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Dr.T.V.Rao MD   1
Why Wound Swabs are
            Important in Patient Care
            Wound Swabs are one of the Important
            Specimens sent to Microbiology
            Departments for Bacteriological and
            Fungal isolation and Antimicrobiologial
            Evaluation. However many basic lacuna
            in Collection, Laboratory identification
            and reporting makes the Deficit in
            Effective care of the Patients and
            increases the potentials for Morbidity
            and Mortality
Dr.T.V.Rao MD                 2
Events in Infected
                    Wounds




Dr.T.V.Rao MD           3
Obtaining a Specimen
            Methods of obtaining a specimen from
            a wound include wound swabbing,
            needle aspiration and wound tissue
            biopsy. Although wound swabbing is
            the most practical and widely used, it is
            important to use a technique that
            produces reliable samples for
            microbiological analysis.

Dr.T.V.Rao MD                  4
Wound Culture Protocols
            Soft skin and tissue infections with open or draining
            lesions (Appearance of) insect/spider bite with
            necrotizing centre, drainage & erythema

            • Abscess - ulcer
            • Infected laceration

            ⇒ Culture wound prior to initiation of antibiotics if
            signs or symptoms of infection are present. If Culture
            & Sensitivity is obtained after antibiotics have been
            started, list the drug on the laboratory C& S request.
Dr.T.V.Rao MD                        5
What are guideline to
                          Follow for
            The technique usually employed
            transferring clinical samples from wounds to
            microbiology laboratories is the wound swab;
            however definitive guidelines for this
            relatively simple procedure have yet to be
            established. Uncertainty about when swabs
            should be taken, the correct collection
            procedure and the appropriate protocols for
            submitting swabs for investigation have
            led to a situation where clinicians regularly
            collect and process unsuitable sample


Dr.T.V.Rao MD                   6
Swabs should be collected
                 with Suspected Infection
            Swabs should
            therefore be
            collected only when
            clinical criteria
            point to a wound
            infection and
            before any
            antimicrobial
            interventions have
            been initiated
Dr.T.V.Rao MD                     7
Are there are Standard Protocol
           in Collection of Specimens
            It should be noted that the best technique for swabbing
            wounds has not been identified and validated. The
            following recommendations can be used as a guide and
            should be used in conjunction with local protocols:

            When a swab is indicated, the patient should be given a
            concise explanation of the need for microbiological
            investigation and what the procedure involves, for
            example, that swabs are mainly used to recover species
            from the surface layers rather than from the deep tissues
            of a wound.



Dr.T.V.Rao MD                          8
Cleaning the contaminating
               materials is a priority
      Before a representative
      sample is collected, any
      contaminating materials
      such as slough, necrotic
      tissue, dried exudate
      and dressing residue
      should be removed by
      cleansing the wound
      with tap water, sterile
      saline or debridement


Dr.T.V.Rao MD                    9
Appropriate Specimen is
                      Important
                                Do not
                                culture
                                purulent or
                                necrotic
                                debris or
                                drainage over
                                hard eschar.
Dr.T.V.Rao MD              10
Collecting the Optimal
                  Specimen
                           Sterile swabs with cotton or
                           rayon tips are usually used.
                           If the wound is moist a
                           swab can be used straight
                           from the packaging - if the
                           wound is dry, then the swab
                           tip should be moistened
                           with sterile saline to
                           increase the chances of
                           recovering organisms from
                           the site . Swabs with a
                           transport medium that
                           incorporates charcoal
                           enhance the survival of
                           fastidious organisms
Dr.T.V.Rao MD         11
Basic care in Collecting
             the Specimen
            Care should be
            taken to ensure
            that the swab
            only comes
            into contact
            with the
            wound surface.

