ABSTRACT
The question remains whether wound swabs yield similar culture results to the traditional gold standard, biopsies. Swabs are not invasive and easy to perform. However, they are believed to capture microorganisms from the surface rather than microorganisms that have invaded tissue. Several studies compared swabs and biopsies using different populations and sampling methods, complicating the ability to draw conclusions for clinical practice. This study aimed to compare swab and biopsy in clinical practice, by including a variety of wounds and using standard sampling and culture procedures.
Swabs (Levine technique) and biopsies were taken for microbiological culture in a standardized manner from the same location of one wound for each patient. Statistical analyses were performed to determine overall agreement, and observed agreement and kappa for specific microorganisms. A variety of wounds of 180 patients from different healthcare facilities in the Netherlands were included. Skin flora was more frequently cultured from swabs, resulting in similar recovery rates when excluding skin flora (1.34 vs. 1.35). Swabs were able to identify all microorganisms cultured from biopsies in 131 wounds (72.8%) wounds. Most frequently identified organisms were Staphylococcus aureus, Pseudomonas aeruginosa and beta-hemolytic streptococci species. Observed agreement and kappa for these organisms varied between 87.2-97.8% and 0.73-0.85 respectively. This study demonstrates that swabs and biopsies tend to yield the same culture results when taken from the same location. For frequently occurring microorganisms, agreement between the two methods was even higher. Therefore, there seems to be no direct need for invasive biopsy in clinical practice.
INTRODUCTION
The human skin is a natural barrier against (pathogenic) influences from our environment.
Once the skin is damaged, i.e. the existence of a wound, bacteria and other debris can enter the body and may cause damage to healthy tissue. In healthy people, bacteria and debris are removed effectively by the immune system and the skin and possibly underlying tissues are repaired in a well-orchestrated manner 1,2. However, frequently seen morbidities such as Diabetes Mellitus and arterial or venous insufficiency can impair the wound healing process 3-6. It is therefore not surprising that the existence of non- healing wounds, or chronic wounds, is a commonly seen problem in these patients.
Chronic wounds often show an imbalance between inflammatory cells and their inhibitors, which results in continuous damage to tissue and the inability to progress to further stages of wound healing (formation of new tissue and wound closure) 7-9. In this phase, antibiotic treatment is often used to aid the defense against (harmful) bacteria.
Since microorganisms differ in their antibiotic susceptibility, their identification via microbiological culture is often needed to guide the choice for the appropriate antibiotic treatment 10.
To this day, there is still no consensus about which sampling method is appropriate for microbiological culture 11. Traditionally, wound biopsies have been postulated as gold standard because they are believed to capture microorganisms that have invaded the tissue (causative for tissue damage or infection). Wound biopsies, however, are an invasive wound sampling method and therefore more difficult to perform in clinical practice. Wound swabs are more often used in clinical practice. Wound swabs are easy to perform and non-invasive for the patient, but they are rather believed to capture only microorganisms on the surface of the wound bed rather than causative microorganisms
12.
In the last decades, several studies have compared wound swab and wound biopsy with the aim to justify the use of either sampling method for identification of microorganisms.
Most of these studies, however, did not represent clinical practice within their design.
For example, some studies included only certain types of chronic wounds, like diabetic foot ulcers 13-16, venous leg ulcers 17-19, or pressure sores 20, others aimed at (clinically) infected wounds 13,15-17 or included only non-infected wounds 18,21. Studies that aimed to include a broad range of chronic wounds either had a small sample size 22 or excluded patients types that are frequently seen in wound care centers (e.g. patients with arterial wounds 23, Diabetes Mellitus 17-19 or anticoagulation therapy 23) limiting the generalizability to clinical practice.
In addition, the applicability in clinical practice is often complicated by the absence of a clear description of the sampling method (biopsy, swab) and calculation of outcome measures 11. This study therefore aims to provide a clear comparison of both wound swab and wound biopsy for microbiological discovery in clinical practice. In other words, this study tries to provide insight in which sampling method to use in wound care facilities.
METHODS
This study was designed as a cross-sectional multicenter study, performing wound biopsy and wound swab simultaneously in one and the same chronic wound of each patient. Ethical approval was obtained before the start of the study.
