Infection assessment tools for acute and chronic wounds: a scoping review

Lima, Daniella Cristina Julio; Paes, Graciele Oroski

doi:10.1590/1980-220X-REEUSP-2024-0392en

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REVIEW • Rev. esc. enferm. USP 59 • 2025 • https://doi.org/10.1590/1980-220X-REEUSP-2024-0392en linkcopy

Infection assessment tools for acute and chronic wounds: a scoping review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective: To map the tools available in the literature for assessing wound infection.

Method: This is a scoping review conducted from the Joana Briggs Institute Manual for Evidence Synthesis, in the databases of the Virtual Health Library, PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature and the academic literature repository, Google Scholar. The research question was developed based on the acronym PCC (Population/Concept/Context), resulting in the following formulation: “Which tools available in the literature assess wound infections?”

Results: The analysis included 32 wound infection assessment tools. Of these, 26 using clinical signs and symptoms of infection distributed across scales, checklists, classification systems, and completion forms were identified. In addition to these, 5 electronic devices and 01 software were identified.

Conclusion: The diversity of instruments highlights the complexity of wound infection management, emphasizing the need to discuss their applicability, benefits, and limitations to select the best evidence-based instrument.

DESCRIPTORS
Wound Healing; Risk Assessment; Wound Infection; Diagnostic Techniques and Procedures; Nursing

Search Strategy	Databases/repository	Articles found
(cicatrização) OR (cicatrização de feridas) OR (cicatrização de ferimentos) OR (wound healing) AND (estudo de avaliação) OR (estudos de avaliação) OR (evaluation study) OR (evaluation studies) OR (avaliação em enfermagem) OR (protocolos de enfermagem) OR (nursing assessment) OR (nursing protocols) AND (tool) OR (instruments) OR (ferramentas) OR (instrumentos) AND (infecção dos ferimentos) OR (infecção das feridas) OR (infecção da ferida) OR (infecção de feridas) OR (wound infection)	VHL	89
wound healing AND wound infection AND tool	CINAHL	112
wound healing AND evaluation study OR evaluation studies OR nursing assessment OR nursing protocols AND wound infection AND tool	PubMed	193
wound healing AND wound infection AND tool AND nursing	Scopus	40
“wound infection” AND “wound healing” AND “consensus document” OR “tools” AND “clinical practice”	Google Scholar	6.720

