Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Local Wound Care - Control Bacteria/Infection
Recommendation Level of Evidence
3.3a  The treatment of infection is managed by wound cleansing, systemic antibiotics, and debridement, as needed. Ib
3.3b  Protect pressure ulcers from sources of contamination, e.g., fecal matter. IV
3.3c  Follow Body Substance Precautions (BSP) or an equivalent protocol appropriate for the healthcare setting and the client´s condition when treating pressure ulcers. IV
3.3d  Medical management may include initiating a two-week trial of topical antibiotics for clean pressure ulcers that are not healing or are continuing to produce exudate after two to four weeks of optimal patient care. The antibiotic should be effective against gram-negative, gram-positive and anaerobic organisms. Ib
3.3e  Medical management may include appropriate systemic antibiotic therapy for patients with bacteremia, sepsis, advancing cellulitis or osteomyelitis. Ib
3.3f  To obtain a wound culture, cleanse wound with normal saline first. Swab wound bed, not eschar, slough, exudate or edges. IV
3.3g  The use of cytotoxic antiseptics to reduce bacteria in wound tissue is not usually recommended. IIb

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