Study population
Patients with an open chronic wound were included between May 16th, 2013, and October 30th, 2015, from 5 different study centers in the Netherlands: departments of vascular surgery of Medisch Spectrum Twente hospital (Enschede), Ziekenhuisgroep Twente hospital (Almelo), St Jansdal hospital (Harderwijk) and Streekziekenhuis Koningin Beatrix hospital (Winterswijk), and Livio homecare (Enschede). These study centers were chosen to ensure a representative study population for clinical practice. Patients had to provide informed consent before study participation, and thus were excluded if they were not able to provide informed consent or if they were aged < 18 years. Patients were excluded in case their wound was not suited for either wound biopsy or wound swab; excluding wounds that were malignant, completely covered with exposed periosteum, fully necrotic wound with no possibility of necrotectomy, wounds with a diameter < 3 millimeters, facial wounds, fully dry wounds (e.g. no production of wound fluid in the last 2 days). To lower the risk of uncontrolled bleeding after wound biopsy, patients were excluded if they were diagnosed with hematological disorders with a known high risk of uncontrolled bleeding. Patients using anticoagulation medication were included if the International Normalized Ratio (INR) of their blood was < 4. For these patients, INR was measured prior to study inclusion. Other reasons for study exclusion were the use of antibiotics in the last five days before study participation, allergy or hypersensitivity for lidocaine when local anesthesia was deemed necessary and (prior) known presence of a multi-resistant microorganism in the wound. The reason to exclude the latter group of patients was due to the fact that additional analyses (not related to the purpose of this article) from collected study samples were performed abroad.
We did include patients in our analyses in whom we discovered the presence of multi- resistant microorganisms from samples taken for the purpose of this study (without prior knowledge about this presence) to prevent that their participation would be meaningless.
Sample collection
Eligible patients participated in the study during one regular appointment. After removal of the bandage, the wound was cleansed with sterile saline. A wound swab for microbiological analysis was taken according to the Levine procedure 24; a sterile cotton swab (Copan ESwab™) was twirled for five seconds on a one square centimeter area of the wound bed, while applying light pressure. This Levine swabbing method is believed to be the most accurate, since it allows collection of bacteria from deeper tissue in the wound with the swab 11,25. Subsequently, the wound was anesthetized by directly applying lidocaine drops (lidocaine HCL 20 mg/ml) onto the wound bed if anesthesia was deemed necessary by either the patient or the physician, nurse practitioner or wound care nurse. After a few minutes, the skin around the wound was cleaned with chlorhexidine digluconate 0.5% in 70% alcohol. To further prevent contamination during the biopsy procedure the wound bed was punctuated for biopsy with a 3-millimetre sterile punch biopsy under sterile conditions (sterile cloth, sterile gloves), and tissue was placed in a sterile container. Both wound swab and wound biopsy were taken from the same location of the wound bed, preferably from granulation tissue. Both specimens were stored in a refrigerator at 4 °C until transportation (within 2.5 hours after collection) to the microbiological laboratory.
Microbiological culture
Both biopsies and swabs were inoculated onto media for the detection of aerobic bacteria (Acinetobacter species, Alcaligenes species, Arcanobacterium species, Citrobacter species, Enterobacter species, Enterocossus species, Escherichia coli, Klebsiella species, Morganella species, Oligella species, Proteus species, Pseudomonas species, Serratia species, Staphylococcus species, Stenotrophomonas species, Streptococcus species): Columbia agar with 5% sheep blood, chocolate agar, Columbia blood agar with nalidixin, cystine-lactose-electrolyte deficient agar for 24 to 48 hrs at 36±2 °C and at 5% carbon dioxide. In addition, brain-heart-infusion was inoculated with an incubation time of 14 days at 36±2 °C, ambient air. Media for the detection of anaerobic bacteria (Bacteroides species, Fusobacterium species, Prevotalla species) were also inoculated: CDC anaerobe 5% sheep blood agar with phenylethyl alcohol, Schaedler CNA agar with 5% sheep blood, and Schaedler agar with nalidixin and vancomycine for
24 to 48 hrs at 36±2 °C in anaerobic jars. Isolated pathogens were identified using MALDI-TOF (Bruker). Antibiotic susceptibility testing was performed by using the Vitek2 (automated system), disc diffusion or E-test method according to Eucast guidelines. The exact method used for the detection of antibiotic susceptibility depended on the exact species found.
