an ulcer probes to bone, osteomyelitis must be suspect-
ed. Antibiotics for longer periods are necessary, usually for at
least 4 to 6 weeks. Treatment progress can be monitored
with x-rays, erythrocyte sedimentation rate, C reactive pro-
tein, and, rarely, nuclear scans. Nonhealing ulcers may
require surgical debridement. For a more detailed discussion
on this topic, see Recommendation 8 of Best Practices for the
Prevention, Diagnosis, and Treatment of Diabetic Foot Ulcers
by Inlow et al on page 63.

28 OstomyWound Management
Recommendation 11
Select Appropriate Dressing for Local Moisture
Balance to Stimulate Granulation Tissue and
Re-epithelialization
Compared to dry wounds, a moist wound environment
accelerates wound healing by as much as 50%, often with
more rapid epithelialization.41 Using clinical judgment to
select a type of moist wound dressing suitable for an ulcer is
important. Seven dressing recommendations have been put
forward since the Agency for Health Care Policy and
Research guidelines came out in 1994.42 They were pub-
lished in Ostomy/Wound Management by Liza Ovington in
1999,43 and are discussed below:
1. Use a dressing that will keep the wound bed continuously
moist. Wet-to-dry saline dressings are not considered contin-
uously moist and should be used only for debridement.
Kim44 reported that occlusive hydrocolloid dressings for the
treatment of Stage I and II pressure ulcers were less time-
consuming and less expensive, compared to saline-soaked
gauze dressings. Colwells trial showed that a hydrocolloid
dressing increased healing rate and was less costly than moist
gauze dressings.45 If saline-soaked gauze is used, it must be
moist with frequent dressing changes or harm may result.
2. Use clinical judgment to select a type of moist wound
dressing suitable for an ulcer. Studies of different types of
moist wound dressings showed no differences in pressure
ulcer healing outcomes. Mulder46 looked at three types of
dressings, all providing moist wound healing, and found no
statistical differences with wound healing.
3. Choose a dressing that keeps the surrounding peri-ulcer
skin dry while keeping the ulcer bed moist.
4. Choose a dressing that controls exudate but does not
desiccate the ulcer bed. If the exudate is not controlled, it
will come in contact with the surrounding peri-ulcer skin
and cause maceration, which could lead to breakdown and
further deterioration of the wound. There must be a balance
in choosing a dressing to avoid drying of the wound surface.
Continuous assessment of the wound and changes in the
dressing material used is needed to achieve optimal moisture
balance. Maceration may be controlled by certain dressing
materials that provide a vertical wicking and trap the wound
fluid in the matrix of the dressing (ie, calcium alginate
ropes, hydrofibers).
5. Consider caregiver time when selecting a dressing. A
dressing that is easier to apply and does not require frequent
changes decreases the healthcare providers workload and the
financial burden to the patient, family, and society. 6.

30 OstomyWound Management
 TABLE 8
CHOOSING APPROPRIATE DRESSINGS
Dressing Category Appearance of Wound Bed Appearance of Granulation Tissue
Black Yellow Sloughy Red Red Red Pink/Purple
(Necrotic) (Dry) (Moist) (Infected) (Wet) (Bleeding) (healthy granulation/
re-epithelialization)
1. Foam ++ ++ +++
Absorbent

2. Hydrofiber +++ ++ +++ +

3. Crystalline +++ +++ ++
NaCl gauze
++
4. Calcium alginate + +++ +++ +++
5. Hydrocolloid + ++ ++ ++ ++
6. Hydrogel ++ +++ + + +++
+++
Membrane

