Adv Wound Care · 2022
Reliance on Clinical Signs and Symptoms Assessment Leads to Misuse of Antimicrobials: Post hoc Analysis of 350 Chronic Wounds
Serena, T.E., Gould, L., Ousey, K., & Kirsner, R.S.
Advances in Wound Care (Mary Ann Liebert), accepted Oct 2021
In brief
This post hoc analysis of the FLAAG trial, a study of 350 chronic wounds at 14 US wound care centers, examined whether clinicians' antimicrobial prescribing, based on clinical signs and symptoms of infection, matched the bacterial load measured by tissue biopsy. Antimicrobials were prescribed at similar rates for wounds with and without signs of infection (75.0% vs 72.8%, p = 0.76, not significant), prescribing did not track bacterial load, and 33.3% of patients prescribed systemic antibiotics had no signs of infection. The authors conclude that relying on clinical signs alone leads to haphazard antimicrobial use and that better ways of identifying bacterial burden are needed to support antimicrobial stewardship.
The SerenaGroup Research Foundation conducted the FLAAG trial behind this analysis, sponsored by MolecuLight.
Plain-language summary by SerenaGroup. See the full text for complete methods and results.
Abstract
Bacteria frequently impede wound healing and cause infection. Clinicians rely on clinical signs and symptoms (CSS) to assess for bacteria at the point of care, and inform prescription of antibiotics and other antimicrobials. Yet, robust evidence suggests that CSS has poor sensitivity for detection of problematic bacterial burden and infection, hindering antimicrobial stewardship efforts. This study evaluated CSS-based antimicrobial prescribing practices across 14 wound care centers. Approach: Data were analyzed from the fluorescence assessment and guidance (FLAAG) trial, a study of 350 chronic wounds across 20 clinicians. Clinicians reviewed patient history and assessed for CSS using the International Wound Infection Institute infection checklist. Wounds with >3 criteria or any overwhelming symptom were considered CSS+. Bacterial levels were confirmed with quantitative tissue culture of wound biopsies. Results: Antimicrobials (including dressings, topicals, and systemic antibiotics) were prescribed at a similar rate for wounds identified as CSS+ (75.0%) and CSS- (72.8%, p = 0.76). Antimicrobial dressings, the most frequently prescribed antimicrobial, were prescribed at a similar rate for CSS+ (83.3%) and CSS- (89.5%, p = 0.27) wounds. In 33.3% of patients prescribed systemic antibiotics, no CSS were present. Prescribing patterns did not correlate with bacterial load. Innovation: This study is the first to evaluate antimicrobial prescribing trends in a large, multisite cohort of chronic wound patients. Conclusions: Reliance on CSS to diagnose clinically significant bacterial burden in chronic wounds leads to the haphazard use of antimicrobials. Improved methods of identifying bacterial burden and infection are needed to enhance antimicrobial stewardship efforts in wound care. Clinicaltrials.gov ID. NCT03540004. Thomas E. Serena, MD Submitted for publication August 25, 2021. Accepted in revised form October 9, 2021. *Correspondence: SerenaGroup Research Foundation, 125 Cambridge Park Drive, Cambridge, MA 02140, USA (e-mail: serena@ serenagroups.com).
Keywords
antimicrobial stewardshipantibiotic prescribingbacterial burdenchronic woundsclinical decision supportdiagnostic pathwaywound clinic
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