Statistical analyses
Demographic data were analyzed using descriptive analyses in IBM SPSS Statistics, version 22. Microbiological culture results from wound swab and wound biopsy were compared using the following statistical parameters; total observed agreement, observed agreement per microorganism and kappa per microorganism. Total observed agreement was calculated as the percentage of wounds in which culture results from wound swab and wound biopsy were identical, i.e. the percentage of wounds in which both sampling methods found exactly the same microorganisms. Observed agreement per microorganisms was calculated as the percentage of wounds in which both wound swab and wound biopsy were positive (microorganism present) or negative (microorganism absent) for a specific microorganism (genus). For each microorganism, Cohen’s kappa was calculated together with a 95% confidence interval. Exploratory (sub) analyses were performed to identify whether there are differences in agreement or kappa between patients with different wound types. In addition, descriptive analyses were used to explore the impact of biopsy or swab use on antibiotic therapy (i.e. the number of deviations between antibiotic susceptibility of microorganisms cultured from biopsy versus swab).
RESULTS
A total of 180 patients were included in this study. The majority of patients were male (63.9%), and median age was 68. As frequently seen in clinical practice, wound existence differed enormously between patients (3 weeks – almost 20 years) with a median duration of 14 weeks. The most frequently seen wound types were diabetic foot ulcers and traumatic ulcers (table 3.1).
Table 3.1. Demographic and clinical characteristics of the study population (n = 180).
Frequency (%) Median
(range)
Sex Male 115 (63.9)
Female 65 (36.1)
Age in years 68.0
(28.0 – 95.0)
Wound type Venous leg ulcer 19 (10.6)
Arterial leg ulcer 11 (6.1)
Diabetic foot ulcer 64 (35.6)
Pressure ulcer 17 (9.4)
Postoperative wounds 16 (8.9)
Traumatic ulcers 42 (23.3)
Other* 11 (6.1)
Wound existence in weeks
14.1
(2.7 - 1021.7) Appearance of the
wound
Increased pain 15 (8.3)
Redness 46 (25.6)
Oedema 47 (26.1)
Warmth 31 (17.2)
Purulent exudate 19 (10.6)
Serous exudate 99 (55.0)
Delayed wound healing 110 (61.1) Discoloration of granulation tissue 57 (31.7) Friable granulation tissue 31 (17.2) Pockets of granulation tissue 32 (17.8)
Odour 22 (12.2)
Damaged epithelium 24 (13.3)
Fever, suspected to be related to the wound
7 (3.9)
* Other wound types consisted of wounds after split skin graft (SSG), bursitis, impetigo bullosa, erysipelas, erythema nodosum bulleus, removal of an infected CAPD catheter, pyoderma gangrenosum and mixed arterial and venous leg ulcers.
Culture results
A total of 21 different genera, including 46 different species, of microorganisms were identified (table 3.2). Normal skin flora was captured more often by wound swabs (in 73 wounds) than wound biopsies (25 wounds). Wound swabs were able to capture microorganisms (excluding skin flora) in 161 wounds, leaving 19 wounds with negative culture results (no growth). Twenty-five wounds had negative culture results according to wound biopsy, while microorganisms were captured in the remaining 155 wounds.
Both sampling methods had a comparable average recovery rate; 1.34 versus 1.35 microorganisms per wound for wound swab and wound biopsy respectively.
Table 3.2. Overview of cultured micro-organisms from wound swab and wound biopsy (n = 180 cultured wounds).
