Journal of Infectious Diseases & Therapy
Open Access

Diabetic foot, venous leg and pressure ulcers as well as other nonhealing wounds afflict millions of patients and burden healthcare systems worldwide. The presence of bacteria in open wounds, often in a biofilm phenotype, impede the healing process and lead to costly complications [1-5]. Our study “Reliance on clinical signs and symptoms assessment leads to misuse of antimicrobials: Post hoc analysis of 350 chronic wounds”, published in 2022 in Advances in Wound Care [6], underscores the challenges clinicians specializing in wound care management face in diagnosing and treating bacterial infections. Reliance on subjective clinical signs and symptoms leads to misuse of antibiotics. The data point to the urgent need for objective, real time diagnostics to enhance antimicrobial stewardship efforts amidst escalating concerns of antibiotic resistance.

Antibiotic misuse and resistance

Antibiotic resistance is an escalating global threat, fueled by misuse and over-prescription of antibiotics in many healthcare settings. In wound clinics, antibiotics are indiscriminately prescribed based on habit or subjective assessments of clinical signs and symptoms rather than evidence-based diagnostic measures [7,8]. This approach not only fails to address the underlying cause of infection, but also contributes to the emergence and spread of antibiotic-resistant bacterial strains [9-13].

Our work revealed a concerning trend: Antimicrobials were prescribed at similar rates for wounds identified as positive (83%) or negative (90%) for clinical signs of infection [6]. This discrepancy between clinical assessment and antibiotic prescribing practices highlights its inadequacy as a standalone diagnostic method. We also discovered that many patients (33%) were prescribed systemic antibiotics despite an absence of clinical signs of infection. Together, these results give a snapshot into the ubiquitous antimicrobial prescribing occurring at American Wound Care Centers, underscoring the urgent need for a paradigm shift towards objective, evidence-based diagnostic measures.

The urgent need for objective diagnostic measures

Objective, evidence-based approaches offer a promising avenue for enhancing the accuracy and precision of bacterial diagnosis in nonhealing wounds. Gold-standard techniques such as quantitative tissue culture of wound biopsies provide concrete evidence of bacterial presence and load, enabling targeted antimicrobial therapy tailored to individual patient needs. This approach optimizes treatment outcomes and mitigates the risk of antibiotic resistance. However, widespread adoption of objective diagnostic measures in clinical practice necessitates investment in research, education, and infrastructure to ensure accessibility and affordability. Furthermore, the results from sample-based techniques are often delayed, leading to the prescription of empirical antimicrobials and antibiotics. There is also a significant risk of sampling error in obtaining a culture [14].

Antibiotic stewardship programs

Antibiotic Stewardship Programs (ASPs) play an essential role in de-escalating antibiotic resistance by promoting responsible antibiotic use and optimizing patient outcomes. However, the effectiveness of these programs hinges on accurate and timely diagnostics to guide antimicrobial therapy. Medical technology holds immense promise in enhancing the impact of ASPs. Our own experience incorporating fluorescence imaging of bacterial loads ( MolecuLight ® ) into our diagnostic algorithm has yielded positive results. By providing clinicians with rapid and precise diagnostic information at the bedside [1,15,16], fluorescence imaging empowers Healthcare Professionals (HCPs) to locate harmful bacteria, audit their debridement efforts, and better assess the need for antibiotics to reduce unnecessary exposure [17]. The automatic differentiation of Pseudomonas aeruginosa also helps tailor antibiotic therapy to individual patient needs [18,19]. Regular use of bacterial fluorescence imaging in our practice facilitates real-time monitoring of treatment efficacy, allowing for timely adjustments to therapy. Thus, integrating such diagnostic technologies into ASPs not only enhances patient care but preserves antibiotic efficacy to help sustain global public health efforts.

Antimicrobial stewardship efforts should not be solely reliant on clinical assessment of bacterial infection in chronic wounds. This questionable practice perpetuates the cycle of antibiotic misuse and resistance. I cannot overemphasize the importance of adopting objective, evidence-based diagnostic technologies, which empower clinicians to optimize patient care, preserve antibiotic efficacy and safeguard public health in the face of this pressing global health crisis of antibiotic resistance.

1. Le L, Briggs P, Bullock N, Cole W, di Marco D, et al. (2021) Diagnostic accuracy of point-of-care fluorescence imaging for the detection of bacterial burden in wounds: Results from the 350-patient FLAAG trial. Adv Wound Care 10:123-136.

   [Crossref] [Google Scholar] [PubMed]

2. Goswami AG, Basu S, Banerjee T, Shukla VK (2023) Biofilm and wound healing: From bench to bedside. Eur J Med Res 28:157.