Dr.T.V.Rao MD                 12
Care in When Collecting the
                      Swabs
            1.Cleanse wound by removing excess debris from
            wound base with normal saline

            2. Thoroughly flush wound with sterile saline.

            3. Gently blot excess saline from wound bed with
            sterile gauze.

            4. Remove soiled gloves; apply hand sanitizer.

            5. Apply clean gloves



Dr.T.V.Rao MD                        13
Practical Approach to
                Collections of Swabs
                               The swab should be
                               moved across the
                               wound surface in a
                               zigzag motion , at the
                               same time as being
                               rotated between the
                               fingers . Downward
                               pressure to release
                               fluid from the wound
                               surface has been
                               advocated, but this
                               may be painful for the
Dr.T.V.Rao MD             14
                               patient.
Bigger Wounds Needs
                   Multiple Specimens
            A representative area of the
            wound should be sampled.
            If the wound is large, it may
            not be feasible to cover the
            entire surface, but at least
            1cm² should be sampled and
            material from both the
            wound bed and wound
            margin should be collected.
            If pus is present, the
            clinician should ensure that
            a sample is sent to the
            laboratory.

Dr.T.V.Rao MD                               15
Devices and Collection of
               Swabs




Dr.T.V.Rao MD     16
Collecting the Swabs
            Open sterile culture collection/transport kit containing
            Amies or Stuarts transport medium and remove swab.

            If wound is dry, moisten tip of swab with transport fluid
            at the bottom of the transport sleeve or sterile
            preservative-free saline (pink saline fish or saline bullet). If
            wound is moist (weepy) after cleaning, this might not be
            necessary.

             Without touching swab to surrounding wound edges or
            skin, rotate tip of swab over a 1cm area of open wound for
            5 seconds (preferred method), or rotate the swab while
            making a zigzag pattern across the wound at 10 points
Dr.T.V.Rao MD                            17
Steps in Collection in
                          Specimen
            Cleanse intact skin with antiseptic and allow to dry.

             Expel all air from a 10mL syringe with a 22 gauge
            needle prior to aspiration. Insert needle into intact
            skin and apply suction (aspirate).

                Aspirate approximately 0.5mL of wound fluid.

            Label syringe (see Swab Culture, above).

      . After labelling syringe, place in lab biohazard
      transport bag and transport to the Laboratory

Dr.T.V.Rao MD                          18
Transport the Swabs
                     Promptly
                              Immediately
                              following
                              collection, the swab
                              should be returned
                              to its container
                              (placed into the
                              transport medium)
                              and accurately
                              labelled

Dr.T.V.Rao MD            19
Label and Promptly
                    Transport
            Label culture
            collection/transport
            kit with name, birth
            date, specimen
            source, date and
            time of culture.
            Place in lab
            biohazard transport
            container

Dr.T.V.Rao MD                      20
Swabs should be Transported
               without delay
            Swabs must be transferred to the laboratory
            as quickly as possible and ideally processed
            within four hours of collection
             The laboratory report should list the
            potential pathogens isolated and the amount
            of growth observed. The antibiotic
            susceptibilities of any organisms present in
            the wound may be included, but whether the
            isolates are of pathogenic and relevant to the
            Clinical Details furnished
Dr.T.V.Rao MD                    21
Appropriate Culturing Yields
               Precise Results
            Apply sufficient
            pressure to cause
            tissue fluid to be
            expressed. It is
            the bacteria in
            the tissue fluid
            that is desired
            for culture.

Dr.T.V.Rao MD                    22
Clinicians should Support
                 with Information
            Any supporting documentation for the
            laboratory should immediately be
            completed and a note included in the
            patient's records. It is important to
            provide information to the laboratory
            staff that will aid their use of the
            standard operating protocol, such as
            any underlying co-morbidities, the
            patient's age, on-going treatment and
            wound location
Dr.T.V.Rao MD                23
Microbiological and Clinical
        Correlation is the Best Option
 Antibiotic susceptibilities of any
organisms present in the wound may be
included, but whether the isolates are of
clinical significance or whether antibiotic
therapy is required is a matter of clinical
judgement. Spreading cellulitis and
clinical infections will require systemic
antibiotics.
Dr.T.V.Rao MD         24
Limitation of Swab
                    Techniques
            To examine the diagnostic validity of swab
            techniques, analyses of the accuracy as
            compared to tissue cultures in identifying
            microbial load provide insight into the utility of
            swab techniques used for this purpose. The
            accuracy of swab specimens based on Levine's
            technique was significantly higher than those
            based on Z-technique and approached
            significance when compared to swabs based on
            wound exudates


