Antimicrobial Stewardship in Wound Care

Antimicrobial stewardship (AMS) is defined as “coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial drug regimen including dosing, duration of therapy, and route of administration.”1 Programs focused on AMS have improved various clinical outcomes, including reductions in inappropriate antimicrobial usage and length of hospital admissions and can lead to substantial cost savings.2 A reduction in antimicrobial resistance (AMR) is another important target of AMS programs. According to the World Health Organization, AMR is mainly driven by inappropriate and unnecessary antimicrobial use and is currently one of the greatest threats to global health.3 Although robust evidence for a positive impact of AMS programs on AMR is lacking,4 such programs reduce inappropriate antimicrobial use, which may act as a surrogate marker for mitigating future AMR development.5 Further, Lindford et al6 eradicated a facility-acquired multidrug-resistant organism in patients receiving wound care following AMS initiatives. The practice of AMS is broad and encompasses a number of different areas ranging from antimicrobial usage in the agriculture industry to use of mobile clinical support tools in clinical settings. Benefits seen from AMS interventions can be realized in wound care practices; therefore, it is important to consider the implementation of AMS in wound care. This brief review will provide a general overview of AMS, discuss barriers in implementing AMS in the field of wound care, and highlight the importance of implementing AMS principles in this care setting. BARRIERS TO AMS IN WOUND CARE Wound care is a complex field that requires an evidence-based approach. Numerous barriers have been identified in the literature with respect to implementing AMS practices universally in wound care programs.7–9 For example, geographic and socioeconomic factors can result in challenges in providing and accessing care. Resource-limited settings may face significant barriers with respect to staffing shortages and resource availability.10 These barriers result in a lack of standardization among AMS programs nationwide.7 Wound care studies evaluating AMS interventions cover a broad range of topics, including investigating the effects of various dressings on wound infections and assessing the role of prospective audits and feedback from patients receiving antimicrobials for wound infections. A review by Rippon et al11 looked at the evidence for bacterial-binding dressings (ie, dressings that physically retain bacteria and reduce the bioburden of pathogenic organisms in the wound bed) in both acute and chronic wounds. Significant improvements were noted for a number of outcomes, although many of the studies reviewed had limitations such as a small sample size and lack of control groups. Some examples of improvements included a reduction in surgical site infections compared with standard surgical dressings,12 a shorter duration of antimicrobial use in infected pressure injuries compared with standard care,13 and equal rates of bacterial infection elimination from wound beds compared with therapy with topical mupirocin.14 Nauriyal et al15 looked at the effects of postprescription review and feedback on patients requiring burn and wound care in Nepal. They reported a significant decrease in mean days of IV antibiotic use and changes in antibiotic-prescribing practices over the 6-month postintervention period. Additional improvements included increases in justified use of antibiotics, de-escalation, accurate documentation, and adherence to local prescribing guidelines.15 Limitations identified in this study included the increased workload on physicians due to the need for manual data entry and associated data entry inconsistencies attributable to time constraints. This illustrates another potential barrier for AMS programs: these programs require a significant time commitment from healthcare workers to function well. This potential barrier is particularly relevant in low-resource settings and regions where documentation remains paper-based. In addition, AMS program implementation in resource-limited countries is more significantly impacted by a lack of dedicated funding, worker shortages, and poor infrastructure.10 These factors are also necessary for wound care programs to function and, as such, are limiting factors in the implementation of AMS programs specific to wound care. PRINCIPLES OF STEWARDSHIP IN WOUND CARE Many of the general principles of AMS are particularly relevant in the setting of wound care (Figure). The following principles are imperative for the judicious use of antimicrobials and to minimize potentially harmful antimicrobial exposure to patients:9,16Figure: PRINCIPLES OF ANTIMICROBIAL STEWARDSHIP (AMS) IN WOUND CARE Identify wound infections and avoid antimicrobial therapy in noninfected wounds Understand the importance of source control (eg, hardware removal in prosthetic joint infections) Identify when to stop antimicrobials Recognize when to change therapy route of administration (eg, IV to oral route) Select the correct antimicrobial at the correct dose Implement a team approach involving prescribing clinicians, pharmacists, nurses, infection control professionals, and other allied health members Acquire appropriate microbiology samples to target specific pathogens The following scenario exemplifies several AMS principles as they pertain to wound care in a clinical setting. Jane is a 75-year-old woman with poorly controlled diabetes (hemoglobin A1c of 13.0) and peripheral arterial disease related to longstanding diabetes and smoking. She does not have a good understanding of her medical conditions and recently cut her foot without realizing it, because of diabetic neuropathy. Unfortunately, it takes several weeks for Jane to realize she has a foot wound, which is noticed by her husband one evening when she puts her feet up in a recliner. She goes to her primary care provider and is diagnosed with a diabetic foot ulcer. She is referred to an interprofessional wound care clinic the following day. She attends this clinic and meets with a team of healthcare professionals including a general practitioner, nurse, and occupational therapist. She undergoes wound cleansing and moisture-balanced wound care. She then receives foot care education, including how to dress and unload her foot ulcer, and is taught the importance of smoking cessation and diabetes control to improve wound healing. The team correctly identifies that there is no role for antimicrobials at this time and reviews the signs and symptoms of infection with Jane so that she can seek medical attention should she develop an infection in the future. A letter is sent to Jane’s primary care provider detailing her visit to the wound care clinic. Jane is also given resources to review the various aspects of wound care discussed at the clinic, and a follow-up appointment with a wound care nurse for reassessment and dressing change is arranged. Education is a vital component of stewardship practices and is important for both healthcare professionals and patients.17 Healthcare professionals should have a strong understanding of wound care management so that a comprehensive approach is used in treating patients with chronic wounds, which may not require antimicrobials. This approach encompasses managing chronic conditions (eg, diabetes) and risk factors (eg, smoking), the use of pressure offloading and compression stockings,18 and the infection and chronic wound care principles previously discussed to facilitate wound healing. From a patient perspective, providing educational material and explaining the differences between a chronic wound and wound infection can encourage patient autonomy, mitigate unrealistic wound healing expectations, and minimize requests for antimicrobials when they are not indicated. Most importantly, in addition to applying principles of AMS where possible, an individualized approach to the assessment and management of a patient with a wound is key. Finally, certain stewardship strategies in wound care may aid in the case of chronic wounds where antimicrobial therapy is not indicated. Some of these strategies include negative-pressure wound therapy and hyperbaric oxygen therapy for wound healing. The use of physical sequestration dressings, where bacteria are physically immobilized and bound within the dressing, in place of antimicrobial dressings is another means to minimize antimicrobial use.8 Other strategies are being studied to determine their impact in wound care management. One such example is point-of-care testing to assess bacterial burden in wounds, which may be a useful decision-making tool with respect to antimicrobial therapy initiation but is not yet routinely performed in the clinical setting.19 CONCLUSION Wound care is an important area in medicine requiring ongoing study to determine the best strategies to manage wounds and wound infections while optimizing antimicrobial use. Some of the barriers identified in establishing AMS programs in wound care include geographic and socioeconomic barriers and challenges with interpretation of available wound care literature due to study quality. Wound care is a complex field where fundamental AMS principles should be applied in an interdisciplinary setting in order to provide optimal patient care. PRACTICE POINTS Foundational AMS principles can be applied to the practice of wound care. Optimal wound care requires an interdisciplinary setting with well-trained healthcare professionals. Antimicrobial stewardship in wound care is a growing field that requires further study and clear guideline development to standardize wound care practices nationally. A number of wound care strategies are being used to minimize unnecessary antimicrobial use, but more evidence is required before these can be implemented into routine wound care practices.

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