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34 Classication ofWound Infections
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[68]. The diagnosis of infected PUs is often challenging. As for vascular ulcers, classical signs of
infection (high temperature, erythema, tenderness, purulent discharge, and foul odor) may not
be present, and sometimes delayed wound healing is the only sign of infection [69].
34.3 Classication Systems
Given the wide variety in terms of clinical presentation and disease severity of both acute and
chronic infected wounds, accurate classication
and scoring systems are of paramount importance to guide appropriate management. In this
sense, a correct assessment of wounds is
necessary to guide the physician to identify the
infection and to decide the most adequate management, the setting (outpatient versus hospitalization), the need for invasive treatments (e.g.,
surgery or limb amputation), the route of administration of antibiotics, the type of antimicrobial
therapy, and the need for non-antimicrobial treatments (e.g., hyperbaric oxygen). Furthermore,
classication systems allow effective comparison
of the outcome among different physicians and
different centers, as to assist the treatment strategies and research activity. Although there are several studies focusing on assessment, diagnosis,
and classication of skin and soft tissue infections, most of these tools does not specically
focus on infected ulcers.
34.3.1 Available Skin andSoft Tissue
Infection Classication
Systems
The traditional denitions of skin and soft tissue
infection aim to group all the infectious process
involving the skin, subcutaneous tissue, fascia, or
muscle [70]. In 1998, the FDA proposed the rst
categorization of skin and soft tissue infections
into “uncomplicated” and “complicated”,
whereby the rst referred to localized supercial
infections (such as cellulitis, simple abscesses,
impetigo, and furuncles), and the latter referred
to more severe infections involving deep layers
(such as infected ulcers, infected burns, major
abscesses, infections affecting immunocompromised patients or those presenting with signs of
systemic sepsis, and/or requiring a major surgical
intervention). The differentiation of uncomplicated and complicated infections was mainly
aimed to address the need for inpatient management, surgical or other invasive procedures. Of
note, these guidelines did not specically
addressed infected wounds resulting from animal
or human bites, necrotizing fasciitis, diabetic foot
infection, and decubitus ulcer infection [71].
Eron etal. classied skin and soft tissue infections into four classes according to the severity of
clinical presentation and the existence of comorbidities [72]. Class 1 patients have no systemic
signs or symptoms of infections, and no uncontrolled comorbidities. In class 2, patients were
systemically ill (e.g., febrile), but with any
uncontrolled comorbidity. Class 1 and 2 patients
are generally managed with oral antibiotics as
outpatients. Class 3 and class 4 patients are those
with systemic signs and symptoms of infection
(class 3) and sepsis (4), or those who are nonsystemically ill, but with unstable comorbidities
that may interfere with their outcome. Class 3
and 4 patients usually require hospitalization, and
sometimes surgical treatment as well [72]. Eron’s
classication was uniquely inclusive of every
kind of infection. However, no distinction
between various types of ulcers was made.
Di Nubile and Lipsky attempted another, more
complete, classication system, based on anatomic, pathogenic, and epidemiologic aspects of
skin infections, distinguishing them into complicated and uncomplicated. The complicated ones
involved wounds, which were further categorized
in acute wound infections (traumatic, biterelated, and post-surgical), and chronic wound
infections (diabetic foot infections, venous stasis
ulcers, and pressure wounds) [73].
Since 2013, the US Food and Drug
Administration (FDA) has introduced the new
concept of “Acute Bacterial Skin and Skin
Structure Infections (ABSSSI)” that dene the
acute bacterial skin and soft tissue infections as a
lesion area of at least 75cm2 assessed by manual
determination (ruler technique) or by digital pla-
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nimetry [74]. According to this novel denition,
the diagnosis of ABSSSI is generally based
according to clinical judgment and physical evaluation. Almost every type of skin infection was
contemplated, e.g., cellulitis/erysipelas, wound
infections, and major cutaneous abscess. The
denition of infected wound according to the US
FDA was based on the presence of purulent
drainage from a wound with surrounding signs of
inammation [74]. The main purpose of this system was to make the denition of skin and soft
tissue infections more homogeneous in clinical
trials.
