Antimicrobial stewardship pathway

Venous leg ulcers

Assess

Perform holistic patient and wound assessment with TIMERS (see below)¹⁻¹²

Is the wound infected? Do you observe two or more clinical signs and symptoms?

Urgently consult vascular team in CLTI, DVT, severe PAD, severe calcification or severe cardiac insufficiency

Centres for Disease Control and Prevention (CDC) classification of surgical site infections (SSIs)¹¹⁹ ¹⁴

Superficial incisional SSI:

Involves only skin and subcutaneous tissue of the incision

Deep incisional SSI:

Involves deep soft tissues of the incision (for example, fascial and muscle layers

Organ/spacel SSI:

Involves the organ/space tissues (deeper than the fascia/muscle

Contamination

Microorganisms present
No host reaction
No clinical signs
No delayed healing
No proliferation

Colonisation

Microorganisms present
No host reaction
No clinical signs
No delayed healing
Limited proliferation

Covert local infection

Hypergranulation
Bleeding, friable granulation tissue
Epithelial bridging and pocketing
Increasing exudate
Delayed healing

Overt local infection

New/increasing pain
Erythema or changed skin tone
Swelling
Increasing malodour
Purulent discharge
Increased exudate
Local warmth
Wound breakdown and enlargement

Spreading infection

Spreading erythema (>2cm from wound edge)
Extended induration
Crepitus
Wound breakdown
Lymphangitis

Systemic infection

Malaise
Lethargy
Loss of appetite
Pyrexia/fever
Sepsis
Septic shock
Organ failure

Increasing microbial burden in wound

Consider signs and symptoms of biofilm: covert infection, recurrent infections, low-level chronic inflammation/erythema or antimicrobial treatment failure⁶

Consider signs of sepsis⁷

Signs of sepsis²⁴

Sepsis is a life-threatening condition in which the body's response to infection causes injury to its tissues and organs. Organ dysfunction is a key component in any diagnosis of sepsis.

Act on any of the following red flags:

S. Slurred speech or confusion

E. Extreme shivering or muscle pain

P. Passing no urine (in a day)

S. Severe breathlessness

I. It feels like you are going to die

S. Skin mottled or discoloured

Treat

Perform wound bed preparation (therapeutic cleansing, debridement and repeat cleansing)¹⁰⁻¹⁴

Is there a need for a dressing for infection control or treatment?

Control microbial burden in wound

contamination or colonisation

First-line: Microbial-binding dressings¹⁵⁻¹⁹*

Treat covert or overt local wound infection

Referral: Consider specialist referral
First-line: Microbial-binding dressings¹⁵⁻¹⁹*
Second-line: Antiseptic dressings¹

Treat spreading or systemic wound infection

Referral: Surgical referral
Culture: Swab or biopsy¹
Antibiotics: Targeted systemic antibiotics used with dressings^{1, 20}
First-line: Microbial-binding dressings¹⁵⁻¹⁹*
Second-line: Antiseptic dressings¹

Review

Notes

*Microbial-binding dressings have a DACC coating that can control microbial burden to prevent or manage infection in a way that is not expected to contribute to antimicrobial resistance. All treatments should be used per local policy and where clinically appropriate. See below for supplementary tables and references.

Abbreviations

CEAP=Clinical, Etiological, Anatomical Pathophysiological Classification of Venous Disease; CLTI=critical limb-threatening ischaemia; DACC=dialkylcarbamoyl chloride; DVT=deep vein thrombosis; PAD=peripheral arterial disease; TIMERS=Tissue, Infection/Inflammation, Moisture balance, Edge/epithelialisation, Regeneration and repair, Social factors

Aspects of a holistic patient assessment in venous leg ulceration

– adapted from TIMERS^{1-6, 8-12}

Patient assessment

Comorbidities
Current medication
Functionality and mobility
Nutritional assessment
Skin assessment (including skin tone)
Social factors
Surgical and medical history

Lower-leg assessment

Ankle or toe brachial pressure index
CEAP classification
Doppler/vascular ultrasound
Leg and foot pulses
Oedema
Skin perfusion
Skin temperature
Surrounding skin condition
Transcutaneous oxygen pressure
Vitals

Wound assessment

Classification
Imaging as appropriate
Location, duration, size and depth
Odour
Pain
Periwound condition
Previous investigations and treatments
Tissue biopsy (if appropriate in ≥3 months duration or atypical wound presentation)
Tissue types on wound bed (necrotic, sloughy, granulation or epithelial

