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W
ound infection is defined as the (IWII) presented a revision of the wound infection
presence of a wound environment continuum that aligned the phases of infection
characterised by microbes in sufficiently with the clinical response of the individual and
large numbers, or of sufficient virulence to provoke the wound (IWII, 2016). The wound infection
an immune response locally, systemically or both. continuum revision was developed using a
Whenever there is a break in the skin integrity, consensus voting (Delphi) process underpinned
bacteria can enter the body and begin multiplying. by a literature review. In an iterative, three-round
Without the protective barrier of the skin, sensitive voting process, experts from the IWII executive
tissues in the wound bed are vulnerable to committee reached agreement on wound
microbial colonisation. When microorganisms infection definitions and terminology, as well as an
invade a wound and start proliferating, local tissue update on the conceptualisation and presentation
damage occurs and wound healing is disrupted of the wound infection continuum (IWII, 2016).
(Eberlein, 2006; Siddiqui and Bernstein, 2010). This process, which used a previously validated
and published method, allowed the participants
Update to the wound infection to reach agreement on statements using a valid
continuum and reliable that had been adapted to an online
The wound infection continuum characterises the process (Haesler et al, 2018).
progression of infection in a wound. A ‘continuum’ The first phase of the wound continuum is
Emily Haesler is Adjunct Associate
Professor, Curtin University, is a continuous sequence in which adjacent considered to be contamination. This recognises
School of Nursing, Midwifery and elements are not perceptibly different from the well-established fact that all wounds acquire
Paramedicine, Perth, Australia; each other, but the extremes are quite distinct micro-organisms, often from normal flora from the
Honorary Senior Lecturer, (Merriam-Webster Online Dictionary, 2018). This periwound skin. However, if the wound bed does
Australian National University,
conceptualisation of the impact that infection not provide an appropriate environment for the
ANU Medical School, Academic
Unit of General Practice, Canberra, has on a wound and the person with a wound microbials species they will no multiply or persist,
Australia; Honorary Associate, as a continuum recognises that distinct stages and their presence is neither detrimental nor
La Trobe University, School of of infection are difficult to define and identify. persistent (Cooper, 2005; IWII, 2016).
Nursing and Midwifery, Bundoora, However, there is a large and easily distinguishable Contamination describes the point at which
Australia; Karen Ousey is Professor
difference between a non-infected wound and microbial species successfully grow and divide.
of Skin Integrity, Director for the
Institute of Skin Integrity and an individual with systemic infection arising from At this point, microbes being to proliferate in a
Infection Prevention, University microbes in a wound. favourable environment, but are not in sufficient
of Huddersfield, Department of As stages of infection cannot be neatly levels or virulence to disturb wound healing or
Nursing and Midwifery, England. demarcated, there has been ongoing debate provoke an immune response (Dow et al, 1999;
Adjunct Professor, School of
about the distinct wound infection stages and Enoch and Harding, 2003). There are no clinical
Nursing, Faculty of Health,
Queensland University of their relationship to clinical signs and symptoms. In signs and symptoms as the healing trajectory
Technology, Australia 2016, the International Wound Infection Institute continues as expected; however, laboratory
Figure 1. The International Wound Infection Institute’s Wound Infection Continuum and associated signs and symptoms of wound infection
stages (reproduced with permission) (Edwards and Harding, 2004; WUWHS, 2008; Lipsky and Hoey, 2009).
specimens from the wound would confirm and Harding, 2004). The stage is considered to be
microbes in proliferating numbers. when a chronic wound displays signs of delayed
The term ‘critical colonisation’ has previously healing, and the term implies that a critical number
been included into the wound infection continuum or virulence of microbials has been reached.
as a stage following contamination. The term was However, the literature provides no guidance on
used to refer to growth of bacteria within a chronic what this critical level may be, and the term ‘critical
wound without causing the signs and symptoms colonisation’ has remained poorly defined (White
traditionally associated with infection (Edwards and Cutting, 2005; White et al, 2006). The difficulty
in determining when critical colonisation is undermining can occur. Friable granulation tissue
reached led the IWII Executive Committee to reach can occur due to bacterial burden interfering with
agreement to remove this term from the revised healthy collagen formation (Sibbald et al, 2003).
wound infection continuum (IWII, 2016) (see the Because the classic Celsian signs of local wound
revised continuum in Figure 1). infection are generally easy to detect by simply
visualising the wound bed, the IWII refers to this
Local wound infection — covert and stage on the wound infection continuum as overt
overt signs and symptoms (classic) signs of local infection (IWII, 2016).
