Reliance on Clinical Signs and Symptoms Assessment Leads to Misuse of Antimicrobials: Post-hoc Analysis of 350 Chronic Wounds

Thomas Serena , Lisa Gould , Karen Ousey, Robert Kirsner

Research output: Contribution to journalArticlepeer-review


Objectives: Bacteria frequently impede wound healing and cause infection. Clinicians rely on clinical signs and symptoms (CSS) to assess detrimental effects of bacteria at point-of-care and inform the prescription of antibiotics and other antimicrobials. Yet, robust evidence suggests poor sensitivity of CSS for detection of problematic bacterial burden and infection. This study evaluated CSS based antimicrobial prescribing practices across 14 wound care centres.Approach: Data was analyzed from the fluorescence assessment and guidance (FLAAG) trial, a study of 350 chronic wounds across 20 clinicians. Clinicians reviewed the patient’s history and assessed for CSS using the International Wound Infection Institute (IWII) checklist. Wounds with >3 criteria or any overwhelming symptom were considered CSS+. Bacterial levels were confirmed with quantitative tissue culture of wound biopsies.Results: Antimicrobials were prescribed at a similar rate for wounds identified as CSS+ (75.0%) and CSS- (72.8%, p=0.76). Antimicrobial dressings, the most frequently prescribed antimicrobial, were prescribed at a similar rate for CSS+ (83.3%) and CSS- (89.5%, p=0.27) wounds. In one third of patients prescribed systemic antibiotics, no CSS were present. Prescribing patterns did not correlate with bacterial load; all CSS+ wounds with <104 CFU/g received antimicrobials, in contrast to only 66.7% of CSS+ wounds with >108Innovation: This study is the first to evaluate antimicrobial prescribing trends in a large, multi-site cohort of chronic wound patients.Conclusion: Reliance on CSS to diagnose clinically significant bacterial burden in chronic wounds leads to the haphazard use of antimicrobials and is not sufficient to establish a meaningful stewardship program.
Original languageEnglish
JournalAdvances in Wound Care
Early online date29 Oct 2021
Publication statusE-pub ahead of print - 29 Oct 2021


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