Risk factors for wound infection

– adapted from the International Wound Infection Institute^{1, 20, 21}

Patient risk factors

Alcohol, smoking or illicit drug use
Conditions associated with hypoxia or poor perfusion (e.g. anaemia, cardiac disease, respiratory disease, peripheral arterial disease, renal impairment or rheumatoid arthritis)
Connective tissue disorders (e.g. Ehlers-Danlos syndrome)
Corticosteroid use
Immune disorders (e.g. acquired immune deficiency syndrome
Lymphoedema
Malnutrition or obesity
Neuroarthropathy
Peripheral arterial disease (inc. ischaemia)
Peripheral neuropathy (sensory, motor and autonomic)
Poor adherence to treatment plan
Poorly controlled diabetes
Radiation therapy or chemotherapy

Wound risk factors

Atypical wounds
Duration of wound
Foreign body presence (e.g. drains, sutures or wound dressing fragments)
Haematoma
Impaired tissue perfusion
Increased exudate and oedema that is not adequately managed
Involvement of tissue deeper than skin and subcutaneous tissues (e.g. tendon, muscle, joint or bone)
Necrotic or sloughy wound tissue

Environmental risk factors

Hospitalisation (due to increased risk of exposure to antimicrobial-resistant microorganisms)
Inadequate hand hygiene and aseptic technique
Inadequate management of moisture (e.g. due to exudate, incontinence or perspiration)
Unhygienic environment (e.g. dust, unclean surfaces, or presence of mould/mildew)

Signs of sepsis⁶

Sepsis is a life-threatening condition in which the body's response to infection causes injury to its tissues and organs. Organ dysfunction is a key component in any diagnosis of sepsis.

Act on any of the following red flags:

S. Slurred speech or confusion

E. Extreme shivering or muscle pain

P. Passing no urine (in a day)

S. Severe breathlessness

I. It feels like you are going to die

S. Skin mottled or discoloured

Guidance

Conte et al (2019)

Global vascular guidelines on the management of chronic limb-threatening ischemia

European Wound Management Association (2023)

Lower leg ulcer diagnosis & treatment

European Wound Management Association (2024)

Holistic management of wound-related pain

International Wound Infection Institute (2022)

Wound infection in clinical practice

Lurie et al (2020)

Update of the CEAP classification

Nair et al (2024)

Leg ulceration in venous and arteriovenous insufficiency: assessment and management

DACC™-coated dressings instructions for use

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venous leg ulcers in full here:

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click for REFERENCES

International Wound Infection Institute. Wound infection in clinical practice: principles of best practice – Wounds International. 2022. 2. Atkin L et al. J Wound Care.
2019;28:S1–50.
Fletcher J et al. Wounds UK. 2018;1–24.
Conte MS et al. Eur J Vasc Endovasc Surg. 2019;58:S1–S109.
Isoherranen K et al. J Wound Care. 2019;28:S1–92.
Schultz GS et al. Wound Rep Regen. 2017;25:744–757.
UK Sepsis Trust. Spotting the signs of sepsis. 2025.
Fletcher J et al. Best practice statements: effectively assessing ABPI in leg ulcer patients. 2024.
Lurie F et al. J Vasc Surg Venous Lymphat Disord. 2020;8:342–352.
Atkin L & Tickle J. Wounds UK. 2016;12:32–36.
Isoherranen K et al. J Wound Manag. 2023;24:S1–S76.
Nair HK et al. J Wound Care. 2024;33:S1–S31.
Haesler E et al. Wounds Int. 2025;1–52.
Schultz GS et al. Wound Rep Regen. 2003;11:S1–28.
Bjarnsholt T et al. Wounds Int. 2020;1–32.
Blackburn J et al. Int Wound J. 2025;22:e70684.
Cole W et al. Wounds. 2025;37:S1–S24.
Mosti G et al. J Wound Care. 2015;24:121–127.
Rippon MG et al. J Wound Care. 2021;30:284–296.
Assadian O et al. J Wound Care. 2023;32:3–4.
Garc.a Nores GD et al. J Invest Dermatol. 2018;138:325–335

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Closed surgical incisions

Hard‑to‑heal wounds

Diabetes-related foot ulcers

Venous leg ulcers