Is Your Wound Bioburdened? Case 5

CASE

• An 87-year-old female with past medical history of right nephrectomy and renal cell carcinoma, chronic obstructive pulmonary disease, dyslipidemia, hypertension, and chronic kidney disease sustained a fall and fractured her right femur while alone at her home.
• The patient was unable to stand and remained immobile on the floor for several days until she was found and helped.
• As a result, a deep sacral pressure injury (PI) developed. It was classified as unstageable during her initial evaluation.
• At the moment of admission, she was further diagnosed with rhabdomyolysis, renal failure, hypothyroidism and low albumin.

INITIAL EXAMINATION & TREATMENT

• The initial treatment plan included a course of systemic antibiotics and wound hygiene sessions with hypochlorous acid 1:20 alternated with betadine-soaked gauze.
• After 1.5 weeks it was noted that the wound was not improving; therefore, a decision was made to start negative pressure wound therapy with instillation (NPWTi) of hypochlorous 1:20 acid. The wound size was 15 x 9 cm at the beginning of this treatment.
• At week 2 the first fluorescence (FL) image is documented. Image 1a shows the NPWTi in place, with evident + red fluorescence signal in the dressing, indicating high bacterial loads (>10⁴ CFU/g). Image 1b was taken after the dressing was removed. At this stage, the wound size had decreased to 12 x 8 x 3.5 cm
• Despite this good clinical progress, as per institutional policy (Standard of Care, SoC), the NPWTi was switched at 10 days for NPWT without instillation (Weeks 2–3), assuming the bacterial load had been eliminated.
• At week 4, the wound stalled with no clear indication why (Image 2a), fluorescence imaging, however, did demonstrate bright and widespread red bacterial fluorescence under the clear adhesive and throughout the NPWT foam (Image 2b)

CLINICAL DECISION

• Fluorescence image findings prompted an immediate dressing change and switch back to NPWTi of hypochlorous acid (1:20).
• Wound swabs taken at this time confirmed heavy growth of Escherichia coli, Staphylococcus aureus and Enterococcus faecalis, and light growth of Proteus vulgaris.
• The patient remained in NPWTi for a total of 14 additional days based on fluorescence imaging and clinical findings.
• By week 6 the wound had decreased to 8 x 6 cm and 4.5 cm deep, and granulation tissue covered 100% of its surface area, indicating that the healing process was progressing.
• Throughout the following weeks a fluorescence image informed therapeutic approach was implemented, targeting FL+ areas when needed through localized cleansing and verifying that the fluorescence signal was removed after.
• Through this approach a progressive improvement in symptoms and decrease in wound size were evidenced. Table 1 depicts this therapeutic journey in detail.
• By following this approach, the patient had a full recovery. This complex, large, deep wound healed completely in 17 weeks without requiring more advanced interventions, systemic antibiotics, or any new courses of NPWT after week 14.

TAKE-HOME POINTS

• Fluorescence imaging (MolecuLight i:X) through the transparent NPWT adhesive dressing evidenced high, pathogenic bacterial loads in the NPWT foam, as well as in the wound bed and surrounding periwound tissue.
• Fluorescence image findings were corroborated by microbiological results obtained through swabbing. This suggests that FL-imaging can be used as a non-invasive measure to accurately monitor pathogenic bacterial presence through transparent NPWT sealed adhesive dressings. Figure 4 shows the absence of fluorescence signal through the transparent dressing.
• As evidenced by the clinical evolution of this patient, the therapeutic decisions that were a direct result of the fluorescence imaging findings resulted in clinical improvement. Ultimately there was complete healing of a wound which initially had a poor prognosis.
 
Rose Raizman, RN-EC, PHCNP, NSWOC, WOCC(C), MSc, MScN, is an Adjunct Lecturer at Lawrence S. Bloomberg Faculty of Nursing, University of Toronto. She is in Professional Practice at Scarborough Health Network Centenary Hospital.

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