In 2014, the Infectious Diseases Society of
America (IDSA) proposed a new classication
for skin and soft tissue infection based on many
clinical variables, including purulent and nonpurulent discharge, severity (mild, moderate, and
severe), and tissue necrosis (necrotizing versus
non-necrotizing). The IDSA classication
entailed 10 different types of infection, including
necrotizing infection, cellulitis, simple abscesses,
impetigo, furuncles, infected ulcers, infected
burns, and major abscesses [70]. In 2018, the
WSES/SIS-E consensus conference updated its
own classication of skin and soft tissue infections, identifying three main groups: surgical site
infections (SSIs), non-necrotizing, and necrotizing infections [75]. However, no mention to
infections related to acute or chronic ulcers is
present in the WSES/SIS-E classication.
Alternative classication systems classied skin
infections according to the severity of local and
systemic signs and the patients’ comorbidities
[72], the anatomical tissue layers involved (supercial and deep infections), the anatomic location,
the rate of progression, and clinical presentation
or severity [76, 77].
34.3.2 Clinically Useful
Classications forInfected
Wounds
Although skin and soft tissue infections and
infected wounds share many etiologic and therapeutic characteristics, none of the above classication systems specically performs for wound
infections. At the time of the present chapter, vascular, pressure, and traumatic ulcers lack of specic classication systems when infected,
whereas several classications of diabetic foot
infections have been proposed. Each of these
classication systems work as a tool for risk
stratication and assessment and guide the clinician to the choice of the most appropriate management. To the best of our knowledge, there is
no consensus on which system should be used in
general practice.
The International Working Group on the
Diabetic Foot (IWGDF) proposed a system for
classifying DFU and DFIs which evaluates (1)
perfusion, (2) extent (size), (3) depth (tissue
loss), (4) infection, and (5) sensation (neuropathy) (PEDIS). Of note, the PEDIS system always
requires Doppler evaluation of the limb, to correctly dene the perfusion of the wound. The
Infectious Diseases Society of America (IDSA)
categorizes DFU in mildly infected, moderately,
and severely infected on the basis of clinical presentation [42] (Table34.1).
Both these tools offer the advantage of contemporary dening the infection and grading the
severity of the wound. In addition, both identify
DFU as clinically infected or uninfected, and further classify those infected according to their
severity. Of note, only IDSA classication has
been prospectively validated as a prediction score
for hospitalization and for limb amputation [10,
78].
The Meggitt-Wagner (MW) and the University
of Texas Diabetic foot classication system (UT)
have been the most widely used tools to categorize DFUs during the last decades. The MW
score grades depth, infection, and gangrene
through a numeric scale from 0 to 5 (Table34.1).
Grading is applied by mean of direct clinical
evaluation of tissue changes, except for osteomyelitis, which is diagnosed through radiographs.