	Year/Source or title of the manuscript	Tool type	Tool name	Wound etiology	Infection characteristics assessed by the tool	Country (ies) of study
1	2023/Wound infection in clinical practice Principles of best practice do International Wound Infection Institute(⁹)	Classification System	IDSA System	Diabetic ulcer	Clinical signs and symptoms such as: edema, erythema, purulent exudate, pain, heat, in addition to hemodynamic changes.	Netherlands, Australia, and Portugal
2	2023/Nursing care for people with diabetic foot wounds: construction of an instrument(¹⁴)	Filling form	Instrument for managing nursing care for people with diabetic foot	Diabetic ulcer	Clinical signs and symptoms such as: purulent exudate, pain, erythema, edema, foul odor, heat, in addition to hemodynamic changes.	Brazil
3	2023/Validation of a Wound Tool for Assessment of Surgical Wounds in Infants(¹⁵)	Classification system	University of Alberta Surgical Wound Assessment Tool	Surgical wound	Clinical signs and symptoms such as: purulent exudate, presence of exudate and changes in the skin around the wound (unspecific changes), necrosis or presence of a visible prosthesis.	Canada
4	2022/Development of a surgical wound assessment tool to measure healing and risk factors for delayed wound healing in Vietnam: a Delphi process(¹⁶)	Wound assessment construct	SWAT	Surgical wound	Clinical signs and symptoms such as: edema, erythema, exudate, odor, pain, among other signs.	Vietnam
5	2022/Instrument for the evaluation of the chronic wounded patient: clinical, care and financial indicators(¹⁷)	Filling form	Instrument for assessing patients with chronic wounds at Universidade Federal de Minas Gerais	Chronic wounds of various etiologies	Clinical signs and symptoms such as: detachment, necrosis, exudate, edema, hardening, odor, color of the skin around the wound (not specified); signs of critical colonization in the wound bed and signs of infection in the wound bed (the latter without specification).	Brazil
6	2022/Wound Infection in Clinical Practice -Principles of best practice(⁹)	Conceptual model	Wound Infection Continuum – International Wound Infection Institute (WIC – IWII)	Acute and chronic wounds of various etiologies	Clinical signs and symptoms such as: hypergranulation; friable granulation; increased exudate, delayed healing, erythema, heat, edema, purulent exudate, wound enlargement, pain, odor, in addition to other signs and symptoms and hemodynamic changes.	USA
7	2021/Post-dishcarge surveillance in surgical site infection: validation of an instrument(¹⁸)	Post-discharge surgical site surveillance form	Post-discharge surveillance for detection of surgical site infection at Universidade de São Paulo	Surgical wound	Clinical signs and symptoms such as: purulent exudate, edema, pain, heat, erythema, dehiscence, among other signs and symptoms besides hemodynamic changes.	Brazil
8	2021/Contribution of software for recording, monitoring, and evaluating wounds(¹⁹)	Software	Wounds Monitoring	Acute and chronic wounds of various etiologies	Clinical signs and symptoms such as: exudate, signs of inflammation and/or infection (does not specify which), among others.	Brazil
9	2020/Validity of DMIST for monitoring healing of diabetic foot ulcers(²⁰)	Scale	DMIST	Diabetic ulcer	Clinical signs and symptoms such as: hardening, purulent exudate, unpleasant odor, among other signs and symptoms besides hemodynamic changes.	Japan
10	2020/Therapeutic Index for Local Infections score validity: a retrospective European analysis(²¹)	Classification system	Therapeutic Index for Local Infections score	Lower limb ulcers of various etiologies	Clinical signs and symptoms such as: erythema, heat, edema, pain, delayed healing, odor, purulent exudate, among other “non-direct indicators of infection”.	Germany
11	2020/Wound Infection in Clinical Practice - Principles of best practice(⁹)	Classification system	Infection Management Pathway	Acute and chronic wounds of various etiologies	Clinical signs and symptoms such as: erythema, edema, purulent exudate, pain, foul odor, delayed healing, increased erythema, heat, hypergranulation, friable granulation, wound enlargement, in addition to other signs and symptoms and hemodynamic changes.	Germany
12	2020/Validation of the Harikrishna Peripheral Skin Classification for wound assessment(²²)	Classification system	Harikrishna Peripheral Skin Classification (HPSC)	Acute and chronic wounds of various etiologies	Classifies perilesional skin for infection, through signs such as: inflammation without infection, inflammation with infection, atypical – senescent cells/cancer/subcutaneous emphysema.	Malaysia
13	2020/Management tools in nursing care for children with pressure injury(²³)	Fill-in form and a Flowchart	Instrument for systematizing nursing care for children with pressure injuries and Flowchart of risk and prevention of pressure injuries at Universidade Federal do Espírito Santo	Pressure ulcer	Clinical signs and symptoms such as: edema, increased temperature, hyperemia, and increased necrotic tissue.	Brazil
14	2019/Use of a bacterial fluorescence imaging device: wound measurement, bacterial detection and targeted debridement(²⁴)	Device	MolecuLight	Diabetic, venous, arterial ulcers, surgical wounds and pressure ulcers	Assesses infection through bacterial load.	Canada
15	2019/Evaluation of Wound Photography for Remote Postoperative Assessment of Surgical Site Infections(²⁵)	Photographic record through the use of smartphones	Not applicable	SSI (Surgical Site Infection) or SSO (Surgical Site Occurrence)	Signs of infection reported by patients as present or absent and use of photographic images, associated or not with the report of present or absent infection.	USA
16	2018/Importance of postprocedural Wound, Ischemia, and foot Infection (WIfI) restaging in predicting limb salvage(²⁶)	Classification system	WIfI	Lower limb ulcers of various etiologies	Clinical signs and symptoms such as: local infection involving only the skin and subcutaneous tissue, local infection with erythema >2 cm or involving structures deeper than the skin and subcutaneous tissues and local infection with signs of systemic inflammatory response syndrome.	USA