7.Adhesive film +++

8. Nonadhesive film
++
9. Enzymes +++ +++ ++
+ = usually appropriate
++= appropriate
+++= highly appropriate

Eliminate wound dead space by loosely filling all cavities
with dressing material. Avoid overpacking the wound.
Stotts47 reports that increased bacterial invasion and
impaired healing results from unfilled dead space. Tightly
packing the wound causes pressure on the newly formed
granulation tissue and may cause damage that will prevent
or delay healing. Overpacking may decrease absorbent
capacity of the dressing material by not allowing the dress-
ing to absorb the wound fluid.
7. Because they are difficult to keep intact, monitor dress-
ings applied near the anus. Day et al48 found that choosing a
dressing specifically designed for the sacral area improves
wear time and healing rate on full-thickness pressure ulcers.
Specifically, a triangular-shaped dressing will fit better with
the tip toward the anus. Shearing and friction forces are
tremendously high in the sacral area, causing rolling and
bunching of the dressing.
To date, no one dressing will complete all the outlined
requirements. The three absorbent dressing groups are foams,
hydrofibers, and crystalline NaCl gauze (see Table 8).
Foams49,50 provide thermal insulation, high absorbency, a
moist environment, and are gas permeable. They are also
nonadherent, easy to cut and shape, and do not shed fibers.
Some foams have additional wound contact layers to avoid
adherence when the wound is overly dry and a polyurethane
backing to prevent excessive fluid loss. Crystalline sodium
chloride gauze (pledgit or packing) is used for highly exuda-
tive wounds, mechanical debridement, and for its antibacter-
ial properties. Hydrofibers have high absorbency, good tensile
strength, and contain the fluid within the fiber. They do not
provide a fluid equilibrium with the wound surface as would
occur with foam dressing. Foams and hydrofibers have long
wear times (up to 1 week) but crystalline sodium chloride
gauze should be changed daily.
Calcium alginates51 are derived from brown seaweed
(kelp). Some alginates have a high content of mannuronic
acid (high gelling property for autolytic debridement) and
others have a high galuronic acid content (high fiber integri-
ty for packing sinuses).52 Calcium alginates are marketed in
ropes (vertical wicking best for hemostasis) and wafers (later-
al wicking to remove surface exudate). The calcium alginates
are excellent for hemostasis postdebridement. The calcium
alginate donates calcium for ion exchange to the wound
fluid to promote hemostasis and accepting sodium ion,
causing the alginate to form a hydrogel for moist interactive
healing.53,54 No crust is formed, and the wound can progress
from the inflammatory to the proliferative stage. If the fiber
is intact with dressing change, then the exudate is not suffi-
cient. Another dressing class should be chosen for subse-
quent dressings. Alginates are excellent for infected wounds,