The UT classication categorizes the depth of the
ulcer from 0 through 3 (pre- or post-ulcerative to
osteitis/osteomyelitis). Each grade is further
staged in four steps which evaluate the presence
of infection or ischemia [79]. Before UT application, the Doppler assessment of the limb is
required, as to categorize the level of ischemia in
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Table 34.1
Tool Wound type Items Considerations
IWGDF (PEDIS)/
IDSA [102]
Meggitt-Wagner
(MW) and the
University of
Texas Diabetic
foot classication
system (UT) [79]
Bate-Jensen
wound assessment
tool [83]
S(AD)/SADSINBAD [84]
DFI Wound Score
[86]
Cutting and
Harding criteria
[89]
Clinically useful tools for infected wound classication
DFUs
DFUs
Pressure ulcers,
DFUs, and venous
leg ulcers
Foot ulcers
DFUs
Post-operative
ulcers healing by
second intention
• Perfusion, extent (size), depth
(tissue loss), infection, sensation
(neuropathy) (PEDIS)
• Extent of signs of local of systemic
inammation (IDSA)
• Depth, infection and gangrene
(MW)
• Depth of the ulcer (grade 0, 1, 2,
3), and
• Presence of infection (stage B),
ischaemia (stage C) or both (stage
D) (UT) [104]
• 13 items assessing wound status
and tracking wound healing (size,
depth, edges, undermining,
necrotic tissue type and amount,
granulation and epithelialization
tissue, exudate type and amount of
exudate, skin colour, oedema, and
induration). Each item is scored
from 1 to 5
• Size (area, depth), sepsis
(infection), Arteriopathy, and
denervation (S(AD)/SAD)
• Site, ischemia, neuropathy,
bacterial infection, and depth
(SINBAD), graded as either 0 or 1
point
• 10-item score: Purulent discharge,
non-purulent discharge, erythema,
induration, tenderness, pain,
warmth, size, depth, undermining
• 8-item score: Erythema, induration,
tenderness, pain, warmth, size,
depth, undermining
• Presence of abscess, cellulitis,
discharge, delayed healing,
discoloration, easily bleeding
granulation tissue, pain, pocketing/
bridging at the base of the wound,
abnormal smell, wound breakdown
• Evaluates the presence of
infection and identies
four grades of severity
• Requires clinical
examination and standard
blood and imaging tests
• Valid to predict the
prognosis of the infected
wound, the need for and
duration of hospitalization,
the likelihood of
complications and the
need for limb amputation
[10, 102, 103]
• Evoluted in COCLASSTI
scheme
• Does not allow for specic
identication of peripheral
arterial disease,
neuropathy or infection
• Arteriopathy and infection
are not differentiated for
supercial lesions [103]
• UT tool predicts the
amputation risk
• Originally developed for
assessment of pressure
sores; however, reliability
and validity were
demonstrated for other
types of chronic ulcers
[105]
• Useful to evaluate wound
healing over time
• Simple and quick to use,
requires clinical
examination alone
• Has been validated for
both ulcer healing and
amputation prediction
• Specically designed
with research purpose
• Linearly correlates with
the severity of DFI and the
clinical response
• Difcult to apply in
clinical practice
• The rst developed
criteria-tool for diagnosis of
wound infection.
(continued)
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Table 34.1
Tool Wound type Items Considerations
Clinical Signs and
Symptoms
Checklist [88]
Cutting and
White’s revised
criteria [89]
Infection
management (IM)
pathway
IWII Wound
Infection
Continuum [94]
World Union of
Wound Healing
Societies criteria
[1]
Wound, ischemia,
foot infection
classication
(WIFi) [95]
NERDS and
STONEES [96]
(continued)
A variety of ulcers
(vascular
insufciency,
trauma,
neuropathy,
pressure, surgical
incision, and
DFUs)
DFUs, pressure
ulcers, arterial and
venous ulcers
Arterial ulcers,
venous leg ulcers,
pressure ulcers,
DFU and surgical
wounds
Every type of
wound
Every type of
wound
DFU and vascular
ulcers
Chronic wounds of
every origin
• 12 clinical signs and symptoms of
chronic wound infection, including 5
classic signs/symptoms of wound
infection and 7 secondary signs and
symptoms (e.g., the existence of pain,
signs of local inammation, presence
of exudate, delayed healing,
granulation tissue, wound base, wound
breakdown and odour)
• Signs and symptoms of infection:
Cellulitis, pain, delayed healing,
malodour, and wound breakdown
• ABCDE approach (assess patient,
wellbeing and wound, bring in a
multi-disciplinary team and
informal carers to promote holistic
patient assessment, control and
treat the underlying causes and