17	2018/Diagnostic value of fluorine-18 deoxyglucose positron emission tomography/computed tomography in deep sternal wound infection(²⁷)	Positron emission computed tomography (PET/CT)	Not applicable	Surgical wound	Signs of infection through the affected area shown in the image.	China
18	2018/Elaboration of an algorithm for wound evaluation and treatment(²⁸)	Algorithm	Algorithm for wound assessment and treatment at Universidade do Vale do Sapucaí	Acute and chronic wounds of various etiologies	Clinical signs and symptoms such as: heat, erythema, edema, pain, purulent exudate, in addition to hemodynamic changes.	Brazil
19	2017/The inter-rater reliability between nurse-assessors clinically assessing infection of chronic wounds using the WUWHS criteria(²⁹)	Filling form	WUWHS	Chronic wounds of various etiologies	Clinical signs and symptoms such as: pain, delayed healing, edema, friable granulation tissue, foul odor, discoloration, increased exudate, induration, erythema, in addition to hemodynamic changes.	Netherlands
20	2017/Wound Infection in Clinical Practice -Principles of best practice(⁹)	Classification system	WIRE	Acute and chronic wounds of various etiologies	Clinical signs and symptoms such as: pain, necrotic tissue, friable granulation, exposure of underlying organs, delayed healing, erythema, heat, edema, odor, exudate, among others.	United Kingdom
21	2017/Inter-rater and intra-rater reliability outcomes of a rapid bacteria counting system with pressure ulcer samples(³⁰)	Dispositivo Panasonic Healthcare DU-AA01NP-H	Not applicable	Pressure ulcer	Assesses infection through bacterial load.	Japan
22	2016/The Wound Trend Scale: A Retrospective Review of Utility and Predictive Value in the Assessment and Documentation of Lower Leg Ulcers(³¹)	Scale	WTS	Lower limb ulcers of various etiologies	Clinical signs and symptoms such as: exudate, necrotic tissue and debridement, depth, purulence, periwound skin, edema, pain and risk of infection (erythema, heat, edema and pain, in addition to infection screening through exams).	Canada
23	2016/Evaluation of a Surgical Site Discharge Teaching Tool Using Pictures and a Mirror(³²)	Health education for teaching self-assessment of surgical incisions.	Not applicable	Surgical wounds, specifically after laparotomy	Clinical signs and symptoms such as: heat, drainage, purulent exudate, erythema, edema, pain/sensitivity, itching, among other signs and symptoms.	USA
24	2015/Cultural adaptation and validation for the Portuguese population of a chronic wound monitoring instrument: RESVECH 2.0 scale(³³)	Scale	RESVECH 2.0	Chronic wounds of various etiologies	Clinical signs and symptoms such as: pain; erythema, edema, heat, increased exudate, purulent exudate, friable tissue, stagnant wound, tissue compatible with biofilm, odor, hypergranulation, increased wound size, satellite lesions, tissue pallor, among other signs and symptoms.	Portugal
25	2015/Construction of a data collection instrument for people with wounds based on Wanda de Aguiar Horta’s theory(³⁴)	Filling form	Data collection instrument for people with wounds based on the theory of Wanda de Aguiar Horta from the Universidade Federal da Paraíba	Diabetic ulcer	Clinical signs and symptoms such as: edema, heat, erythema, tissue increase, pain and exudate.	Brazil
26	2013/Reliability and validity of the Chinese version of DESIGN-R, an assessment instrument for pressure ulcers(³⁵)	Filling form	DESIGN-R	Pressure ulcer	Clinical signs and symptoms, but does not specify which ones, as well as other general characteristics assessed of the wound such as: wound depth, exudate, size, infection, granulation and necrosis.	China
27	2012/A systematic review of the ASEPSIS scoring system used in non-cardiac-related surgery(³⁶)	Classification system	ASEPSIS	Surgical wounds	Clinical signs and symptoms, but does not specify which ones, as well as other general characteristics assessed of the wound such as: serous secretion, erythema, purulent exudate, separation of deep tissues, isolation of bacteria, and hospitalization for more than 14 days.	United Kingdom
28	2006/Wound Infection in Clinical Practice - Principles of best practice(⁹)	Classification system	NERDS and STONES	Chronic wounds of various etiologies	Clinical signs and symptoms such as: non-healing wounds, oozing wounds, red and bleeding granulation tissue on the wound surface, debris on the wound surface, foul smell or odor from the wound, increase in size, increased temperature, probing or exposure of bone, new split areas or satellites injuries, exudate, erythema, edema.	Canada
29	2001/A tool to assess clinical signs and symptoms of localized infection in chronic wounds: development and reliability(³⁷)	Checklist	Clinical Signs and Symptoms Checklist (CSSC)	Chronic wounds of various etiologies	Clinical signs and symptoms such as: increased pain in the ulcer area, erythema, edema, heat, purulent exudate, serous exudate associated with inflammation, delayed ulcer healing, discoloration of granulation tissue, friable granulation tissue, foul odor, satellite wounds, and pocketing at the ulcer base.	USA
30	1997/The Sessing Scale for measurement of pressure ulcer healing(³⁸)	Scale	Sessing Scale	Pressure ulcer	Clinical signs and symptoms such as: purulent drainage, foul odor, necrotic tissue, in addition to septic symptoms.	USA
31	1997/Monitoring wound healing by odour(³⁹)	Device with sensors	AromaScan	vascular ulcer	Aroma of lesions and its relationship with microorganisms present in the wound.	United Kingdom
32	1995/Wound registry: development and validation(⁴⁰)	Form	State University of New York Completion Form	Traumatic wounds	Clinical signs and symptoms such as: Erythema, heat, tenderness or drainage, combined with clinical judgment, and short-term assessment of cosmetic appearance.	USA

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