Dr.T.V.Rao MD                      25
Programme Created By Dr.T.V.Rao MD
                    for Medical and Paramedical
                Professionals in the Developing World
                               Email
                      doctortvrao@gmail.com

Dr.T.V.Rao MD                   26

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Wound Swabs basics

  • 2. Why Wound Swabs are Important in Patient Care Wound Swabs are one of the Important Specimens sent to Microbiology Departments for Bacteriological and Fungal isolation and Antimicrobiologial Evaluation. However many basic lacuna in Collection, Laboratory identification and reporting makes the Deficit in Effective care of the Patients and increases the potentials for Morbidity and Mortality Dr.T.V.Rao MD 2
  • 3. Events in Infected Wounds Dr.T.V.Rao MD 3
  • 4. Obtaining a Specimen Methods of obtaining a specimen from a wound include wound swabbing, needle aspiration and wound tissue biopsy. Although wound swabbing is the most practical and widely used, it is important to use a technique that produces reliable samples for microbiological analysis. Dr.T.V.Rao MD 4
  • 5. Wound Culture Protocols Soft skin and tissue infections with open or draining lesions (Appearance of) insect/spider bite with necrotizing centre, drainage & erythema • Abscess - ulcer • Infected laceration ⇒ Culture wound prior to initiation of antibiotics if signs or symptoms of infection are present. If Culture & Sensitivity is obtained after antibiotics have been started, list the drug on the laboratory C& S request. Dr.T.V.Rao MD 5
  • 6. What are guideline to Follow for The technique usually employed transferring clinical samples from wounds to microbiology laboratories is the wound swab; however definitive guidelines for this relatively simple procedure have yet to be established. Uncertainty about when swabs should be taken, the correct collection procedure and the appropriate protocols for submitting swabs for investigation have led to a situation where clinicians regularly collect and process unsuitable sample Dr.T.V.Rao MD 6
  • 7. Swabs should be collected with Suspected Infection Swabs should therefore be collected only when clinical criteria point to a wound infection and before any antimicrobial interventions have been initiated Dr.T.V.Rao MD 7
  • 8. Are there are Standard Protocol in Collection of Specimens It should be noted that the best technique for swabbing wounds has not been identified and validated. The following recommendations can be used as a guide and should be used in conjunction with local protocols: When a swab is indicated, the patient should be given a concise explanation of the need for microbiological investigation and what the procedure involves, for example, that swabs are mainly used to recover species from the surface layers rather than from the deep tissues of a wound. Dr.T.V.Rao MD 8
  • 9. Cleaning the contaminating materials is a priority Before a representative sample is collected, any contaminating materials such as slough, necrotic tissue, dried exudate and dressing residue should be removed by cleansing the wound with tap water, sterile saline or debridement Dr.T.V.Rao MD 9
  • 10. Appropriate Specimen is Important Do not culture purulent or necrotic debris or drainage over hard eschar. Dr.T.V.Rao MD 10
  • 11. Collecting the Optimal Specimen Sterile swabs with cotton or rayon tips are usually used. If the wound is moist a swab can be used straight from the packaging - if the wound is dry, then the swab tip should be moistened with sterile saline to increase the chances of recovering organisms from the site . Swabs with a transport medium that incorporates charcoal enhance the survival of fastidious organisms Dr.T.V.Rao MD 11
  • 12. Basic care in Collecting the Specimen Care should be taken to ensure that the swab only comes into contact with the wound surface. Dr.T.V.Rao MD 12
  • 13. Care in When Collecting the Swabs 1.Cleanse wound by removing excess debris from wound base with normal saline 2. Thoroughly flush wound with sterile saline. 3. Gently blot excess saline from wound bed with sterile gauze. 4. Remove soiled gloves; apply hand sanitizer. 5. Apply clean gloves Dr.T.V.Rao MD 13