barriers to wound healing, decide
appropriate treatment, evaluate and
reassess the treatment and wound
management outcomes)
• Classical clinical signs/symptoms
to describe various stages of
wound, from colonization to
infection
• 7 clinical indicators of infection:
New pain/increasing pain or altered
pain in the ulcer area, malodour,
increase in ulcer area, wound
breakdown, delayed healing,
erythema, and increase inlocal
temperature
• A combination of scores for wound
(depth of ulcer or extent of
gangrene), ischaemia (ankle
pressure, toe pressure or TcPO2)
and foot infection (IWGDF/IDSA
criteria)
• Symptoms of supercial (NERDSnon-healing wound, exudative
wound, red and bleeding wound,
debris in the wound, smell from the
wound) and deep (STONEES- size
increasing, temperature, probes to
bone, new breakdown, oedema/
erythema, exudate, and smell)
infection
• May predict the infection
of the wound with more
accuracy than others
• Increasing pain and wound
breakdown are sufcient
to predict infection with
100% specicity, but none
of the evaluated clinical
signs is necessary in
identifying infection [88]
• Lacks of information on
the number of signs
required to conrm
infection [89]
• Does not allow a severity
scoring
• Pus or abscess are not
considered
• Standardises the
assessment and diagnosis
wound infection
• Provides a treatment plan
based on which signs/
symptoms
• Clinical signs/symptoms
are indicators of different
wound infection stages
• Useful as a teaching tool
• No differentiation between
different types of chronic
wounds
• No signicant association
between clinical signs of
infection and
microbiological cultures [6]
• Provides a one-year risk
for amputation and
one-year benet for
revascularisation (stratied
as very low, low, moderate
or high) [106]
• Requires the use of
specialist measurement of
foot perfusion indices
• Assess levels of bacterial
damage in chronic wounds
• Low sensitivity (0.69) and
moderate specicity (0.8)
[96]
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Table 34.1
Tool Wound type Items Considerations
Therapeutic index
for local infections
score [97]
the ulcer. Real-life validations of the MW-UT
classication have been performed. The UT system has demonstrated to signicantly predict the
amputation and to be superior to the Wagner system in the prediction of the probability of wound
healing [80–82]. Despite the suitability in everyday practice, the MW and the UT classications
have strong limitations. Neuropathy is not considered and infections are not differentiated for
supercial lesions. Furthermore, neither MW or
UT account for severity of ischemia nor distinguish gangrene due to infection versus
arteriopathy.
(BTAW) is a holistic approach based on clinical
examination of the wounds (Table 34.1). It
records 13 items that assess visual characteristics
of the wounds, including size, depth, edges,
undermining, necrotic, granulation and epithelialization tissue, exudate type and amount of exudate, colour, oedema, and induration [83].To
date, very few studies have been conducted to
assess clinical utility of the BWAT.Moreover, no
evidence of its usefulness in wound infection
assessment exists.
Antonio group as an attempt to categorize foot
ulcers based on their size (area and depth), presence of sepsis (infection), arteriopathy, and
denervation (each variable is scored from 0 to 4).
This scoring system differs from the others with
respect to the inclusion of neuropathy variable
(Table34.1).
(continued)
Acute and hard-to
heal wounds
DFUs diabetic foot ulcers
• 6 non-specic clinical criteria
(indirect indicators) for the
diagnosis of infected wounds (e.g.,
erythema to surrounding skin, heat,
oedema, induration or swelling,
pain or pressure, stalled wound
healing, smell of exudate) and 3
additional criteria strictly related to
infection (microbiological isolate,
surgical septic wound, presence of
pus)
The Bate-Jensen wound assessment tool
The S(AD)/SAD system was proposed by San
• Concordant with the
expert assessment of the
wounds with almost 5 out
6 indirect criteria.
In 2008, a comparative analysis between the
MW, the UT, and the (S(AD)SAD) systems was
conducted. The authors showed that all these systems predicted ulcer outcome. Of note, the presence or the absence of infection was the most
relevant factor considered by S(AD)SAD classication, as it directly relates to the prognosis. On
the contrary, the presence or absence of arteriopathy or neuropathy did not correlate with the
healing times and prognosis [84].
