Guidelines for Point-of-Care Fluorescence Imaging for Detection of Wound Bacterial Burden Based on Delphi Consensus

Abstract

Excessive levels of bacteria impede wound healing and can lead to infectious complications. Unfortunately, clinical signs and symptoms of elevated bacterial burden are often unreliable. As a result, point--of--care fluorescence imaging, used to detect critical bacterial burden in wounds, is becoming widely recognized and adopted by clinicians across the globe as an accepted and added component of wound assessment protocol. A Delphi method was employed to establish consensus guidelines describing fluorescence imaging use. A multidisciplinary panel of 32 wound experts (56% MD, 22% podiatrist, 12.5% nurses/nurse practitioners) representing multiple sites of service (e.g., hospital outpatient, inpatient, private office, long-term care) completed two rounds of online questionnaires. The Delphi included key topics, including competencies required to perform imaging, clinical indications for imaging (e.g., signs/symptoms present, procedures warranting imaging), frequency of imaging, and a clinical workflow algorithm. Describing their clinical experiences of imaging impact, >80% reported changes in treatment plans, 96% reported that imaging-informed treatment plans led to improved wound healing, 78% reported reduced rates of amputations, and 83% reported reduced rates of microbiological sampling. The guidelines provided here will help to standardize use of fluorescence imaging among wound care providers and enhance the quality of patient care.

Diagnosis and treatment of the invasive extension of bacteria (cellulitis) from chronic wounds utilising point‐of‐care fluorescence imaging

“…This is consistent with prior reports in which (a) fluorescence information aided wound bed preparation in >85% of wounds, 16 , 23 (b) wound bed preparation aided by fluorescence information was associated with an increase in 12‐week healing rate and 33% decrease in antibiotic prescribing, 30 and is in line with recently published consensus guidelines. 26 In the current study, there were several instances where persistence of red fluorescence signals after these traditional strategies were used indicated that they were insufficient. Together with the irregular pattern of fluorescence extending outside the wound region that suggested cellulitis, this supported the decision to immediately initiate oral antibiotics.…”

“…A fluorescence scan was performed based on medical necessity to aid knowledge of bacteria location at levels requiring treatment, as previously described by Oropallo et al 26 Briefly, these criteria included presence of comorbidities (eg, history of wound infection, non‐healing wounds), presence of clinical signs and symptoms of infection (eg, erythema), indication of bacteria on previous fluorescence scan, or as part of baseline wound assessment. After capturing a fluorescence scan, images were reviewed to identify patterns of fluorescence indicative of bacteria at loads >10 4 CFU/g.…”

“…White arrows point to regions of red fluorescence indicative of bacteria at loads >10 4 CFU/g. ‡Based on guidelines developed by Oropallo et al 26 …”

“…This large, observational study designed to report on real‐world complex wounds provided evidence that point‐of‐care fluorescence imaging of the presence and location of bacterial loads enhanced identification of wounds with invasive extension of bacteria, particularly in patients lacking obvious symptoms of wound‐related cellulitis. Fluorescence scans performed before, during, and after procedures aimed at removing bacterial burden (eg, debridement, cleansing), 26 or prior to prescribing antibiotics, enabled proactive wound care and provided immediate feedback on treatment efficacy that helped to (a) limit the progression of wound‐related cellulitis, (b) avoid hospitalisation (no cellulitis cases required inpatient admission), and (c) likely prevented costly cellulitis complications in at least a subset of these patients.…”

“…Fluorescence scanning was performed by the clinical team and repeated iteratively after cleansing or debridement, as needed. 26 The fluorescence scans were acquired per the intended use of the device, which is part of our routine care. Therefore, no formal written informed consent was required from patients.…”