Genus Species Number of
swab cultures
Number of biopsy cultures
Acinetobacter Acinetobacter baumannii complex 3 3
Acinetobacter haemolyticus 1 0
Acinetobacter pittii 1 1
Alcaligenes Alcaligenes faecalis 2 1
Arcanobacterium Arcanobacterium haemolyticum 0 1
Bacteroides Bacteroides fragilis 1 0
Bacteroides ovatus 1 0
Bacteroides vulgatus 1 0
Citrobacter Citrobacter species 2 1
Enterobacter Enterobacter cloacae 1 1
Enterobacter cloacae complex 7 5
Enterococcus Enterococcus faecalis 5 6
Enterococcus faecium 0 1
Escherichia Escherichia coli 8 7
Fusobacterium Fusobacterium gonidiaformans 1 1
Fusobacterium species 1 0
Klebsiella Klebsiella oxytoca 4 5
Klebsiella pneumoniae 2 1
Morganella Morganella morganii 3 2
Oligella Oligella urethralis 0 1
Prevotella Prevotella bivia 1 1
Proteus Proteus mirabilis 11 7
Proteus vulgaris 3 2
Pseudomonas Pseudomonas aeruginosa 19 18
Serratia Serratia marcescens 1 1
Staphylococcus Staphylococcus aureus 114 107
Methicillin-resistant Staphylococcus aureus (MRSA)
2 2
Staphylococcus capitis 0 1
Staphylococcus epidermidis 2 5
Staphylococcus haemolyticus 0 1
Staphylcoccus sciuri 0 1
Staphylococcus simulans 1 2
Stenoptrophomonas Stenotrophomonas maltophilia 2 1
Streptococcus
*alpha-haemolytic streptococci
Viridans streptococci 0 1
Streptococcus oralis 0 1
*beta-haemolytic streptococci group B
Streptococcus agalactiae 13 15
*beta-haemolytic streptococci group C
Streptococcus dysgalactiae 0 1
Streptococcus equisimilis 8 7
Streptococcus group C 1 1
*beta-haemolytic streptococci group G
Streptococcus group G 18 16
Streptococcus canis 1 0
*beta-haemolytic streptococci group F
Streptococcus milleri group 0 1
(Non-pathogenic) skin flora 73 25
Total number of micro-organisms cultured 314 254
Total number of micro-organisms cultured excl. skin flora 241 229
Total number of wounds with any growth 161 155
Total number of wounds with no growth 19 25
Total observed agreement was 51.7%, i.e. culture results from both sampling methods were identical in 93 wounds, when normal skin flora was included in the analyses. For the discovery of microorganisms (excluding ‘skin flora’), 131 wounds (72.8%) showed identical culture results. Observed agreement and kappa (95% CI) for the most frequently cultured microorganisms are presented in table 3.3. These microorganisms cover 82.7% of the total number of microorganisms cultured in all included wounds.
Highest observed agreement (99.4%) and kappa (0.93) were found for Escherichia, while culture results of wound swab and wound biopsy had lowest observed agreement (84.4%) and kappa (0.66) for Staphylococcus spp.
Table 3.3. Observed agreement and kappa of swab versus biopsy for the most frequently cultured microorganisms.
Observed agreement Kappa
(95% CI) Biopsy
Enterobacter Present Absent
Swab Present 6 2
98.9% 0.85
(0.65 – 1.00)
Absent 0 172
Biopsy
Escherichia Present Absent
Swab Present 7 1
99.4% 0.93
(0.80 – 1.00)
Absent 0 172
Biopsy
Klebsiella Present Absent
Swab Present 4 2
97.8% 0.66
(0.32 – 0.99)
Absent 2 172
Biopsy
Proteus Present Absent
Swab Present 8 6
96.1% 0.68
(0.44 – 0.91)
Absent 1 165
Biopsy
Pseudomonas Present Absent
Swab Present 16 3
97.2% 0.85
(0.72 – 0.98)
Absent 2 159
Biopsy Staphylococcus (all*) Present Absent
Swab Present 103 15
84.4% 0.66
(0.54 – 0.78)
Absent 13 49
Biopsy Staphylococcus aureus Present Absent
Swab Present 101 15
87.2% 0.73
(0.62 – 0.83)
Absent 8 56
Biopsy Streptococcus (all) Present Absent
Swab Present 35 6
92.2% 0.78
(0.67 – 0.89)
Absent 8 131
Biopsy Beta-haemolytic
Streptococci group B Present Absent
Swab Present 11 2
96.7% 0.77
(0.59 – 0.95)
Absent 4 163
Biopsy Beta-haemolytic
Streptococci group C Present Absent
Swab Present 7 2
97.8% 0.77
(0.54 – 0.99)
Absent 2 169
Biopsy Beta-haemolytic
Streptococci group G Present Absent
Swab Present 14 5
96.1% 0.78
(0.62 – 0.94)
Absent 2 159
* In some wounds, two species of the genus Staphylococcus were found; Staphylococcus species were found 119 times in 118 wounds from wound swabs and 119 times in 116 wounds from wound biopsy.
There were no substantial differences in observed agreement and kappa for specific wound types. We did not observe substantial differences in agreement between both methods for specific wound types; results for the most frequently included wound types, diabetic foot ulcers, versus all other chronic wounds are presented in table 3.4.
Table 3.4. Observed agreement and kappa of swab versus biopsy in diabetic foot ulcers and other chronic wounds.
