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Sep 13, 2022

The Risk of Infection and Indication of Systemic Antibiotics in Chronic Wounds

Chronic wounds are associated with a significant increase in health care utilization and health care costs,3 increased morbidity and mortality. Can the Wounds at Risk (WAR) score help to assess the risk of infection in patients by scoring several host factors that can contribute to an increased risk for infection in wounds?

Up to 2% of the US population has a chronic wound, including diabetic foot ulcers (DFUs), venous leg ulcers (VLUs), arterial ulcers, nonhealing surgical wounds, and pressure ulcers/injuries (PU/Is).

No widely accepted guidelines exist to assist clinicians in determining when a chronic wound is infected or at risk for infection. No definitive guidelines exist to aid the clinician in determining the indication or duration of systemic antibiotics. Up to 60% of patients with chronic wounds are treated with at least 1 systemic antibiotic within a 6-month period despite a lack of evidence to support the benefits or efficacy of systemic antibiotics for chronic wound healing rates.

The Infectious Diseases Society of America (IDSA), the British Society for Antimicrobial Chemotherapy, and the European Wound Management Association all concur that no universally accepted diagnosis criteria for an infected chronic wound exists.

The Wounds at Risk (WAR) score is a tool used to assess the risk of infection in patients by scoring several host factors that can contribute to an increased risk for infection in wounds. In 2010, an international group of wound experts created the WAR score to better assess the risk of infection in chronic wounds by evaluating both the actual wound and host factors that can contribute to an increased risk of infection.

The listed risk factors for infection are represented by 1, 2, or 3 points; a score over 3 justifies the use of systemic antibiotics, as it indicates an increased risk for infection. Patients with a score at or below 3 are not at an overall increased risk for infection; therefore, the use of antibiotics is not clearly indicated. The measured bacterial burden and potential pathogen(s) of chronic wounds play a significant role in determining bacterial colonization versus bacterial infection in wounds. Pseudomonas and methicillin-resistant Staphylococcus aureus (MRSA) are common pathogens found in chronic wounds, but do not necessarily cause true infection. Jockenhöfer et al noted that most of the patients with chronic wounds had the presence of both Pseudomonas and MRSA, and especially in those patients with a WAR score of less than 3. 

All patients with wounds present for at least 3 weeks who were admitted to the hospital between November 5, 2018, and December 13, 2018, were given a WAR score based on data obtained from the electronic medical records (EMRs). 

Rachel L and Coll conducted this study based on the patient’s WAR score, the EMR note read: 

  • “WAR scale score ≤ 3: patient not at increased risk for infection; systemic antibiotics may not be indicated”; or
  • “WAR scale score ≥ 4: patient at increased risk for infection; systemic antibiotics may be indicated.”

Data were collected on the use and indication of systemic antibiotics and other clinical data, including wound measurements, type of wound, microbiological burden, and pathogen (if culture was obtained), and demographic data.

The indications or diagnoses for antibiotic use were divided into 9 categories.

During their hospital stay, 85% of the total sample population (N = 135) received systemic antibiotics. 

Patients with chronic wounds are at an increased risk for morbidity and mortality, and they also are more likely to be exposed to unnecessary antibiotics, which is the leading cause of acquiring of infections.

Despite this, the analysis does support the use of a WAR score to help clinicians determine the risk for infection and deciding on the appropriateness of systemic antibiotics and the importance of raising awareness of this issue.


Authors: Rachel L Reitan and coll.

Newspaper Wounds2020 Jul;32(7):186-194.

Source: https://pubmed.ncbi.nlm.nih.gov/33166266/