The SINBAD (Site, Ischemia, Neuropathy,
Bacterial Infection, and Depth) classication is a
revised version of the S(AD)SAD score. The
main difference stays in the inclusion of site of
ulcer (forefoot vs hindfoot) [85].
The DFI wound score was specically
designed with research purpose, as to measure
outcomes of various antimicrobial treatments for
DFIs. It assesses the presence/absence of signs of
local inammation, the wound size, and depth.
The prospective analysis from the SIDESTEP
trial found that the DFI wound score linearly correlated with the severity of DFI and the clinical
response. In other terms, patients with higher
scores have more severe wounds, and clinical
response rates were indirectly proportional to the
numeric score [86]. The main limitation of DFI
wound score is its usefulness only in clinical trials, since it is inapplicable in the daily clinical
practice due to its complexity (Table34.1).
In 1994, Cutting and Harding published a list
of criteria to identify an infected wound. These
were meant to be applied to a variety of post-
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operative ulcers healing by second intention.
However, they are not applicable to either traumatic wounds or chronic non-post-surgical ulcers
[87]. Relying on the Cutting and Harding’s diagnostic criteria, in 2001, Gardner etal. developed
the Clinical Signs and Symptoms list (CSSC)
(Table34.1). This score and its modied version
evaluate 12 clinical signs and symptoms of
chronic wound infection, including ve classic
signs/symptoms of wound infection and seven
secondary signs and symptoms (e.g., the existence of pain, signs of local inammation, presence of exudate, delayed healing, granulation
tissue, wound base, wound breakdown, and odor)
(Table 34.1) [88]. A small analysis found that
some of the parameters of CSSC may predict the
infection of the wound with more accuracy than
others. In this study, increasing pain, friable granulation tissue, foul odor, and wound breakdown
were the most important prediction for development of wound infection [88]. Of importance, the
population of patients included in the study by
Gardner et al. included 36 non-arterial chronic
wounds mainly derived from vascular insufciency, trauma, neuropathy, pressure, and surgical incision, with only two patients affected by
DFUs [88].
In 2013, Cutting and White published a
revised version of Cutting and White criteria for
diagnosis of infection in different types of chronic
wounds, including DFUs, pressure ulcers, arterial and venous ulcers [89]. According to this
tool, the most reliable signs, and symptoms of
infection in all chronic wound types include the
presence of cellulitis, pain, delayed healing, malodor, and wound breakdown [89]. Uncertainty
remains regarding the number of signs and symptoms required to achieve the diagnosis of wound
infection. The revised version of Cutting and
White criteria does not include information
regarding the severity of the infection.
The Infection Management (IM) Pathway was
proposed by a multidisciplinary expert panel
based on the European Wound Management
Association position document [90], the
International Wound Infection Institute panel
(Table 34.1) [91], and an international survey
aimed to identify health professionals’ chal-
lenges relating to biolm in chronic wounds [92].
Both arterial ulcers, venous leg ulcers, pressure
ulcers, diabetic foot ulcers, and surgical wounds
were included. Overall, the IM pathway tried to
standardize the assessment and the diagnosis of
infected wounds and to guide the treatment plan.
The pathway is based on an ABCDE approach
(Assess patient, wellbeing and wound, Bring in a
multi-disciplinary team and informal careers to
promote holistic patient assessment, Control and
treat the underlying causes and barriers to wound
healing, Decide appropriate treatment, Evaluate
and reassess the treatment and wound management outcomes) [93].
The International Wound Infection Institute
(WII) regularly publishes a consensus document
referred to every type of wounds (Table 34.1).
The IWII classication system presents classical
clinical signs/symptoms to describe various
stages of wound, from colonization to infection,
providing a grading of severity of the infection as
well [94].