Diabetic foot ulcera (n = 64)
Other chronic wounds (n = 116) Observed
agreement
Kappa (95% CI) Observed agreement
Kappa (95% CI) Enterobacter 98.4% 0.90 (0.71 - 1.00) 99.1% 0.66 (0.01 - 1.00) Escherichia 100% 1.00 (1.00 - 1.00) 99.1% 0.85 (0.57 - 1.00) Klebsiella 96.9% 0.73 (0.37 - 1.00) 98.3% 0.49 (0.00 - 1.00)
Proteus 96.9% 0.65 (0.17 - 1.00) 95.7% 0.69 (0.42 - 0.96)
Pseudomonas 95.3% 0.77 (0.52 - 1.00) 98.3% 0.90 (0.76 - 1.00) Staphylococcus aureus 85.9% 0.71 (0.54 - 0.89) 87.9% 0.74 (0.61 - 0.87)
Staphylococcus (all) 82.8% 0.64 (0.45 - 0.83) 85.3% 0.67 (0.52 - 0.81)
Streptococcus (all) 90.6% 0.80 (0.65 - 0.95) 93.1% 0.73 (0.54 - 0.91)
Beta-haemolytic Streptococci group B
95.3% 0.77 (0.52 - 1.00) 97.4% 0.76 (0.48 - 1.00)
Beta-haemolytic Streptococci group C
96.9% 0.78 (0.49 - 1.00) 98.3% 0.74 (0.39 - 1.00)
Beta-haemolytic Streptococci group G
92.2% 0.75 (0.54 - 0.96) 98.3% 0.79 (0.51 - 1.00)
Differences in antibiotic susceptibility
Antibiotic susceptibility reports were available for 145 out of 180 patients. In 23 patients (15.9%), both wound swab and wound biopsy did not find any (pathogenic) growth.
Therefore, antibiotic susceptibility testing was not performed for these patients.
Comparison of antibiotic susceptibility of microorganisms cultured from wound swab versus wound biopsy was not possible in another 17 (11.7%) patients, since different microorganisms were found in wound biopsy and wound swab. For the remaining 105 patients, wound swab and wound biopsy found at least 1 similar microorganism. In 101 (96.2%) patients, both methods led to identical antibiotic susceptibility reports. On the level of microorganisms; antibiotic susceptibility was exactly the same for 135 (97.1%) out of 139 microorganisms.
DISCUSSION
This study demonstrated the differences between wound swab and wound biopsy for microbiological discovery in clinical practice. The generalizability to clinical practice was central to this study, since there still is no uniform guidance to what sampling method to use. We resembled clinical practice by including a broad variety of wounds and by using standard sampling and culture methods. This is in contrast to previous studies, which included relatively small sample sizes (varying between 9 and 83 patients 13-17,19-23 and were often limited to specific wound types 13-17,19,20.
We recovered an average of 1.34 and 1.35 pathogens per wound for swab and biopsy respectively, which is similar to the recovery rates found by Huang et al. (2016) and Demetriou et al. (2013). There have been studies published that found significantly higher recovery rates 17,21. For example, Smith et al. (2014) found an average of 4.26 (swab) and 4.00 (biopsy) isolates per wound and Cooper et al. (2009) recovered an average of 5.35 (swab) and 3.45 (biopsy) isolates per wound. These different recovery rates might have been due to the fact that in our study average recovery rates did not include cultured skin flora. In addition, the type of patients included in the studies performed by Smith et al. (2014) and Cooper et al. (2009) might have been the reason for their higher recovery rates. In the former study, active and former injection-drug- users were included at a mobile needle exchange station 21. It is plausible that a lack of hygiene might cause a higher amount of colonization in their wounds. Cooper et al.
(2009) included patients who had a local infection 17, in which it also might have been plausible that more isolates are recovered than would have been in a population in which both non-infected and (in a lower amount) infected wounds were included.
The type of organisms cultured through our study design resembled culture results reported in earlier studies 12,26,27, with Staphylococcus aureus, Streptococcus species, Pseudomonas aeruginosa, Escherichia and Enterococcus species as most frequently cultured microorganisms. As there have been studies that describe possible antimicrobial effects of lidocaine and other local anesthetics in wounds 28,29, we examined the effect of the provision of local anesthesia with lidocaine drops in our study. We compared culture results from tissue samples between the group of patients who were anesthetized with lidocaine drops (n = 105) versus patients who did not receive local anesthetics (n = 67). We had to exclude 8 patients from these comparisons, as we could not determine with certainty whether they did or did not receive local anesthetics. We did not find any significant differences between the two groups in recovery rates of the type of cultured microorganisms (data not shown).