   [Crossref] [Google Scholar] [PubMed]

3. Metcalf DG, Bowler PG (2013) Biofilm delays wound healing: A review of the evidence. Burns Trauma 1:5-12.

   [Crossref] [Google Scholar] [PubMed]

4. Moore MF (2017) Biofilms, their role and treatment options in the chronic non-healing wound. Surg Technol Int 31:sti31/916.

   [Google Scholar] [PubMed]

5. Schultz G, Bjarnsholt T, James GA, Leaper DJ, McBain AJ, et al. (2017) Consensus guidelines for the identification and treatment of biofilms in chronic non-healing wounds. Wound Repair Regen 25:744-757.

   [Crossref] [Google Scholar] [PubMed]

6. Serena TE, Gould L, Ousey K, Kirsner RS (2022) Reliance on clinical signs and symptoms assessment leads to misuse of antimicrobials: Post hoc analysis of 350 chronic wounds. Adv Wound Care 11:639-649.

   [Crossref] [Google Scholar] [PubMed]

7. Lipsky BA, Dryden M, Gottrup F, Nathwani D, Seaton RA, et al. (2016) Antimicrobial Stewardship In Wound Care: A Position Paper From The British Society for Antimicrobial Chemotherapy and European Wound Management Association. J Antimicrob Chemother 71:3026-3035.

   [Crossref] [Google Scholar] [PubMed]

8. Caputo WJ, Monterosa P, Beggs D (2022) Antibiotic misuse in wound care: Can bacterial localization through fluorescence imaging help? Diagnostics 12:3207.

   [Crossref] [Google Scholar] [PubMed]

9. van Buul LW, van der Steen JT, Veenhuizen RB, Achterberg WP, Schellevis FG, et al. (2012) Antibiotic use and resistance in long term care facilities. J Am Med Dir Assoc 13:568.e1-e13.

   [Crossref] [Google Scholar] [PubMed]

10. Huemer M, Shambat SM, Brugger SD, Zinkernagel AS (2020) Antibiotic resistance and persistence-implications for human health and treatment perspectives. EMBO Rep 21: e51034.

    [Crossref] [Google Scholar] [PubMed]

11. Balcazar JL, Subirats J, Borrego CM (2015) The role of biofilms as environmental reservoirs of antibiotic resistance. Front Microbiol 6:1216.

    [Crossref] [Google Scholar] [PubMed]

12. Howell-Jones RS, Wilson MJ, Hill KE, Howard AJ, Price PE, et al. (2005) A review of the microbiology, antibiotic usage and resistance in chronic skin wounds. J Antimicrob Chemother 55:143-149.

    [Crossref] [Google Scholar] [PubMed]

13. Appaneal HJ, Caffrey AR, Jiang L, Dosa D, Mermel LA, et al. (2018) Antibiotic resistance rates for Pseudomonas aeruginosa clinical respiratory and bloodstream isolates among the Veterans Affairs Healthcare System from 2009 to 2013. Diagn Microbiol Infect Dis 90:311-315.

    [Crossref] [Google Scholar] [PubMed]

14. Serena TE, Snyder RJ, Bowler PG (2023) Use of fluorescence imaging to optimize location of tissue sampling in hard-to-heal wounds. Front Cell Infect Microbiol 12:1070311.

    [Crossref] [Google Scholar] [PubMed]

15. Raizman R, Little W, Smith AC (2021) Rapid diagnosis of Pseudomonas aeruginosa in wounds with point-of-care fluorescence imaing. Diagnostics 11:280.

    [Crossref] [Google Scholar] [PubMed]

16. Rennie MY, Lindvere-Teene L, Tapang K, Linden R (2017) Point-of-care fluorescence imaging predicts the presence of pathogenic bacteria in wounds: A clinical study. J Wound Care 26:452-460.

    [Crossref] [Google Scholar] [PubMed]

17. Price N (2020) Routine fluorescence imaging to detect wound bacteria reduces antibiotic use and antimicrobial dressing expenditure while improving healing rates: Retrospective analysis of 229 foot ulcers. Diagnostics 10:927.

    [Crossref] [Google Scholar] [PubMed]

18. Jacob A, Jones LM, Abdo RJ, Cruz-Schiavone SF, Skerker R, et al. (2023) Lights, fluorescence, action-Influencing wound treatment plans including debridement of bacteria and biofilms. Int Wound J 28:3279-3288

    [Crossref] [Google Scholar] [PubMed]

19. Andersen CA, McLeod K, Steffan R (2022) Diagnosis and treatment of the invasive extension of bacteria (cellulitis) from chronic wounds utilising point-of-care fluorescence imaging. Int Wound J 19:996-1008.

    [Crossref] [Google Scholar] [PubMed]