The World Wound Healing Societies
(WUWHS) listed ve major clinical criteria to
assess infection of chronic wounds (Table34.1).
Both acute and chronic wounds were included.
Classical signs and symptoms of infection were
rated, and if two or more criteria were present,
wound infections were suspected [1]. To note that
no distinction was provided between different
types of wounds as regards clinical presentation.
Moreover, no association between clinical signs
of infection and microbiological cultures was
found [6].
The Wound, ischemia, and foot infection
(WI) classication was proposed by the Society
for Vascular Surgery as a prediction tool for the
risk for amputation (Table34.1) [95]. The WI
classication provides a 4-grade scale (from 0 to
3) to provide accurate and early risk stratication
for predicting risk of amputation at 1 year.
According to the system, the risk of limb amputation has been classied as very low, low, moderate, and high risk [95]. Although intuitive and
reliable, WIFi is not applicable out of DFU and
vascular ulcers settings.
NERDS and STONEES are mnemonics proposed by Sibbald etal. to assess levels of bacte-
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rial damage in chronic wounds, by evaluating
classic local signs of infection (Table 34.1).
Overall, the ulcers characterized by signs identied in NERDS are supercial and require local
treatment, while those associated with STONEES
should be managed systemically [96]. This score
applies to chronic wounds of every origin.
However, a cross-sectional study including 112
patients with chronic wounds found that this
score was neither sufciently sensible nor specic to rule in or rule out a diagnosis of wound
infection [96].
Therapeutic index for local infections (TILI)
score was proposed by the German society
Initiative Chronische Wunden (ICW) with the
aim to facilitate the early identication and
decision- making for infected wounds
(Table 34.1) [97]. It consists of two stepapproach. The rst step evaluates six non-specic clinical criteria (indirect indicators) for the
diagnosis of infected wounds (e.g., erythema to
surrounding skin, heat, oedema, induration or
swelling, pain or pressure, stalled wound healing, and smell of exudate); the second includes
three additional criteria strictly related to infection (microbiological isolate, surgical septic
wound, presence of pus). In clinical practice,
TILI score was tested on 307 patients with leg
ulcers of different types. The analysis showed
that TILI score was signicantly concordant
with the expert assessment of the wounds with
almost 5 out 6 indirect criteria [97].
During the last decade, many efforts have
been made to promote automated classifications of infection and ischemia of DFU based
on artificial intelligence [98–101]. Machine
learning systems use automatic algorithms
that analyses and categorize the images using
different parameters (color, image texture,
thermography, etc.). Major goals of these tools
systems are reducing biases due to human
error, reducing costs, reducing time, and limit
the personnel needed for patients ‘monitoring.
Among the last published analysis, Guley
et al’s algorithm in noteworthy [101]. They
showed that machine learning methods could
properly recognize the presence of ischemia
and infection in DFU images. The dataset was
specifically produced by two healthcare specialists in the diabetic foot because of visual
evaluation of DFU images. The authors found
that the automated method reached 90% in
terms of accuracy in ischemia classification
and 73% in infection classification. Although
current studies relating machine learning to
manage DFUs are promising, there is still lack
of validation of any of these systems. Existing
systems are based on small studies and limited
datasets; therefore, they do not allow generalizing results to the whole population.
34.4 Conclusions
Among the above-mentioned classication systems, the PEDIS, IDSA/IWGDF, UT, and S(AD)
SAD represents the most intuitive and easy to use
in everyday practice. We also believe that the
IDSA/IWGDF classication is the tool which
more accurately predict the prognosis of the
infected wound, the need for and duration of hospitalization, the likelihood of complications and
the need for limb amputation.
We encourage the clinician to conduct a
multi- disciplinary clinical evaluation of the
wounds. The combination of the available classication tools with other routine clinical
assessment by a “wound team” (e.g., infectious
disease consultant, diabetologist, orthopedic,
surgeon, and nurses) allows an overall evaluation of the wound and to appropriately achieve
the best management.
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