Preparing the Wound Bed – Debridement, Bacterial Balance, and ...

Preparing the Wound Bed – 

Debridement, Bacterial 

Balance, and Moisture Balance 

– R. Gary Sibbald, MD, FRCPC; Diane Williamson, MB, MRCP(UK); Heather L. Orsted, RN, BN, ET; Karen 

Campbell, RN, MScN; David Keast, MD, CCFP; Diane Krasner, PhD, RN, CWOCN, CWS, FAAN; and Debra 

Sibbald, BScPhm 

ABSTRACT 

Successful diagnosis and treatment of patients with chronic wounds 

involve holistic care and a team approach. The integration of the 

work of an interdisciplinary care team that includes doctors, nurses, 

and allied health professionals with the patient, family, significant 

others, and caregivers offers an optimal formula for achieving 

wound resolution. Such an approach challenges practitioners and 

everyone participating in wound care to integrate data and information 

that arise from a number of sources and mitigating factors. 

In this article, the authors define the changing paradigm that links 

treatment of the cause and focuses on three components of local 

wound care: debridement, wound-friendly moist interactive dressings, 

and bacterial balance. The authors demonstrate that the 

treatment of chronic wounds can be accomplished through a series 

of recommendations and rationales based on the literature and 

their experience. These recommendations lay the groundwork for 

thorough assessment and evaluation of the wound. 

Ostomy/Wound Management 2000;46(11):14–35 

Achronic wound is one in which the orderly 

sequence of repair is disrupted at one or several 

points of the inflammatory, proliferative, re-epithelization, 

and remodeling stages. 1 Key articles of Winter in 

the 1960s 2–3 demonstrated the benefits of moist interactive 

healing. Unfortunately, clinical practices have not always 

14 OstomyWound Management 

kept pace with the evidence base. The chronic wound must 

be directed back to this orderly nexus of events. Despite 

treating the cause, providing appropriate local wound care, 

and attending to patient-centered concerns, a certain percentage 

of wounds do not heal with best practices. Three 

components involved in healing the wound that must be 

considered by the healthcare professional include: treating 

the cause, providing local wound care, and addressing 

patient-centered concerns (see Figure 1). This paper focuses 

on local wound care involving preparation of the wound. 

The recommendations to follow can be used as a guide for 

multidisciplinary teams to consider in order to obtain optimal 

healing (see Table 1). 

Recommendation 1 

Assess the Patient for Adequate Blood Supply and 

Host Factors for Healability 

The local wound must be considered with underlying 

causes, the patient’s physical condition, and related extenuating 

and mitigating circumstances. One important consideration 

is to ensure that the wound has enough blood supply to 

heal prior to initiating wound management. 4 This is an 

especially important principle for wounds of the lower 

extremity. If a palpable dorsalis pedis or posterior tibial pulse 

is present, the systolic pressure is approximately 80 mm Hg 

or greater. The Doppler ankle brachial pressure index 

(ABPI) is often used to diagnose arterial disease. 5 A systolic 

Dr. Sibbald is Associate Professor of Medicine at the University of Toronto. Ms. Williamson is a Fellow in Wound Care at the Women’s College 

Campus, Sunnybrook and Women’s College Health Sciences Centre, Toronto. Ms. Orsted is a Clinical Specialist, Skin and Wound Management, 

with Calgary Wound Care, Calgary, Alberta. Ms. Campbell is a Clinical Nurse Specialist at Parkwood Hospital, University of Western Ontario, 

London, Ontario. Dr. Keast is a physician specializing in family medicine at Parkwood Hospital. Dr. Krasner is a Wound Care Consultant and 

Adjunct Associate Professor, Johns Hopkins University School of Nursing, Baltimore, Md. Ms. Sibbald is Senior Lecturer, Faculty of Pharmacy, 

University of Toronto. Address correspondence to: R. Gary Sibbald, MD, FRCPC, Women’s College Campus, SWCHSC, 76 Grenville Street, 

Toronto, Ontario, Canada.

This necrotic heel ulcer was caused by perioperative pressure. 

Black eschar can be seen over the ulcer. A pulse is present 

(> 80 mm Hg), indicating enough blood supply to heal. 

For sharp surgical debridement, a scalpel and scissors have 

been used to lift the eschar, revealing the underlying healthy, 

viable tissue. 

In this unhealthy wound bed, fronds of bright red, friable 

granulation tissue, increased wound exudate, and a white 

macerated wound margin were all signs of an increased bacterial 

burden. 

Autolytic debridement of a necrotic heel ulcer. Cross-hatching 

the wound can be used to facilitate autolytic debridement 

with moist interactive dressings. 

This leg ulcer has a base of loose slough and debris. The devitalized 

tissue is an excellent bacterial culture media with the 

green discoloration indicating the presence of pseudomonas. 

In this wound, a healthy pink granulation base is surrounded 

by a thin rim of a new purple epithelium. 

November 2000 Vol. 46 Issue 11 15

pressure ratio of 0.8 (eg, ankle systolic 80 mm Hg, brachial 

systolic 100 mm Hg) and higher indicates the absence of 

significant arterial disease, but a ratio below 0.5 suggests 

severe arterial compromise and a low probability of healing. 

The introduction of the handheld Doppler into clinics and 

homecare settings 6 has allowed practitioners to help identify 

patients with arterial disease. 

Patients with diabetes often have calcification of larger 

vessels, which leads to their noncompressibility. This will 

result in a falsely high ABPI value and healability should be 

assessed with transcutaneous partial oxygen saturation of 

>30% or toe arterial pressures (taken by photophlethysmography) 

of >40 mm Hg. Patients with symptoms of intermittent 

claudication at rest also should be assessed for surgery. 

Not all patients are candidates for vascular procedures, 

and if extensive and diffuse distal dis- 

ease is present, these procedures will not be beneficial. 

If nonhealability is established, then 

moist interactive local wound care is contraindicated. 

Topical antiseptics to dry the wound and 

prevent proximal bacterial invasion of viable tissue 

are recommended (see Recommendation 6). 


Assess and Monitor the Wound History 

and Physical Characteristics (location, 

size, base, exudate, the condition of surrounding 

skin, staging, and pain) 


Chronic Wound 

Diagnosis 

Treat Cause Local Wound Care Patient-Centered 

Concerns 

Debridement 

Bacterial Balance 

Non-healing Wound 

Biological Agents 

•Growth Factors 

•Cells – skin substitutes 

•Acellular matrix 

Figure 1 

This algorithm demonstrates an approach to the treatment of chronic wounds. 

Moist Interactive 

Healing 

Chronic wound care must 

include ongoing, consistent documentation 

of wound characteristics 

as part of continuous 

monitoring for complications 

and appropriate management. 

Wound history. Patients 

should be asked about the duration 

of the current ulcer and if 

he or she has had an ulcer previously 

and what, if any, treatment 

has been provided. The 

more chronic an ulcer becomes, 

the more difficult it is to heal. If 

it is recurrent, issues of prevention 

may not have been adequately 

addressed. 

Wound location and size. 

The precise location of the 

wound should be noted and can 

often be outlined on a body map or diagram. Measuring the 

length (usually the longest diameter) and the maximum 

width at right angles to the diameter is important. This is 

usually documented in centimeters. 7 Wound circumference 

can be traced onto a transparency or plastic page protector. 