  • 14. Practical Approach to Collections of Swabs The swab should be moved across the wound surface in a zigzag motion , at the same time as being rotated between the fingers . Downward pressure to release fluid from the wound surface has been advocated, but this may be painful for the Dr.T.V.Rao MD 14 patient.
  • 15. Bigger Wounds Needs Multiple Specimens A representative area of the wound should be sampled. If the wound is large, it may not be feasible to cover the entire surface, but at least 1cm² should be sampled and material from both the wound bed and wound margin should be collected. If pus is present, the clinician should ensure that a sample is sent to the laboratory. Dr.T.V.Rao MD 15
  • 16. Devices and Collection of Swabs Dr.T.V.Rao MD 16
  • 17. Collecting the Swabs Open sterile culture collection/transport kit containing Amies or Stuarts transport medium and remove swab. If wound is dry, moisten tip of swab with transport fluid at the bottom of the transport sleeve or sterile preservative-free saline (pink saline fish or saline bullet). If wound is moist (weepy) after cleaning, this might not be necessary. Without touching swab to surrounding wound edges or skin, rotate tip of swab over a 1cm area of open wound for 5 seconds (preferred method), or rotate the swab while making a zigzag pattern across the wound at 10 points Dr.T.V.Rao MD 17
  • 18. Steps in Collection in Specimen Cleanse intact skin with antiseptic and allow to dry. Expel all air from a 10mL syringe with a 22 gauge needle prior to aspiration. Insert needle into intact skin and apply suction (aspirate). Aspirate approximately 0.5mL of wound fluid. Label syringe (see Swab Culture, above). . After labelling syringe, place in lab biohazard transport bag and transport to the Laboratory Dr.T.V.Rao MD 18
  • 19. Transport the Swabs Promptly Immediately following collection, the swab should be returned to its container (placed into the transport medium) and accurately labelled Dr.T.V.Rao MD 19
  • 20. Label and Promptly Transport Label culture collection/transport kit with name, birth date, specimen source, date and time of culture. Place in lab biohazard transport container Dr.T.V.Rao MD 20
  • 21. Swabs should be Transported without delay Swabs must be transferred to the laboratory as quickly as possible and ideally processed within four hours of collection The laboratory report should list the potential pathogens isolated and the amount of growth observed. The antibiotic susceptibilities of any organisms present in the wound may be included, but whether the isolates are of pathogenic and relevant to the Clinical Details furnished Dr.T.V.Rao MD 21
  • 22. Appropriate Culturing Yields Precise Results Apply sufficient pressure to cause tissue fluid to be expressed. It is the bacteria in the tissue fluid that is desired for culture. Dr.T.V.Rao MD 22
  • 23. Clinicians should Support with Information Any supporting documentation for the laboratory should immediately be completed and a note included in the patient's records. It is important to provide information to the laboratory staff that will aid their use of the standard operating protocol, such as any underlying co-morbidities, the patient's age, on-going treatment and wound location Dr.T.V.Rao MD 23
  • 24. Microbiological and Clinical Correlation is the Best Option Antibiotic susceptibilities of any organisms present in the wound may be included, but whether the isolates are of clinical significance or whether antibiotic therapy is required is a matter of clinical judgement. Spreading cellulitis and clinical infections will require systemic antibiotics. Dr.T.V.Rao MD 24
  • 25. Limitation of Swab Techniques To examine the diagnostic validity of swab techniques, analyses of the accuracy as compared to tissue cultures in identifying microbial load provide insight into the utility of swab techniques used for this purpose. The accuracy of swab specimens based on Levine's technique was significantly higher than those based on Z-technique and approached significance when compared to swabs based on wound exudates Dr.T.V.Rao MD 25
  • 26. Programme Created By Dr.T.V.Rao MD for Medical and Paramedical Professionals in the Developing World Email doctortvrao@gmail.com Dr.T.V.Rao MD 26