Is Your Wound Bioburdened? Case 4

CASE & INITIAL EXAMINATION
 
• A 94-year-old male, active and in overall good health, with chronic venous leg insufficiency and hypertension.
 
• Treated regularly in our clinic for bilateral venous leg ulcers with good wound hygiene, absorptive dressings and compression bandaging.
 
• On one of these visits the patient complained of an area of discomfort on a callus located on the medial aspect of his right second toe including the interdigital area between toes 1 and 2.
 
• There were no abnormal clinical signs on inspection in the interdigital area, and no overt signs of infection on the callus itself, but the callus was noted to be soft and macerated (Figure 1A).
 
• A decision was made to use fluorescence imaging to investigate possible bacterial contamination.
 
CLINICAL DECISION
 
• Fluorescence imaging (MolecuLight i:X) revealed bright and blush red fluorescence in the callus and the area around it, indicating high bacterial loads (>10⁴ CFU/g). The red fluorescence signal extended towards the plantar surface of the second toe and into the interdigital space between toes 1 and 2, corresponding with the patient’s symptoms (Figure 1B).
 
• We cleaned the anatomically narrow interdigital area in a way that would not inadvertently transfer bacteria to non-colonized areas (evidenced by cleansing under fluorescence imaging), utilizing gauze moistened with hypochlorous acid, using a procedure which we later named “Toe flossing.”
 
• Toe flossing has become a staple in our clinic. It entails utilizing an elongated gauze soaked in wound cleanser (hypochlorous acid) and guiding it between the toes in a “flossing” motion, such that the gauze is pressed against the sides of the toes. This effectively catches and removes the bacteria from the skin without touching other areas of the foot (see video).
 
OUTCOME
 
• The effectiveness of this procedure can only be identified using point-of-care fluorescence imaging. Figure 2 shows how pathogenic levels of bacteria in the plantar surface and interdigital area were removed. Some bacteria persisted, probably at a deeper level within the tissue. We commonly encounter this with macerated skin and callus.
 
• No ulcers/wounds developed in the area.
 
PATIENT ENGAGEMENT
 
• We have found that fluorescence imaging is a visually engaging tool that allows patients to understand the importance of appropriate foot hygiene. Once educated on foot hygiene, patients can focus more closely on areas of their feet such as the interdigital spaces of the toes to aid in the prevention of long-term problems and complications.
 
CLINICAL PERSPECTIVES
 
• We theorize that these areas of increased bacterial loads in the interdigital spaces may be related to micro abrasions or micro fissures, which could eventually evolve into an ulcer.
 
• This is particularly relevant in those patients whose underlying pathologies and conditions (eg, diabetes, elderly) put them at a higher risk for foot ulcers and severe ulcer-related complications. The immunocompromised patient population rarely presents symptoms and signs early enough to prevent a wound or ulcer.
 
• Fluorescence imaging (MolecuLight i:X) is key for identifying these at-risk patients so that early intervention strategies can be implemented.
 
Dot Weir, RN, CWON, CWS, is affiliated with the Saratoga Hospital Center for Wound Healing and Hyperbaric Medicine, Saratoga Springs, NY.

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