November 2000 Vol. 46 Issue 11 31

but systemic antibiotics are needed if deeper tissue symp-
toms and signs are present (see Recommendations 6 and 9).
Hydrogels53-56 provide a high concentration of water in
insoluble polymers. They may be synthetic or semisynthetic
with bases of propylene glycol, saline, or hydrocolloids.
They are inert to normal biological processes and permeable
to metabolites with some absorptive and water-donating
properties. They are best in dry, sloughy wounds with low
exudate levels. They require changing every 24 to 72 hours
and have very little anti-infective properties. They are avail-
able in amorphous or sheet forms.
Hydrocolloids57 are occlusive dressings containing car-
boxymethylcellulose, other polysaccharides, and proteins.
They have both dry (elastomers) and wet tack (adhesives),
changing physical form by slowly reacting with wound fluid
to form a linked matrix gel. Fibrinolytic activity is due to
pectin and antibacterial properties, owing partly to a low
pH. Occlusion is accomplished by a foam or film sheet
backing. Hydrocolloids provide an anaerobic environment
that can sometimes promote hypertropic granulation. They
are best for autolytic debridement and mild to moderately
exudating wounds.58 They are relatively contraindicated with
arterial insufficiency, vasculitis, and infection. They have a
long wear time (2 to 7 days), but must be changed if the
wound fluid leaks through the edges. The hydrocolloid
residue may be mistaken for infection and should be
cleansed prior to wound bed assessment.
Film dressings are best for the late stages of wound heal-
ing. Many are permeable to water vapor and oxygen, but
impermeable to water and micro-organisms unless leakage
channels develop from the periphery. They vary in their
moisture-vapor permeability properties with Opsite (Smith
& Nephew, Largo, Fla) (MVTR 862 gm/m2/24 hrs) and
Tegaderm (3M Pharmaceuticals, London, Ontario, Canada,
and Minneapolis, Minn.) (MVTR 846 gm/m2/24 hrs)59
compared to IV 3000 (MVTR 3000, Smith and Nephew,
Largo, Fla) designed to keep areas around cannulas dry, but
this dressing would be too dehydrating for most chronic
wounds. Film dressings come in adhesive and nonadhesive
forms. They function best for superficial, nonexudative
wounds.60 They can be left in place for long periods or until
they fall off if the seal is intact. Removal by stretching the
edges will minimize superficial tears.
Friable or bleeding wounds may benefit from the tack
provided by fenestrated silicone surfaces (ie, Mepitel,
Mepilex; Molnlycke, Oakville, Ontario, Canada) that can be
left intact while secondary dressings are changed.
32 OstomyWound Management
Recommendation 12
Evaluate the Expected Rate of Wound Healing to
Determine if Treatment is Optimal
An orderly sequence of healing should occur if the under-
lying cause has been treated, optimized local wound care
implemented, and patient-centered concerns addressed. It is
essential to have systematic wound documentation. Deep
ulcers with significant depth (those progressing from Stage
IV to Stage II) can be measured with alginate molds that are
weighed and the weight related to volume or precise deter-
minations. In most clinical settings, depth can be measured
with a wooden stick in the deepest portion of an ulcer or an
average of the deepest and most superficial portion used for
documentation. Length and width are very accurate for
superficial wounds with the widest width being measured at
right angles to the longest length.61 For precise determina-
tions, tracings of superficial ulcers can be analyzed with
computer planimetry. All sinuses and areas of undermining
also should be documented. All ulcers will heal after the
removal of nonviable tissue through maturation of granula-
tion base and filling the defect to re-epithelialization.
During the early debridement stage, a wound may actual-
ly increase in size before it contracts. Two studies have used
a modified Gillman formula to demonstrate that healing
rates of venous ulcers at 4 weeks can be used to accurately
predict ulcers that will heal by week 12.62,63 A wound that is
not 30% smaller between weeks 0 and 4 is unlikely to heal
by week 12. If an ulcer is not progressing in a measurable
way, the treatment of the cause, local wound care, and
patient-related issues must be reassessed. If all these factors
are optimal, biological agents or adjunctive therapies may be
indicated.
Recommendation 13
Use Biological Agents When Other Factors Have
Been Corrected and Healing Does not Progress at the
Expected Rate
Biological agents are expensive, but they stimulate wound
healing. To date, growth factors have been relatively disap-
pointing because they can be likened to a symphony orches-
tra, using only one player, such as the flute, without the rest
of the orchestra. The single player does not allow for an
orderly progression of healing. Despite these limitations,
however, platelet-derived growth factor in a hydrogel
(Regranex; Ortho-McNeil Pharmaceutical, Inc., Raritan,
NJ) has been marketed for use in the treatment of diabetic
neurotropic foot ulcers. Platelet-derived growth factor is very
important as a catalyst very early on in wound healing to
promote cellular migration and collagen synthesis. It is
applied daily, and the study showed that with best clinical
practices and Regranex, healing rate was increased by 15%
in a 20-week trial from 35% in the control group to 50%
having complete wound closure in diabetic neurotropic foot
ulcers.
Recent advances in tissue culture techniques (Reinwald
and Green)64 have made it possible to culture cells from
human foreskin donors. Donated newborn foreskins are
used to extract epidermal precursor cells and fibroblasts to
master skin banks. Both cells and the mothers are extensive-
ly and repeatedly screened for possible infectious agents.
From one piece of donated tissue, these cells are transferred
to working cell banks and can produce enough skin substi-
tute to cover four to six football fields. Dermagraft
(Advanced Tissue Sciences/Smith & Nephew Inc., La Jolla,
Calif. and Largo, Fla.) is a human fibroblast-derived dermis
consisting of bio-absorbable polygalactin mesh on which
fibroblasts are seeded. The cells proliferate on the mesh in
specialized bioreactors to form tissue that is cryopreserved
and frozen for long-term storage.
Dermagraft in the therapeutic range, increased the 12-
week healing of DNFU from 32% to 54% over best clinical
practices. This difference in healing rate was maintained
over the 32-week trial period demonstrating the potential
long-term benefits of advanced therapies. Apligraf
(Organogenesis, Canton, Mass. and Novartis, East Hanover,
NJ) consists of dermal fibroblasts and Type I bovine colla-
gen matrix with an epidermis and differentiating stratum
corneum. In a controlled trial, 63% of venous ulcers healed,
compared with 48% of active control patients by week 24.
A subanalysis of ulcers present for more than 1 year demon-
strated complete healing of 47% of patients treated with
Apligraf/ and compression compared to 19% treated with
compression therapy alone.
Recently hyaluronic acid in a bipolymer has been made
available for difficult to treat wounds. Hyaluronic acid is a
major carbohydrate component of the extracellular matrix,
inducing a prompt angiogenic response, promoting rapid
formation of granulation tissue, assisting fibroblast growth
and migration, and directing the organization of collagen
disposition.65 This agent has shown promise in case series,
but no controlled trials have been published to date.
Conclusion
The wound care professional has an ever-expanding tool-
box for ideal wound care. Debridement, bacterial balance,
and moist interactive healing all must be optimized as inte-
gral parts of preparing the wound bed. If the underlying
cause, patient-related factors, and the wound bed have all
been appropriately treated, the new and expanding drawer
of biologicals offers increased hope for some of our most dif-
ficult chronic wounds. - OWM
Acknowledgment
Some concepts presented in this paper were first devel-
oped through a series of articles by Diane Krasner and R.
Gary Sibbald on wound care in Nursing Clinics of North
America27; Hyperbaric Medicine Practice, 2nd Edition66; and
The Diabetic Foot, 6th Edition.67 The local wound care para-
digm (debridement, bacterial balance, and moisture balance)
was presented by R. Gary Sibbald as part of a planning ses-
sion at The Symposium on Advanced Wound Care and
Medical Research Forum on Wound Repair in Dallas, Texas,
April 14, 2000. Concepts used in the charts have been
modified from an educational retreat sponsored by an unre-
stricted educational grant from Smith & Nephew Canada
and a 1998 Peel regional initiative and wound care guide,
compiled by Caremark Ltd.
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