Use disposable plastic wrap next to the skin to avoid bacterial 

contamination. A maximum depth should be measured 

with a probe (sterile metal surgical instrument, sterile plastic 

depth guide, or even a sterile cotton-tipped applicator or 

sterile swab). Place the depth gauge in the deepest part of 

the wound and use a gloved finger or a pen mark at the surface 

to determine the depth that can be measured with a 

ruler. The wound base also should be probed with caution 

Ostomy/Wound Management 2000;46(11):14–35 

L 

KEY POINTS 

❏ The provision of optimal local wound care involves a myriad of 

patient and wound assessment variables, environmental considerations, 

and treatment option decisions. 

❏ Using a holistic approach, the authors developed 13 general wound 

care recommendations while providing sufficient background information 

to tailor each of their recommendations to the needs of the 

individual patient. 

❏ As the number of wound treatment choices continues to increase, 

it is important to remember, and start with, the basic principles of 

good wound care (debridement, bacterial balance, and moist 

interacive healing). 

3

TABLE 1 

QUICK REFERENCE GUIDE TO THE 13 

RECOMMENDATIONS FOR PRACTICE: 

PREPARING THE WOUND BED 

1. Assess the patient for adequate blood supply and host factors 

for healability. 

2. Assess and monitor the wound history and physical characteristics 

(location, size, base, exudate, the surrounding skin, 

staging, and pain). 

3. Correct treatable causes of tissue damage. 

4. Provide education and support for patient-centered care to 

increase compliance. 

5. Debride healable wounds, removing necrotic and nonviable 

tissue. 

6. Assess the wound for bacterial balance and infection. 

7. Cleanse wounds with normal saline or water.The use of 

topical antiseptics should be reserved for wounds that are 

nonhealable or those in which the local bacterial burden is a 

greater concern than the stimulation of healing. 

8. If MRSA is present, assess the patient for colonization or 

infection. Select appropriate topical and/or systemic agent 

for treatment. 

9. Use only nonsensitizing topical antibacterial agents for local 

symptoms and signs of infection or increased bacterial burden. 

10. Use systemic antibiotics if symptoms or signs of infection 

extend beyond wound margin or the ulcer probes to bone. 

11. Select appropriate dressings for local moisture balance to 

stimulate granulation tissue and re-epithelialization. 

12. Evaluate expected rate of wound healing to determine if 

treatment is optimal. 

13. Use biological agents when other factors have been corrected 

and healing does not progress at the expected rate. 

for bone, sinuses, or undermining. One of the best ways to 

document wound characteristics is to use a flow chart. In 

the future, digital photography with color printouts may 

become the norm in everyday practice. 

Wound base. It is helpful to think of the wound in four 

major colors: black (necrotic), yellow (fibrous), red-pink 

(granulation tissue), pink-purple (re-epithelialization), or a 

combination of these colors. Black eschar represents devitalized 

tissue that may be soft or firm. If healability has been 

established, then eschar needs to be removed to promote 

healing. A yellow fibrous base may be firm or sloughy. A 

firm, yellow base represents underlying deep structures such 

as fascia or subcutaneous fat or the fibrin base for subsequent 

granulation tissue and does not need to be removed. 

Soft sloughy yellow material may indicate infection or 

degraded fibrin that needs to be removed. 

Granulation tissue is usually a salmon red-pink 

color, firm and moist. With increased bacterial 

load, this granulation tissue may become darker, 

exuberant, friable, and malodorous. Hypergranulation 

should be documented because it 

may require removal to facilitate re-epithelialization. 

Newly formed epithelialization is a 

pink-purple color that usually appears at the 

flush edges of the wound, but may occur in 

the center around the underlying hair follicle 

structures. 

Exudate. Exudate is usually described by its 

quantity (scant, moderate, and copious); characteristics 

(serous-serum, sanguinous-blood, 

purulent-infection, or a combination of these); 

and odor (presence or absence). In general, 

heavy exudates, even when clear fluid, should 

alert clinicians to problems related to the 

underlying cause (uncontrolled edema) or an 

early sign that there may be increased bacterial 

burden or infection. 

Wound margin and surrounding skin. 

The wound margin should be checked for callus 

formation, excess moisture in the form of 

maceration, edema, or erythema. 

Hyperkeratotic (thick) callus, especially in persons 

with diabetes on the plantar aspect of the 

foot, can lead to increased local pressure. 8 

Removing this type of callus is important. If 

the callus continues to form, pressure offloading 

is not optimal and the patient will require 

reassessment. Maceration of the surrounding skin usually 

presents with white hyperkeratosis and a wet surface. This 

indicates increased hydration of the keratin, and may be a 

reflection of a local dressing that is keeping the ulcer too 

moist or not absorbing exudate, an uncorrected cause (eg, 

limb edema or uncorrected pressure), or a sign of infection. 

The presence of erythema locally is a sign of inflammation 

or infection. If this erythema is warm, hot, and tender, 

infection is most likely. Discreet erythema with well demarcated 

margins that follow the outlines of applied dressings or 

topical treatments may indicate a contact allergic dermatitis. 

Common allergens, such as neomycin, lanolin, and perfumes 

must be avoided at all times. Chronic wounds allow 

optimal penetration of these substances and systemic processing 

by the immune system. 


Nociceptive Pain 

(normal nerve 

function) 

Contact irritant dermatitis also can occur and is less specific. 

There is an absence of the clear outline at the edges of 

the irritation, although erythema, scaling, and some maceration 

may also occur. Chronic irritant dermatitis is best treated 

with protectants such as petrolatum, zinc oxide ointment, 

or commercial barrier preparations around the wound 

margins. Thick materials often can be applied with a tongue 

depressor to decrease frictional resistance. 

Staging of the wound. General and disease-specific tools 

can be used to grade or stage chronic wounds. However, all 

wounds can be classified as partial or full thickness. 9 The 

National Pressure Ulcer Advisory Panel/Agency for Health 

Care Policy and Research (NPUAP/AHCPR) has a fourstage 

system for pressure ulcers, 9 and alternative systems 

should be used for leg and other ulcers. In general, this system 

applies to Stage I for persistent erythema but intact 

skin. Stage II represents an erosion (epidermal base) or 

superficial ulceration (dermal base). Stage III wounds have a 

subcutaneous fat base, and Stage IV wounds have a deeper 

muscle, tendon, bone, or joint base. Staging an ulcer and 

documenting the initial assessment of wounding is important. 

Other descriptors have been recommended for the 

healing process 10 (see Recommendation 8 of Best Practices for 

the Prevention and Treatment of Pressure Ulcers by Dolynchuk 

et al on page 45). For diabetic foot ulcers, the University of 

Texas treatment based classification system addresses neuropathy, 

deformity, vascularity and infection. 11,12 (See 

Recommendation 4 of Best Practices for the Prevention, 

Diagnosis, and Treatment of Diabetic Foot Ulcers by Inlow et 

al on page 59.) 


