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The Rational Clinical Examination
February 8, 2012

Does This Patient Have an Infection of a Chronic Wound?

Author Affiliations

Author Affiliations: Hebrew Rehabilitation Center, Boston, Massachusetts (Dr Reddy); Department of Medicine, Division of Geriatric Medicine, Queen's University, Kingston, Canada (Dr Gill); Women's College Research Institute, Women's College Hospital, Toronto, Canada (Drs Kalkar and Rochon and Mr Wu); and Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada (Dr Rochon).

JAMA. 2012;307(6):605-611. doi:10.1001/jama.2012.98
Abstract

Context Chronic wounds (those that have not undergone orderly healing) are commonly encountered, but determining whether wounds are infected is often difficult. The current reference standard for the diagnosis of infection of a chronic wound is a deep tissue biopsy culture, which is an invasive procedure.

Objectives To determine the accuracy of clinical symptoms and signs to diagnose infection in chronic wounds and to determine whether there is a preferred noninvasive method for culturing chronic wounds.

Data Sources We searched multiple databases from inception through November 18, 2011, to identify studies focusing on diagnosis of infection in a chronic wound.

Study Selection Original studies were selected if they had extractable data describing historical features, symptoms, signs, or laboratory markers or were radiologic studies compared with a reference standard for diagnosing infection in patients with chronic wounds. Of 341 studies initially retrieved, 15 form the basis of this review. These studies include 985 participants with a total of 1056 chronic wounds. The summary prevalence of wound infection was 53%.

Data Extraction Three authors independently assigned each study a quality grade, using previously published criteria. One author abstracted operating characteristic data.

Data Synthesis An increase in the level of pain (likelihood ratio range, 11-20) made infection more likely, but its absence (negative likelihood ratio range, 0.64-0.88) did not rule out infection. Other items in the history and physical examination, in isolation or in combination, appeared to have limited utility when infection was diagnosed in chronic wounds. Routine laboratory studies had uncertain value in predicting infection of a chronic wound.

Conclusions The presence of increasing pain may make infection of a chronic wound more likely. Further evidence is required to determine which, if any, type of quantitative swab culture is most diagnostic.

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