WOU N D & SKI N C AR E

Obtaining a wound swab culture specimen

By Heidi Huddleston Cross, MSN, RN, FNP-BC, CWOCN

ONE OF THE BODY’S strongest de-
fenses against infection is intact skin.
After a break in the skin, the wound
quickly becomes contaminated with
organisms that predominate on the
skin, such as Staphylococcus aureus.
These Gram-positive organisms are
generally followed by Gram-negative
organisms such as Pseudomonas, E. coli,
Klebsiella, and Proteus. Later, anaerobic
organisms and fungi join the fray.1
If bacteria continue to proliferate,
the wound moves through the stages
of bacterial bioburden, ranging from
contamination to colonization to criti-
cal colonization to actual infection.
Wound infection is defined as a quan-
titative bacterial count of 105 colonies
of bacteria (greater than or equal to
105 colony-forming units [CFUs]/
gram of tissue or mL wound fluid).2
(See The burdening stages of bioburden.)
Keep in mind that every wound is
contaminated, so a positive culture
doesn’t necessarily indicate infection.
This must be clinically determined
based on wound characteristics and
signs and symptoms of infection
such as erythema, edema, pain, heat,
and increased exudate and odor.
Culture and sensitivity testing shows
the type of bacteria in the wound
and guides antimicrobial therapy.
Specimens for culture and sensitiv-
ity testing can be obtained by tissue
biopsy, needle aspiration, or swab.
Although tissue biopsy is considered
the gold standard, swab specimens
are more commonly used because
they’re most easily collected and
readily available.2 This article reviews
the current best practice for obtaining
a swab specimen for wound culture.
Ten steps to success
Using proper technique to obtain a
swab specimen is vital to avoid false-
negatives and false positives in a
wound culture, which may result in
either overtreatment or undertreat-
ment with antimicrobials. The Z
technique (rotating the swab in a zig-
zag fashion covering the entire in-
jured area across the wound, without
touching the wound edges) is no lon-
ger recommended (63% sensitivity,
53% specificity).3 Current best prac-
tice calls for the Levine technique
(91% sensitivity, 57% specificity).1,4-6
(See Using the Levine technique.) Fol-
low these steps to obtain a specimen
with the Levine technique:1,6
1. If possible, obtain the specimen
before the patient starts antimicrobial
therapy, which interferes with micro-
organism growth.7
2. Assemble all equipment: un-
sterile gloves, 10-mL syringe pre-
filled with 0.9% sodium chloride,
sterile gauze pads, culture swab,
sterile swab container, and the ap-
propriate wound dressing. Even
though a 35 cc syringe with a 19
gauge angiocath is recommended for
optimally cleansing the wound, this

The burdening stages of bioburden

All chronic wounds are contaminated by bacteria (or microorganisms); this is referred to as the “bioburden” of the wound. If
microorganisms replicate and multiply in the wound, it’s often due to poor host immune response or other underlying systemic
factors. This leads to increased bioburden, the stages of which are detailed below:1

Contamination Colonization Critical colonization Infection

Wounds can be contami-
nated by any of the more
than 200 species of bacteria
that constitute the normal
flora of human skin, or by
bacteria from the environ-
ment or within the human
body.2
With colonization, the mi-
croorganisms adhere to the
surface of the wound and
replicate. The bacteria aren’t
pathogenic and don’t re-
quire treatment with local
or systemic antibiotics.1
Replicating microorganisms Microorganisms invade tis-
are present on the wound sue and yield a local or sys-
and are attached to the cells temic response. Cultures are
and structures in the wound. obtained to direct antibiotic
This level of bacteria inhibits selection.1
wound healing but the host
doesn’t exhibit classic signs
of infection. Topical antimi-
crobials are indicated.

References
1. Stotts N. Wound infection: diagnosis and management. In: Bryant R, Nix D, eds. Acute and Chronic Wounds: Current Management Concepts. St. Louis, MO: Elsevier
Mosby; 2012:270-278.
2. Salcido R. What is bioburden? The link to chronic wounds. Adv Skin Wound Care. 2007;20(7):368-369.

68 l Nursing2014 l July www.Nursing2014.com

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Using the Levin technique
may be hard to come by. So using a
10-mL syringe with 0.9% sodium
chloride (which is more readily
available) is sufficient for flushing
away wound debris before obtaining
the culture.8
3. After performing hand hygiene
and putting on unsterile gloves irrigate
the wound with 0.9% sodium chloride
and wipe gently with the gauze pad.
4. Moisten the swab with 0.9% so-
dium chloride (a moist swab provides
more accurate data than a dry swab).
5. Identify a small area (1 cm2)
of clean viable tissue and rotate the
swab on it, avoiding any necrotic tis-
sue. Applying pressure, try to express
as much nonpurulent wound fluid as
possible. A wound culture must be
taken from clean tissue because pus
or necrotic tissue will not provide an
accurate profile of the microflora
contained within the tissue.
6. Insert swab into the sterile
container.
7. Redress the wound and perform
hand hygiene.
8. Assess the patient and ensure
that any wound pain has been man-
aged. (This is done initially and again
during the process.)
9. Complete the lab slip and/or
electronic document, including
wound site, time the specimen was
collected, and any antimicrobials the
patient is receiving.
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10. Send the specimen to the lab
immediately (within 1 hour) to keep
the specimen stable.1
Closely follow these 10 steps
whenever obtaining a swab specimen
to ensure patient safety and success-
ful antimicrobial therapy. ■
REFERENCES
1. Stotts N. Wound infection: diagnosis and man-
agement. In: Bryant R, Nix D, eds. Acute and Chron-
ic Wounds: Current Management Concepts. St. Louis,
MO: Elsevier Mosby; 2012:270-278.
2. Wounds International. Infection update. 2012.
http://www.woundsinternational.com/pdf/content_
10386.pdf.
3. Rondas AA, Schols JM, Halfens RJ, Stobberingh
EE. Swab versus biopsy for the diagnosis of chronic
infected wounds. Adv Skin Wound Care. 2013;26(5):
211-219.
4. Gardner SE, Frantz RA, Saltzman CL, Hillis SL,
Park H, Scherubel M. Diagnostic validity of three
swab techniques for identifying chronic wound
infection. Wound Repair Regen. 2006;14(5):548-557.
5. Cooper R. Ten top tips for taking a wound swab.
2010. http://www.woundsinternational.com/
practice-development/ten-top-tips-for-taking-a-
wound-swab/page-4.
6. Bonham PA. Swab cultures for diagnosing
wound infections: a literature review and clinical
guideline. J Wound Ostomy Continence Nurs.
2009;36(4):389-395.
7. Centers for Disease Control and Prevention. Clini-
cian guide: get smart for healthcare. 2012. http://
www.cdc.gov/getsmart/healthcare/implementation.
html.
8. Gabriel A. Wound irrigation. 2013. http://emedicine.
medscape.com/article/1895071-overview.
Heidi Huddleston Cross is an NP of Wound and
Ostomy care at Upstate University Hospital in Syra-
cuse, N.Y.
The author has disclosed that she has no financial
relationships related to this article.
DOI-10.1097/01.NURSE.0000446645.33489.2e
July l Nursing2014 l 69