TABLE 2 

AN APPROACH TO PAIN MANAGEMENT 

Type of Pain/Symptoms Treatment 

Aching, throbbing, 

sharp, easily localized 

Neuropathic pain 

Shooting, stabbing 

Mild 

Moderate 

Severe 

Nerve irritation 

(burning) 

Nerve damage 

(shooting, stabbing) 

Acetominophen, aspirin or nonsteroidal anti-inflammatory, 

plus a co-analgesic 

Codeine, oxycodone, or other mild opiod plus 

acetominophen or aspirin plus co-analgesic 

Morphine, hydromorphone, fentanyl, diacetyl morphine 

plus co-analgesic 

Tricyclic antidepressants, gabapentin 

Gabapentin 

Pain. Pain also may be an important indicator of untreated 

disease. Krasner’s 13 model of chronic wound pain divides 

stimuli into incident pain, recurrent episodic pain, and continuous 

pain. Incident pain occurs with debridement or 

major trauma. This type of pain can be relieved with topical 

analgesia, interlesional analgesia, or presedation with agents 

following the World Health Organization pain ladder. 14 

Episodic pain often can occur with dressing changes. Pain 

control, both local and systemic, should be instituted at 

appropriate time periods before dressing changes for comfort 

(see Table 2). Continuous pain may reflect the lack of 

treatment of the underlying cause, local wound irritation, or 

infection. Careful assessment of continuous pain must be 

made to determine if its origin is in the local wound or the 

surrounding anatomical region. 

Wound pain should be routinely assessed and documented 

using the patient’s self report. The 10-cm visual analog 

scale is the gold standard for quantitative pain assessment. 

Using this scale, patients grade their pain by placing a mark 

on the 10-cm line where 0 indicates no pain and 10 indicates 

the worst pain ever experienced. The presence of new 

or increasing pain in the chronic wound patient often signals 

complications such as infection, a Charcot arthopathy, 

or vascular compromise. 


Correct Treatable Causes of Tissue Damage 

It is important to always treat the underlying cause of a 

wound. In other articles in this series, the literature addresses 

the importance of correcting factors associated with venous

leg ulcers, pressure ulcers, and foot ulcers (diabetic and others). 

Regarding venous leg ulcers, Fletcher et al 15 reviewed six 

studies that compared compression versus local ulcer treatment 

alone without compression (eg, hydrocolloid, 16 

polyurethane foam, 17 and film dressing 18 ). A higher proportion 

of patients demonstrated healing in the six studies using 

compression compared to local treatments alone, and five of 

these studies revealed statistical significance. 

Nutrition. In addition to ulcer-specific causes, the 

patient as a whole must be examined. One factor the practitioner 

must consider is to determine that nutrition is adequate 

to produce sufficient protein to support the manufacture 

of granulation tissue. The patient’s weight is a good 

starting point. Being over- or underweight can impinge on 

wound healing. Patients should be as close to ideal body 

weight as possible. In addition to weight, protein intake also 

must be considered. A good intake screen for recent (the 

past few weeks) protein consumption is pre-albumin, and 

for more long-term protein consumption, serum albumin. 

An albumin of higher than 3.0 g/L is normal, but albumin 

levels between 2.0 g/L and 3.0 g/L may cause some delay in 

healing. Below 2.0 g/L, patients are malnourished and will 

have difficulty healing. 

Medications, including medical history. Another factor 

that cannot be overemphasized is the importance of the general 

medical history, including a medication record. A number 

of medications may interfere with wound healing, 

including systemic steroids, immunosuppressive drugs, and 

nonsteroidal anti-inflammatories. The presence of a major 

illness or systemic disease also is detrimental to healing. 

Rheumatoid arthritis and other autoimmune diseases such 

as systemic lupus, uncontrolled vasculitis, or pyoderma gangrenosum 

can all deter the wound healing process. In these 

disorders, the paradox of using systemic steroids or 

immunosuppressive agents to control the underlying process 

is absolutely essential before optimal local wound healing 

can occur. These patients have stimulated immune systems 

that react against their own skin, and this response must be 

curtailed so that an orderly process of healing can occur. 


Provide Education and Support for Patient- 

Centered Care to Increase Compliance/Adherence 

Wound care must be a partnership between healthcare 

professionals, patients, families, and caregivers. Patients must 

understand decisions that are being made about their care, 

and they must be part of the decisions as well. The more the 

patient understands the principles involved in treatment, the 

more likely he/she is to be compliant. Compliance should 

include compression bandaging for healing in patients with 

venous ulcers, followed by support stockings for life; the 

patient should comprehend why this is necessary. A neurotropic 

foot ulcer or pressure ulcer patient who requires 

pressure offloading with regular monitoring and understands 

why this enhances rather than interferes with quality 

of life will have a far better approach to his/her care. 

Another component of compliance includes selecting a 

treatment program that is reasonable and affordable and will 

facilitate an acceptable quality of life. The integration of the 

interdisciplinary team with the patient, family, significant 

others, and caregivers creates an optimal formula for success. 


Debride Healable Wounds, Removing Necrotic and 

Nonviable Tissue 

Debridement involves the removal of dead, devitalized, or 

contaminated tissue and foreign material from a wound. In 

chronic wounds, slough and eschar often accumulate and 

impair healing. Natural mechanisms exist to facilitate 

debridement; however, studies have shown that if this 

process is accelerated, more rapid wound healing occurs. 19 

Debridement reduces wound contamination as well as 

removes wound debris; thereby, potentially reducing tissue 

destruction. Any loculated dead spaces that might otherwise 

harbor bacteria and provoke frank infection need to be 

exposed during debridement. 

Several modes of debridement exist: surgical, autolytic, 

enzymatic, and mechanical (see Figure 2). Once a decision 

has been made to debride, several factors influence the 

choice of debridement method. The use of more than one 

debridement method may be appropriate as outlined below 

(see Table 3). 

Surgical debridement. Surgical debridement is the 

fastest and most effective way to remove debris and necrotic 

tissue. It is highly suitable in wounds with large areas of 

necrosis, high degrees of contamination, or frank infection. 

Therefore, the majority of surgical debridement tends to be 

performed in diabetic foot ulcers and pressure ulcers where 

these criteria are commonly fulfilled. All wounds should be 

appropriately cleansed before debridement. Sharp, sterile 

surgical debridement to a bleeding base has been demonstrated 

by Steed et al 19 to increase the healing rate of diabetic 

neurotropic foot ulcers (DNFUs). This procedure not only 

converts a chronic, nonhealing wound into an acute wound, 


Non-Healable Wounds 

Active debridement and 

moist interactive healing 

contraindicated 

Yes + neuropathic 

(especially in diabetic feet) 

• Level of expertise/setting 

• Institution/home 

Figure 2 

Debriding a wound - feedback loop for improved outcomes. 

but also decreases the surface bacterial burden. Before 

debridement, pain control may be achieved with topical, 

intralesional, oral, or intravenous agents. Topical EMLA 20,21 

(Astra-Zeneca, Wayne, Pa) can be applied in a thick coat 

(like icing a cake) and occluded with a transparent film 

dressing for 30 to 60 minutes prior to the procedure 

(EMLA is approved for this indication in Canada, but not 

in the United States). Intralesional xylocaine (with adrenaline 

to stop bleeding, except on distal extremities) can be 


Color of wound 

(Black or loose, 

yellow) or friable 

No 

No 

healability 

Patient/wound assessment 

• General medical status 

• Healability of wound, etc. 

