Is Your Wound Bioburdened? Case 7

CASE & INITIAL EXAMINATION

Female patient, bedbound due to advanced multiple sclerosis, presenting with recurrent and multiple pressure injuries.

Featured here is a stage 4 sacral pressure injury (Figure 1a).

Clinical inspection showed bone exposure, foul smell, and friable, inflamed tissues. Osteomyelitis was diagnosed via erythrocyte sedimentation rate (ESR) and polymerase chain reaction (PCR) testing of tissue.

BACTERIAL FLUORESCENCE IMAGING

Fluorescence imaging using MolecuLight revealed bright red fluorescence in the peri-wound tissues around the sacral ulcer, as well as blush fluorescence on the wound bed (Figure 1b).

Red fluorescence indicates the presence of gram-positive and gram-negative bacteria at high loads (above 10⁴ colony-forming units per gram).

A white/bright green signal is also present in the inferior portion of the wound bed. This signal indicates biological structures including adipose tissue, fascia, tendon, ligaments, joint capsules, or bone. It is important to differentiate this bright white signal from a cyan signal, which has a bright white center and a green/blue halo. Cyan fluorescence indicates the presence of Pseudomonas aeruginosa above 10⁴ CFU/gr. This signal can be very intense and bright; however, it would not follow any distinguishable anatomical structure found in standard view.

CLINICAL DECISION

Given the bacterial loads present in and around the ulcer and the history of osteomyelitis, a multi-faceted approach was undertaken.

First, the wound was sterilized by soaking in a solution of hypochlorous acid (Vashe^®) for approximately 10 minutes. This was primarily to address bacteria in the intact periwound.

Next, sharp debridement was performed to remove non-viable and bacterial-laden tissues in the wound bed and at the wound edges.

Following these procedures, the wound was re-imaged (Figure 1c), and a significant decrease in red bacterial fluorescence was noted (Figure 1d), although some remained in the peri-wound.

Going forward, the patient was treated for osteomyelitis (an 8-week course of oral antibiotics) as well as weekly sessions where hypochlorous acid (Vashe^®) soak and thorough fluorescence-guided debridement (MolecuLight^®) took place, and negative pressure wound therapy was applied. In addition, the patient had support from her family, a private duty caretaker, and home health visits biweekly.

OUTCOME

Approximately 4 weeks after initial evaluation, the sacral ulcer had decreased in size, tissue began to re-grow to cover the exposed bone, and undermining was reduced from 6 cm to 1.9 cm. By week 15, bone exposure was resolved (Figure 2b). Unfortunately, due to the patient’s condition and environmental factors, complete, normal skin formation was unattainable. However, bone exposure was avoided and was not evidenced by week 28 (Figure 2c).

This stage 4 sacral ulcer was on a faster healing trajectory than the average wound of its type and stage against a difficult prognosis given the patient conditions.

LEARNING OPPORTUNITY

“We have been utilizing MolecuLight during every visit to help guide our decision-making with real-time evidence. The availability of taking post-intervention pictures or videos with MolecuLight allows us to evaluate our approach at the bedside, providing us with the opportunity to finesse or complement our original plans, for patient care and optimizing and accelerating healing.”—Ali Saberi, MD