When bacteria or other microbes present in the
wound move deeper into wound tissue and Beyond the wound — later stages of the
proliferate in a way that overwhelms the immune wound infection continuum
system (Collier, 2004; Siddiqui and Bernstein, 2010), When pathogens proliferate beyond the bounds
colonisation progresses to local infection. In this of the wound, spreading infection has occurred
stage, infection is maintained within the bounds (World Union of Wound Healing Societies
of the wound bed, contained in the one location, [WUWHS], 2008; Leaper et al, 2012). If uncontained
system or structure. by the host response, microbial infection begins
Local wound infection often presents in a subtle to spread beyond the wound into other local
manner that may not be readily identified without structures, including deeper tissue, surrounding
conscientious wound assessment and a strong tissue, muscle, fascia and local organs. The immune
understanding of early indicators that bacteria response to wound infection also becomes evident
may be present in quantities or virulence that outside the bounds of the wound. Signs and
are a threat (Sibbald et al, 2006; 2007). Wound symptoms of spreading infection include extending
breakdown, delayed healing, new pocketing and erythema, extending induration, crepitus and
epithelial bridging are early signs that tissue is not inflammation of the lymph glands and lymphatic
healing along the optimal trajectory (Cutting and vessel walls (lymphangitis).
Harding, 1994; Gardner et al, 2001; Collier, 2004; The individual might lose their appetite and
Gardner and Frantz, 2008). experience malaise, lethargy and other non-
Recognising the earliest signs and symptoms of specific deterioration (WUWHS, 2008; Leaper
wound infection is essential. Intervening promptly et al, 2012; IWII, 2016). During this phase, the
with appropriate infection management strategies wound bed continues to experience dehiscence
is important for preventing more extensive local with or without satellite lesions of infection
tissue damage and avoiding further microbial breakdown, while the overt signs of local wound
proliferation, delays to wound healing and infection remain apparent.
potential severe sequalae. These early and subtle Systemic infection is said to occur when the
indicators of local wound infection gradually impact of wound infection is on the body as a
emerge (particularly in chronic wounds) and are, whole (WUWHS, 2008; Leaper et al, 2012; IWII,
therefore, referred to in the 2016 update of the 2016). Microbials that entered the host through the
Wound Infection in Clinical Practice consensus wound bed gradually proliferate until they extend
document (IWII, 2016) as covert signs of infection. throughout the body via the vascular or lymphatic
Further along the wound infection continuum, systems (WUWHS, 2008; Leaper et al, 2012; IWII,
when the host response to microbial invasion 2016). Clinical signs and symptoms of this invasion
increases, the classic signs of local wound infection reflect systemic inflammatory response from the
become evident. Purulent discharge, erythema and host, including severe sepsis and septic shock,
swelling, local warmth, increasing malodour and organ failure and death.
new or increasing pain are classic signs of infection
in any organ of the body (Sibbald et al, 2003; IWII, Biofilm in the wound infection
2016). The classic signs of local wound infection continuum
reflect the host’s inflammatory response. As the The revised wound infection continuum recognises
host responds, the increase in local blood flow the advancing knowledge on biofilm in chronic
causes a local warmth. Erythema and pain develop wounds and its relationship to both microbial
due to activation of vasoactive mediators (e.g. action and clinical signs and symptoms. It is now
histamine). Purulence and malodour are produced recognised that as microbials increase in number
by bacteria processes (IWII, 2016). and virulence, biofilm form, mature and continually
In wounds, these classic signs of infection are disperse (Cutting and McGuire, 2015; Nouraldin et
also accompanied by delays in wound healing al, 2016; Uppuluri and Lopez-Ribot, 2016). Biofilm
beyond expectations. When bacteria inhibit is likely to be present in chronic wounds that have
the development of healthy granulation tissue, sufficient bacterial virulence or numbers to evoke