Healable 

Wound 

Debridement 

Yes/No 

Type of debridement 

• Surgical 

• Autolytic 

• Enzymatic 

• Mechanical 

• Debridement not 

necessary 

• Moist interactive 

healing 

• Maintain bacterial 

balance 

Yes 

• Cost 

• Speed 

• Allergy 

• Availability 

• Pain 

Surgical preferred 

Reassess at regular 

intervals 

Not healing 

Continued healing 

Yes/No 

Healed 

Yes 

Yes 

No 

placed around the periphery of the lesion if EMLA is not 

available or if deeper anesthetic is required. However, 

surgery cannot be employed in all patients, nor can it be 

used in all settings (see Table 4). Blood clotting must be 

normal and in non-neuropathic wounds, anesthetic is often 

required. These factors almost dictate that significant surgical 

debridement, other than removal of devitalized tissue 

should be performed by a trained individual, often in a hospital 

or clinic setting, where facilities for achieving home-

Speed 

Tissue selectivity 

Painful wound 

Exudate 

Infection 

Cost 

TABLE 3 

KEY FACTORS IN DECIDING 

METHOD OF DEBRIDEMENT 

ostasis are available. Removal of devitalized tissue may only 

be performed by trained healthcare professionals in 

approved care settings. 

Autolytic debridement. Moist interactive dressings – 

especially hydrogels, hydrocolloids, transparent films, and 

alginates – can provide autolytic debridement. These dressings 

create an environment capable of liquifying slough and 

promoting granulation tissue at the same time. 22,23 If tissue 

autolysis is not apparent in 24 to 72 hours, another form of 

debridement should be used. The eschar surface can be 

scored with a scalpal blade, making superficial parallel 

grooves on the hard eschar surface in a grid pattern. The 

grooves are not intended to penetrate viable tissue, and 

bleeding should be minimal or absent. 

Enzymatic debridement. The most selective mode of 

debridement – enzymatic debridement – relies on 

naturally occurring enzymes applied exogenously to 

the wound surface to degrade debris. In Canada, the 

only licensed enzymatic product is collagenase, isolated 

from Clostridium histolyticum. Collagenase exists in 

wounds naturally as a matrix metalloproteinase, where 

it has been shown to degrade immature collagen in 

the wound matrix. Early debridement is promoted 

because collagenase acts as the rate-determining 

enzyme in collagen degradation, catalyzing cleavage of 

glycine in the native collagen triple helix. It is highly 

specific for collagen and is thought to promote 

debridement by digesting collagen bundles that bind 

nonviable tissue to the wound bed. Some small trials 

report faster debridement with collagenase compared 

to placebo. 24,25 Future trials are needed to confirm if 

this agent has a role promoting later stages to stimulate 

granulation tissue and re-epithelialization. 26 


Surgical Enzymatic Autolytic Mechanical 

1* 

2 

4 

1 

1 

4 

* 1 is usually most desirable, and 4 is usually least desirable. 

2 

1 

2 

4 

3 

2 

4 

3 

1 

3 

4 

1 

3 

4 

3 

2 

2 

3 

Collagenase is inactivated by heavy metals 

(silver, zinc) and detergents. In the Unites 

States, papain and papain-urea products 

are also available. 27 

Enzymatic debridement appears to be 

most useful in the removal of eschar from 

large wounds when surgical techniques 

cannot be utilized. Debridement can be 

facilitated by cross-hatching or scoring 

hard eschar prior to application of the 

enzyme. Problems arising from enzymatic 

debridement relate to the production of 

excessive amounts of exudate with these 

agents, local irritation to surrounding 

skin, and possible infection. 

Mechanical debridement. Mechanical debridement 

physically removes debris from the wound. It may be used 

in the management of surgical wounds along with pressure, 

ischemic, and venous leg ulcers. The simplest form of 

mechanical debridement is wet-to-dry gauze, but this technique 

is nursing time-intensive and costly. This often causes 

bleeding and pain with removal, leading to nonselective 

trauma to the wound. Other methods include irrigation, 

pulsatile lavage, and whirlpool therapy. 27,28 In the whirlpool 

or other foot-soaking procedures, the entire foot is 

immersed, causing the maceration and bacterial seeding 

(bacterial soup) of susceptible areas such as the toe webs, 

nail folds, and tiny cracks in the skin (fissures). (See 

Recommendation 9 of Best Practices for the Prevention and 

Treatment of Pressure Ulcers by Dolynchuk et al on page 46.) 

TABLE 4 

CONTRAINDICATIONS FOR SURGICAL 

DEBRIDEMENT OF VIABLE TISSUE 

Absolute Contraindications 

• Lack of expertise in procedure 

• Nonhealable ulcer (ie, insufficient vascular supply to 

allow healing) 

• Septicemia in the absence of systemic antibacterial 

coverage 

• Medically unfit patient 

Relative Contraindications 

• Patient on anticoagulants (dependent on INR [international 

normal ratio]/PTT [activated partial prothrombin 

time] etc.) 

• Home care setting


Assess the Wound for Bacterial Balance and 

Infection 

The presence of wound-associated bacteria alone does not 

indicate infection or impaired wound healing. Indeed, some 

authors have suggested that a small amount of a certain bacteria 

species in a chronic wound facilitates healing. 29,30 In 

clinical practice, assessing when a wound has moved from a 

symbiotic bacterial load that does not cause tissue damage to 

an increased bioburden causing impairment of wound healing 

can be difficult. The following equation demonstrates 

that although bacterial quantity and virulence are significant 

in assessing a wound for infection, host factors are of overriding 

importance. 

Risk of wound infection 31 = Bacterial dose x virulence 

Host resistance 

Factors such as immunosuppression, diabetes, and medication 

all can influence whether any bacteria present will 

impair wound healing. Furthermore, these factors can act to 

mask classical signs of infection such as erythema, increased 

temperature, pain, and edema. 

Swab technique is important to obtain meaningful 

results. 32 The wound should be cleansed with saline or water 

and all debris should be removed. The healthy appearing 

granulation is swabbed in a zigzag pattern, gently rotating 

the tip of the swab (swabs are only recommended if clinically 

indicated). If the wound is relatively dry, the swab may be 

moistened with the transport media prior to swabbing. A 

semiquantitative swab is then inoculated on standard media 

in the lab and streaked in four quadrants. Results will indicate 

no growth to 1 to 4+ growth of an organism, depending 

on the number of streaked quadrants that support bacterial 

growth. These swabs are quick and inexpensive. The 

semiquantitative swab correlates well to the gold standard 

quantitative biopsy results, 33 but there is some loss of specificity. 

Despite the fact this is the procedure of choice in 

most centers, inadequate wound bed preparation will result 

in an excess number of confusing, nonsignificant wound 

surface colonies appearing on the agar plates in the lab. The 

clinical assessment of wound bioburden and the choice and 

route of antibacterial agents should be based on host and 

wound factors in association with wound swab results. 

The concepts of bacterial contamination, colonization, 

critical colonization, and local and systemic infection lend 

themselves to guidance with regard to when to use antimicrobial 

agents in wound care (see Table 5). 

Most wounds are contaminated and contain nonreplicat- 


ing organisms. Colonization occurs when organisms are 

replicating but not causing host injury. Skin commensals 

such as Staphylococcus epidermidis and Corynebacterium 

species are the most common colonizers. Neither contaminated 

nor colonized wounds show signs of infection, and 

impairment of wound healing is unlikely. The concept of 

critical colonization (increased bacterial burden) has recently 

been introduced to describe wounds moving between the 

spectrums of colonization (where the host is unaffected) and 

local infection (in which host injury occurs). It has been 

suggested that during critical colonization, subtle clinical 

signs of infection such as increasing pain/tenderness, increasing 

serous exudate and friable granulation tissue, or failure 

to heal may be present prior to the classical signs of foul 

odor, frank pus, surrounding erythema, increased temperature, 

pain, and swelling associated with infection. 34 It is 

important to emphasize that many people with chronic 

wounds, in particular people with diabetes, have an 

impaired host response. These patients may therefore exhibit 

only subtle signs, or even have a complete absence of signs 

of infection (ie, no elevation in temperature) when bacteria 

are damaging the skin and delaying healing. 35 A semiquantitative 

swab with 4+ growth of a significant pathogen or a 

quantitative biopsy with ≥ 1.0 x 10 6 cfu/g (cfu = colony 

forming unit) of tissue in the presence of nonhealing may be 

an indication for systemic antibacterial therapy. Therefore, 

host monitoring is a vital part of assessment, with factors 

such as raised blood sugar levels in people with diabetes 

often being a helpful indicator of local or systemic infection. 


Cleanse Wounds with Normal Saline or Water. The 

Use of Topical Antiseptics Should be Reserved for 

Wounds that are Nonhealable or the Local Bacterial 

Burden is a Greater Concern than the Stimulation 

of Healing 

Cleansing and irrigation are used to eliminate exudate 

and surface debris from wounds. Not only does this process 

facilitate healing, but it also decreases bacterial burden by 

removing heavily contaminated surface slough and debris. 

Saline or sterile water are agents of choice for most 

wounds. Tap water should not be used for immunosuppressed 

patients and the water source should be reliably 

clean before advocating it as treatment in other chronic 

wounds. 36 

Rodeheaver 28 studied wound cleansers in vitro to assess 

cellular toxicity. He concluded that nonionic agents are best,

Bacterial burden 

Wound clinical symptoms 

and signs 

Bacterial C & S* 

Topical 

antibiotic/antibacterial 

Systemic 

antibiotic/antibacterial 

Enzymatic 

debridement 

Surgical debridement 

* Culture and sensitivity 

TABLE 5 

ASSESSMENT OF AND INTENTION TO TREAT INFECTION 

IN CHRONIC WOUNDS 

Contaminated 

Wound 

progressing 

Host stable 

but their toxicity index is still greater than saline. There are 

four main methods of cleansing. Healthcare practitioners 

who cleanse wounds can a) use a saline moist gauze to soak 

or compress a wound; b) gently pour a solution over a 

wound; c) irrigate the wound with a piston or bulb syringe 

– 5 to 8 pounds per square inch (psi) for cleansing with a 

bulb syringe or 5 to 15 psi to remove slough or eschar with 

an 18- to 20-gauge angiocath (venous access device) and 30cc 

syringe held 4 to 6 inches from the wound; and d) use an 

appropriate commercially prepared spray cleanser with predetermined 

average psi. When higher pressures are used, 

splash back commonly occurs and healthcare providers 

should take appropriate precautions. 

Antiseptic agents are used primarily to decrease bacterial 

growth on inanimate objects. When they are used in 

wounds, they have antibacterial properties, but they also 

inhibit healing (cytotoxic properties. See Table 6). 

If a wound does not have enough blood supply to heal, a 

patient is immunosuppressed, or in negative protein balance, 

the prime objective may be to reduce bacterial burden. 

Tissue toxicity is not the prime concern. Antiseptics would 

then be indicated with the precautions outlined in Table 6. 

Providone/iodine or chlorhexidine would be the agent of 

first choice for most nonhealing wounds (to dry the surface, 

decrease surface bacteria). 

No 

No 

No 

No 

+/- 

Colonized 

+/- early signs of 

local infection 

+/-C & S wound 

+/- 

No 

+/- 

+/- 

Critically colonized 

No/subtle signs and 

symptoms of 

infection 

C & S wound 

Yes 

+/- 

+/- 

+/- 

Local infection 

Local signs and 

symptoms of 

infection 

C & S wound 

Yes 

+/- 

No 

Yes 

Systemic infection 

Constitutional signs 

and symptoms of 

infection 

C & S wound 

Blood culture 

Yes 


If Methicillin Resistant Staphylococcus Aureus is 

Present, Assess the Patient for Colonization or 

Infection. Select Appropriate Topical and/or Systemic 

Agents for Treatment 

With the development of increasing bacterial resistance, 

it is important to restrict the use of antibiotics to 

situations where they are definitely indicated and furthermore, 

to use the narrowest spectrum of antibiotic 

possible. 

Methicillan-resistant Staphylococcus aureus (MRSA) is a 

very common cause of hospital-acquired infections. 

Unfortunately, these bacteria can commonly develop 

resistance to antibiotics. The most important of these is 

MRSA. Bacteria develop resistance to methicillin and to 

other families of antibiotics. Some strains of MRSA can 

spread from patient to patient very readily and have been 

labeled epidemic MRSA. 

Methicillan-resistant Staphylococcus aureus is commonly 

found in ulcers, and although its presence in wounds rarely 

causes death, cross infection into immunocompromised 

hosts can be fatal. It is therefore the responsibility of healthcare 

professionals to try to minimize the risk of the development 

of resistant microorganisms and their subsequent 

spread. 

Yes 

No 

Yes 


The pathogenicity of MRSA may not be significantly different 

from traditional S. aureus infections, but these infections 

may be difficult to control. The incidence of MRSA is 

on the increase in many countries. Unfortunately, healthcare 

providers, through direct contact with patients, may spread 

MRSA from nasal colonization (20% of people are persistent 

carriers, 60% intermittent carriers, and the remainder 

often never carry the organism). The treatment of MRSA 

may vary, depending upon whether it has colonized or 

infected the wound. For topical colonization, mupirocin has 

been the traditional agent of choice. However, with overuse 

of mupirocin, resistance in some centers has been documented. 

37 The use of mupirocin should be limited and 

reserved predominantly for the treatment of MRSA. As 

alternatives to mupirocin in healable wounds, cadexomer 

iodine and new ionized silver technologies have been very 

successful in eliminating colonization. These nonantibiotic 

alternatives are effective against MRSA and can be used to 

minimize the risk of provoking resistance. Ionized silver and 

cadexomer iodine depend on three separate antibacterial 

actions (cell membrane, cytoplasmic organelles, nucleic 

acid); therefore, resistance is highly unlikely to develop. 

Colonization also can be eliminated by the use of 

systemic antibiotics in combination. One protocol calls 


TABLE 6 

WOUND ANTISEPTIC AGENTS – ALL TOXIC TO HEALTHY 

GRANULATION TISSUE 

Hypochlorite solution 

Hydrogen peroxide 

Proflavine, mercuric chloride/crystal 

violet plus other analine dyes 

Cetrimide (quaternary ammonium) 

Chlorhexidine (plus cetrimide = 

Savalon TM [Astra-Zeneca,Wayne, 

Pa]) 

Acetic acid 0.5% – 5.0% 

Providone/iodine (Agent of choice in 

most nonhealing wounds) 

Irritating to skin due to high pH. Buffered preparations 

- Dakins/ Eusol – often select out Gram 

negatives 

De-sloughing agent when effervescent (few seconds). 

It can harm healthy granulation and may 

form air emboli if packed in deep, closed spaces 

Bacteriostatic agents against Gram positives only 

Gram-positive and negative organisms – detergent 

effect – but high tissue toxicity 

Gram-positive and negative action with residual 

effect on tissue 

Low pH effective vs pseudomonas but may select out 

S. aureus 

Broad spectrum of activity (Gram-positive, Gramnegative, 

anaerobes, yeast), but this is decreased 

in the presence of pus or wound exudate. Iodine 

toxicity reported if use prolonged or over large 

areas 

for the use of rifampin with either minocycline or clotrimoxazole. 

Infection may require intravenous treatment 

with vancomycin. Depending on individual sensitivities, 

other antibiotic combinations may work on 

some patients. Because MRSA is stored in the gut, 

recurrences are common, and it is important to monitor 

these patients at regular intervals. The nosocomial 

spread of MRSA has been well documented in one 

author’s unit, and the use of double barriers such as 

handwashing and soapless cleansers should be encouraged 

for staff moving between patients with wounds. 

Documentation of MRSA on tape-measuring guides 

and other instruments that move from patient to 

patient also illustrates the importance of decontaminating 

the environment as well as implementing a rigorous 

handwashing routine. 

Patients with MRSA should have cultures from three 

sites (nares, rectum, and the wound). These cultures 

should be repeated at regular intervals until they are 

negative on three occasions, then long-term monitoring 

is indicated. A modified protocol from the Peel 

Interdisciplinary Wound Healing Committee has been 

reproduced with the permission of Caremark (see 

Figure 3).

Serious infection consult 

Hospitalization 


Use Only Nonsensitizing Topical Antimicrobial 

Agents for Local Symptoms and Signs of Infection or 

Increased Bacterial Burden 

Once the decision to use topical antimicrobial agents has 

been made, the healthcare provider is faced with choosing 

an antimicrobial agent. The aim is to reduce bioburden, and 

the principle factor influencing choice is the offending 

organism (see Table 7). This information is usually gained 

from bacteriology results; however, clinical judgment can 

often detect the presence of some organisms such as 

Pseudomonas. These can be recognized by their distinctive 

odor and a greenish tinge. Anaerobes can be assumed to be 

present in a wound with an accompanying putrid odor or a 

wound duration of longer than 1 month. 38 

MRSA Isolated Through Culture 

Infected Colonized 

Infectious diseases consult 

Treatment based on sensitivity 

results: may include IV vancomycin 

Less serious infection 

• Mupirocin anterior nares if positive. 

Topical treatment or systemic treatment 

to other sites 

• 2% chlorhexidine soap for all 

washing/bathing for duration of 

treatment 

Culture anterior nares, perianal 

and open wounds within 48 

hours of completed treatment 

Repeat cultures weekly x 3 

before labeling “cleared” 

Treatment options based on sensitivity 

results: 

• Oral fusidic acid and rifampin 

• Rifampin and one of minocycline 

or clotrimoxazole 

Positive culture 

Positive: 

• (Consider) infectious 

disease consult 

• Treatment options as 

per sensitivity results 

Consider decolonization therapy 

(individual decision) 

• Mupirocin (Bactroban) ointment 

to anterior nares/wounds and 

oral/topical agents for other sites if 

appropriate (see Table 7) 

• 2% chlorhexidine soap for all 

washing/bathing x 7–10 days 

Repeat culture of anterior nares, 

perianal and open wounds 48 

hours after treatment completed 

Treatment options based on 

sensitivity results: 

• Oral fusidic acid and rifampin 

• Rifampin and one of 

minocycline or clotrimoxazole 

Negative: 

Repeat cultures 

weekly x 3 before 

labeling “cleared” 

Negative culture 

Repeat cultures 

weekly x 3 before 

labeling “cleared” 

Figure 3. 

Wound management for patients infected or colonized with MRSA.Copyright 1998, Caremark Ltd. Adapted with permission. 

Hospital: repeat cultures 

once a month. 

Nursing homes and 

community: repeat every 

3 to 6 months 

One other factor to consider when applying topical 

agents to an ulcer is the propensity to induce sensitization 

that can elicit an allergic contact dermatitis. Neomycin, 

lanolin, and perfumes, which can be present in topical 

antimicrobial vehicles, are common sensitizers and should 

be avoided. 39 Similarly, ointments rather than creams should 

be used to reduce exposure to preservatives that can also act 

as sensitizers. 

Two products listed in Table 7 combine antibacterial 

properties with moist interactive healing. Cadexomer iodine 

(Iodosorb ® , Iodoflex ® ; Healthpoint, Fort Worth, Tex./Smith 

and Nephew, Hall, U.K.) is composed of microspheres of 

starch crosslinked with ether bridges and iodine. This product 

absorbs moisture up to seven times its weight in water 

and slowly releases iodine for antibacterial action that is not 


Safe and Effective 

Selected Use 

Caution 

Cadexomer iodine 

Ionized silver 

Silver sulphadiazine 

Polymyxin B sulphate 

– Bacitracin 

zinc 

Mupirocin 

Metronidazole 

Benzoyl peroxide 

Gentamicin 

Fucidin 

Polymyxin B sulphate 

– Bacitracin 

zinc neomycin 

+ = effective against bacteria 

strong enough for cytoxicity. It should be used with caution 

in patients with thyroid disease and iodine allergy. If cadexomer 

iodine is used on large areas or for long periods, monitoring 

of thyroid function is advised. 

Ionized silver dressing (Acticoat ; Westaim Biomedical, 

Exeter, NH, Fort Saskatchewan, Alberta, Canada) has a slow 

release of silver, combined with an absorptive polyester pad. 

The silver has a broad spectrum of antibacterial coverage 

and can be used very successfully to decrease friable exudative 

tissue on the wound surface. Acticoat must be used 

with sterile water because the chloride in saline precipitates 

the silver to inactive silver chloride. Acticoat contains no 

sulfa, which may be present in other silver preparations. 

Topical antibacterials will only treat the wound surface 

and not deeper infection. Their use should be re-evaluated 

after 2 weeks or if symptoms or signs of deeper infection 

occur. 40 


Use Systemic Antibiotics if Symptoms or Signs of 


TABLE 7 

CHOOSING APPROPRIATE ANTIMICROBIALS 

Staphylococcus 

aureus 

+ 

+ 

+ 

+ 

Weak 

+ 

+ 

+ 

MRSA Streptococcus Pseudomonas Anaerobes 

+ 

+ 

+ 

+ 

+ 

Weak 

+ 

+ 

+ 

+ 

+ 

Weak 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

Weak 

+ 

Comments 

Good autolytic debridement; 

limited potential for bacterial 

resistance. Caution with 

thyroid disease 

Use with water, not saline. 

Limited potential for bacterial 

resistance 

Not for use in sulfa–sensitive 

patients 

Reserve for MRSA and other 

resistant Gram-positive 

organisms 

Reserve for anaerobes and 

odor control 

For use on large wounds. Can 

cause irritation/allergies 

Reserve for oral/IV use 

Ointment contains lanolin, 

which can sensitize to cause 

allergic contact dermatitis 

Contains neomycin, which 

causes an allergic contact 

dermatitis, may cross sensitize 

to aminoglycosides 

Infection Extend Beyond Wound Margin or the 

Ulcer Probes to Bone 

Systemic antibiotics should be used if infection extends 

beyond the ulcer margin. Ulcers of less than 1-month duration 

require primary Gram-positive coverage primarily for at 

least 2 weeks or until clinical symptoms and signs resolve. If 

immunosuppression is an issue, broad spectrum agents, 

including Gram-negatives and anaerobes, should be included. 

A semiquantitative swab is often helpful when patients 

fail to respond to the initial therapy. In complex cases, an 

infectious disease consult is advised. 

If an ulcer probes to bone, osteomyelitis must be suspected. 

Antibiotics for longer periods are necessary, usually for at 

least 4 to 6 weeks. Treatment progress can be monitored 

with x-rays, erythrocyte sedimentation rate, C reactive protein, 

and, rarely, nuclear scans. Nonhealing ulcers may 

require surgical debridement. For a more detailed discussion 

on this topic, see Recommendation 8 of Best Practices for the 

Prevention, Diagnosis, and Treatment of Diabetic Foot Ulcers 

by Inlow et al on page 63.


Select Appropriate Dressing for Local Moisture 

Balance to Stimulate Granulation Tissue and 

Re-epithelialization 

Compared to dry wounds, a moist wound environment 

accelerates wound healing by as much as 50%, often with 

more rapid epithelialization. 41 Using clinical judgment to 

select a type of moist wound dressing suitable for an ulcer is 

important. Seven dressing recommendations have been put 

forward since the Agency for Health Care Policy and 

Research guidelines came out in 1994. 42 They were published 

in Ostomy/Wound Management by Liza Ovington in 

1999, 43 and are discussed below: 

1. Use a dressing that will keep the wound bed continuously 

moist. Wet-to-dry saline dressings are not considered continuously 

moist and should be used only for debridement. 

Kim 44 reported that occlusive hydrocolloid dressings for the 

treatment of Stage I and II pressure ulcers were less timeconsuming 

and less expensive, compared to saline-soaked 

gauze dressings. Colwell’s trial showed that a hydrocolloid 

dressing increased healing rate and was less costly than moist 

gauze dressings. 45 If saline-soaked gauze is used, it must be 

moist with frequent dressing changes or harm may result. 

2. Use clinical judgment to select a type of moist wound 

dressing suitable for an ulcer. Studies of different types of 

moist wound dressings showed no differences in pressure 

ulcer healing outcomes. Mulder 46 looked at three types of 

dressings, all providing moist wound healing, and found no 

statistical differences with wound healing. 

3. Choose a dressing that keeps the surrounding peri-ulcer 

skin dry while keeping the ulcer bed moist. 

4. Choose a dressing that controls exudate but does not 

desiccate the ulcer bed. If the exudate is not controlled, it 

will come in contact with the surrounding peri-ulcer skin 

and cause maceration, which could lead to breakdown and 

further deterioration of the wound. There must be a balance 

in choosing a dressing to avoid drying of the wound surface. 

Continuous assessment of the wound and changes in the 

dressing material used is needed to achieve optimal moisture 

balance. Maceration may be controlled by certain dressing 

materials that provide a vertical wicking and trap the wound 

fluid in the matrix of the dressing (ie, calcium alginate 

ropes, hydrofibers). 

5. Consider caregiver time when selecting a dressing. A 

dressing that is easier to apply and does not require frequent 

changes decreases the healthcare provider’s workload and the 

financial burden to the patient, family, and society. 6. 

30 OstomyWound Management

Absorbent 

Membrane 

Dressing Category 

1. Foam 

2. Hydrofiber 

3. Crystalline 

NaCl gauze 

4. Calcium alginate 

5. Hydrocolloid 

6. Hydrogel 

7.Adhesive film 

8. Nonadhesive film 

9. Enzymes 

+ = usually appropriate 

++= appropriate 

+++= highly appropriate 

Eliminate wound dead space by loosely filling all cavities 

with dressing material. Avoid overpacking the wound. 

Stotts 47 reports that increased bacterial invasion and 

impaired healing results from unfilled dead space. Tightly 

packing the wound causes pressure on the newly formed 

granulation tissue and may cause damage that will prevent 

or delay healing. Overpacking may decrease absorbent 

capacity of the dressing material by not allowing the dressing 

to absorb the wound fluid. 

7. Because they are difficult to keep intact, monitor dressings 

applied near the anus. Day et al 48 found that choosing a 

dressing specifically designed for the sacral area improves 

wear time and healing rate on full-thickness pressure ulcers. 

Specifically, a triangular-shaped dressing will fit better with 

the tip toward the anus. Shearing and friction forces are 

tremendously high in the sacral area, causing rolling and 

bunching of the dressing. 

To date, no one dressing will complete all the outlined 

requirements. The three absorbent dressing groups are foams, 

hydrofibers, and crystalline NaCl gauze (see Table 8). 

Foams 49,50 provide thermal insulation, high absorbency, a 

moist environment, and are gas permeable. They are also 

nonadherent, easy to cut and shape, and do not shed fibers. 

Some foams have additional wound contact layers to avoid 

adherence when the wound is overly dry and a polyurethane 

TABLE 8 

CHOOSING APPROPRIATE DRESSINGS 

Appearance of Wound Bed Appearance of Granulation Tissue 

Black 

(Necrotic) 

+ 

++ 

+++ 

Yellow 

(Dry) 

++ 

+++ 

+++ 

Sloughy 

(Moist) 

++ 

+++ 

+++ 

++ 

+ 

++ 

++ 

Red 

(Infected) 

++ 

++ 

+++ 

+++ 

+ 

Red 

(Wet) 

+++ 

+++ 

++ 

+++ 

++ 

Red 

(Bleeding) 

+ 

+++ 

+ 

Pink/Purple 

(healthy granulation/ 

re-epithelialization) 

++ 

+++ 

+++ 

+++ 

backing to prevent excessive fluid loss. Crystalline sodium 

chloride gauze (pledgit or packing) is used for highly exudative 

wounds, mechanical debridement, and for its antibacterial 

properties. Hydrofibers have high absorbency, good tensile 

strength, and contain the fluid within the fiber. They do not 

provide a fluid equilibrium with the wound surface as would 

occur with foam dressing. Foams and hydrofibers have long 

wear times (up to 1 week) but crystalline sodium chloride 

gauze should be changed daily. 

Calcium alginates 51 are derived from brown seaweed 

(kelp). Some alginates have a high content of mannuronic 

acid (high gelling property for autolytic debridement) and 

others have a high galuronic acid content (high fiber integrity 

for packing sinuses). 52 Calcium alginates are marketed in 

ropes (vertical wicking best for hemostasis) and wafers (lateral 

wicking to remove surface exudate). The calcium alginates 

are excellent for hemostasis postdebridement. The calcium 

alginate donates calcium for ion exchange to the wound 

fluid to promote hemostasis and accepting sodium ion, 

causing the alginate to form a hydrogel for moist interactive 

healing. 53,54 No crust is formed, and the wound can progress 

from the inflammatory to the proliferative stage. If the fiber 

is intact with dressing change, then the exudate is not sufficient. 

Another dressing class should be chosen for subsequent 

dressings. Alginates are excellent for infected wounds, 

++ 


ut systemic antibiotics are needed if deeper tissue symptoms 

and signs are present (see Recommendations 6 and 9). 

Hydrogels 53-56 provide a high concentration of water in 

insoluble polymers. They may be synthetic or semisynthetic 

with bases of propylene glycol, saline, or hydrocolloids. 

They are inert to normal biological processes and permeable 

to metabolites with some absorptive and water-donating 

properties. They are best in dry, sloughy wounds with low 

exudate levels. They require changing every 24 to 72 hours 

and have very little anti-infective properties. They are available 

in amorphous or sheet forms. 

Hydrocolloids 57 are occlusive dressings containing carboxymethylcellulose, 

other polysaccharides, and proteins. 

They have both dry (elastomers) and wet tack (adhesives), 

changing physical form by slowly reacting with wound fluid 

to form a linked matrix gel. Fibrinolytic activity is due to 

pectin and antibacterial properties, owing partly to a low 

pH. Occlusion is accomplished by a foam or film sheet 

backing. Hydrocolloids provide an anaerobic environment 

that can sometimes promote hypertropic granulation. They 

are best for autolytic debridement and mild to moderately 

exudating wounds. 58 They are relatively contraindicated with 

arterial insufficiency, vasculitis, and infection. They have a 

long wear time (2 to 7 days), but must be changed if the 

wound fluid leaks through the edges. The hydrocolloid 

residue may be mistaken for infection and should be 

cleansed prior to wound bed assessment. 

Film dressings are best for the late stages of wound healing. 

Many are permeable to water vapor and oxygen, but 

impermeable to water and micro-organisms unless leakage 

channels develop from the periphery. They vary in their 

moisture-vapor permeability properties with Opsite ® (Smith 

& Nephew, Largo, Fla) (MVTR – 862 gm/m 2 /24 hrs) and 

Tegaderm (3M Pharmaceuticals, London, Ontario, Canada, 

and Minneapolis, Minn.) (MVTR – 846 gm/m 2 /24 hrs) 59 

compared to IV 3000 (MVTR 3000, Smith and Nephew, 

Largo, Fla) designed to keep areas around cannulas dry, but 

this dressing would be too dehydrating for most chronic 

wounds. Film dressings come in adhesive and nonadhesive 

forms. They function best for superficial, nonexudative 

wounds. 60 They can be left in place for long periods or until 

they fall off if the seal is intact. Removal by stretching the 

edges will minimize superficial tears. 

Friable or bleeding wounds may benefit from the tack 

provided by fenestrated silicone surfaces (ie, Mepitel, 

Mepilex; Molnlycke, Oakville, Ontario, Canada) that can be 

left intact while secondary dressings are changed. 



Evaluate the Expected Rate of Wound Healing to 

Determine if Treatment is Optimal 

An orderly sequence of healing should occur if the underlying 

cause has been treated, optimized local wound care 

implemented, and patient-centered concerns addressed. It is 

essential to have systematic wound documentation. Deep 

ulcers with significant depth (those progressing from Stage 

IV to Stage II) can be measured with alginate molds that are 

weighed and the weight related to volume or precise determinations. 

In most clinical settings, depth can be measured 

with a wooden stick in the deepest portion of an ulcer or an 

average of the deepest and most superficial portion used for 

documentation. Length and width are very accurate for 

superficial wounds with the widest width being measured at 

right angles to the longest length. 61 For precise determinations, 

tracings of superficial ulcers can be analyzed with 

computer planimetry. All sinuses and areas of undermining 

also should be documented. All ulcers will heal after the 

removal of nonviable tissue through maturation of granulation 

base and filling the defect to re-epithelialization. 

During the early debridement stage, a wound may actually 

increase in size before it contracts. Two studies have used 

a modified Gillman formula to demonstrate that healing 

rates of venous ulcers at 4 weeks can be used to accurately 

predict ulcers that will heal by week 12. 62,63 A wound that is 

not 30% smaller between weeks 0 and 4 is unlikely to heal 

by week 12. If an ulcer is not progressing in a measurable 

way, the treatment of the cause, local wound care, and 

patient-related issues must be reassessed. If all these factors 

are optimal, biological agents or adjunctive therapies may be 

indicated. 


Use Biological Agents When Other Factors Have 

Been Corrected and Healing Does not Progress at the 

Expected Rate 

Biological agents are expensive, but they stimulate wound 

healing. To date, growth factors have been relatively disappointing 

because they can be likened to a symphony orchestra, 

using only one player, such as the flute, without the rest 

of the orchestra. The single player does not allow for an 

orderly progression of healing. Despite these limitations, 

however, platelet-derived growth factor in a hydrogel 

(Regranex ® ; Ortho-McNeil Pharmaceutical, Inc., Raritan, 

NJ) has been marketed for use in the treatment of diabetic 

neurotropic foot ulcers. Platelet-derived growth factor is very

important as a catalyst very early on in wound healing to 

promote cellular migration and collagen synthesis. It is 

applied daily, and the study showed that with best clinical 

practices and Regranex ® , healing rate was increased by 15% 

in a 20-week trial from 35% in the control group to 50% 

having complete wound closure in diabetic neurotropic foot 

ulcers. 

Recent advances in tissue culture techniques (Reinwald 

and Green) 64 have made it possible to culture cells from 

human foreskin donors. Donated newborn foreskins are 

used to extract epidermal precursor cells and fibroblasts to 

master skin banks. Both cells and the mothers are extensively 

and repeatedly screened for possible infectious agents. 

From one piece of donated tissue, these cells are transferred 

to working cell banks and can produce enough skin substitute 

to cover four to six football fields. Dermagraft 

(Advanced Tissue Sciences/Smith & Nephew Inc., La Jolla, 

Calif. and Largo, Fla.) is a human fibroblast-derived dermis 

consisting of bio-absorbable polygalactin mesh on which 

fibroblasts are seeded. The cells proliferate on the mesh in 

specialized bioreactors to form tissue that is cryopreserved 

and frozen for long-term storage. 

Dermagraft‚ in the therapeutic range, increased the 12week 

healing of DNFU from 32% to 54% over best clinical 

practices. This difference in healing rate was maintained 

over the 32-week trial period demonstrating the potential 

long-term benefits of advanced therapies. Apligraf ® 

(Organogenesis, Canton, Mass. and Novartis, East Hanover, 

NJ) consists of dermal fibroblasts and Type I bovine collagen 

matrix with an epidermis and differentiating stratum 

corneum. In a controlled trial, 63% of venous ulcers healed, 

compared with 48% of active control patients by week 24. 

A subanalysis of ulcers present for more than 1 year demonstrated 

complete healing of 47% of patients treated with 

Apligraf ®/ and compression compared to 19% treated with 

compression therapy alone. 

Recently hyaluronic acid in a bipolymer has been made 

available for difficult to treat wounds. Hyaluronic acid is a 

major carbohydrate component of the extracellular matrix, 

inducing a prompt angiogenic response, promoting rapid 

formation of granulation tissue, assisting fibroblast growth 

and migration, and directing the organization of collagen 

disposition. 65 This agent has shown promise in case series, 

but no controlled trials have been published to date. 

Conclusion 

The wound care professional has an ever-expanding tool- 

box for ideal wound care. Debridement, bacterial balance, 

and moist interactive healing all must be optimized as integral 

parts of preparing the wound bed. If the underlying 

cause, patient-related factors, and the wound bed have all 

been appropriately treated, the new and expanding drawer 

of biologicals offers increased hope for some of our most difficult 

chronic wounds. - OWM 

Acknowledgment 

Some concepts presented in this paper were first developed 

through a series of articles by Diane Krasner and R. 

Gary Sibbald on wound care in Nursing Clinics of North 

America 27 ; Hyperbaric Medicine Practice, 2nd Edition 66 ; and 

The Diabetic Foot, 6th Edition. 67 The local wound care paradigm 

(debridement, bacterial balance, and moisture balance) 

was presented by R. Gary Sibbald as part of a planning session 

at The Symposium on Advanced Wound Care and 

Medical Research Forum on Wound Repair in Dallas, Texas, 

April 1–4, 2000. Concepts used in the charts have been 

modified from an educational retreat sponsored by an unrestricted 

educational grant from Smith & Nephew Canada 

and a 1998 Peel regional initiative and wound care guide, 

compiled by Caremark Ltd. 

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