In slightly less than half (48.3%) of the patients included in this study, wound biopsy and wound swab did not show identical culture results. The main reason for the lack of perfect agreement between both sampling methods originates from culturing normal human skin flora. Human skin flora was cultured significantly more often from wound swabs, which is inherent in the superficial aspect of this sampling technique. The intention when sampling for microbiological culture, however, is to discover possible pathogenic microorganisms rather than human skin flora. When human skin flora is excluded from the comparison, 72.8% of all wounds showed identical culture results.
This implies that in a large part of patients in wound care, both wound biopsy and wound swab yield exactly the same culture results. This is in agreement with other studies
14,16,20,22, and in particular with the study performed by Gardner et al. (2006), who compared wound swab (Levine technique) and biopsy and found concordance in 78% of all wounds 23. For specific microorganisms, observed agreement varied between 99.4 and 84.4%. Kappa was not lower than 0.655, indicating that both methods are fairly similar in recovering specific microorganisms. These results show that, in clinical practice, both wound swab and wound biopsy lead to similar microbiological culture results. An explanation about the comparability between wound swab and wound biopsy was given by Bowler (1999). He noted that many wounds are contaminated with microorganisms from the environment, which makes it highly unlikely that microorganisms that have invaded deeper tissue aren’t present in superficial tissue 12,26.
It is important to bear in mind that there remain differences between both sampling methods. The question, however, is to what extent these differences between both methods lead to different clinical implications. In our exploratory analyses, we showed that the antibiotic susceptibility was the same for microorganisms cultured from either method in almost all patients (96.2%). In almost none of the patients, biopsy would have led to the choice of a different antibiotic treatment. The sampling methods however do have substantial differences when it comes to the impact it places on patients and on clinical practice logistics. The most important disadvantage of wound biopsy is that it is an invasive method 22,30,31. This is in contrast to wound swabs, which are non-invasive, (usually) not painful and relatively easy to perform. Within our study, patients were reluctant to the idea of a punch biopsy because they expected it to be painful, despite of our ability to provide adequate anesthesia, or harmful to wound healing. Another difficulty lies in the fact that it is not always possible to perform biopsy, because of wound characteristics (e.g. size, extremely friable wound tissue, underlying bone) or patient morbidities (e.g. risk of uncontrollable bleeding). Logistically, biopsies are also more difficult to perform. Wound care nurses have to be trained in performing biopsies, as it is an invasive method. In this study, we trained all involved nurses in taking wound biopsies, including all involved home care nurses. Biopsies in home care were performed under supervision of a clinician, who would be able to help in case any complication would occur. In our opinion, it is possible to perform biopsies in home care if there is clinical ‘back-up’ in case of complications. However, this requires more complex logistic planning, which might not be rewarding when comparable results are yielded from wound swabs.
Nonetheless, one should be aware that both sampling methods do not allow identification of all microorganisms actually present in the wound. Some microorganisms are not viable after sampling, and thus will not be recovered from microbiological culture
32. For instance, anaerobic microorganisms are difficult to recover in clinical practice because strict anaerobic techniques are often not used 26. Furthermore, the sensitivity of microbiological culture to detect all microorganisms present in the wound sample might be decreased by the presence of multiple different microorganisms in the wound, i.e.
the polymicrobial nature of wounds 26,32. In addition, standard culture procedures are limited in their ability to detect biofilm, which often includes viable but non-culturable microorganisms 33. These limitations might be resolved by molecular techniques, like 16S rRNA sequencing. Such techniques are proven to detect a greater diversity of microorganisms 34, but one should be aware that they still do not recover all microorganisms present in a wound. Furthermore, results might be difficult to interpret
in clinical practice as it is difficult to determine which microorganisms should be targeted by treatment 35, especially since these techniques do not only amplify living, but also dead microorganisms 36.
Based on our study results, we recommend clinicians to initially choose wound swabs as sampling method for the discovery of microorganisms and antibiotic susceptibility reports. Wound swabs yield similar results to wound biopsy, but impose a lower burden on the patient and clinical logistics than wound biopsies. Since wound swab and wound biopsy do not yield identical culture results in 100% of all cases, clinicians might consider a wound biopsy in case patients do not respond to antibiotic treatment chosen based on swab culture results. Clinicians should, however, be aware that neither wound biopsy nor wound swab allow identification of all of all microorganisms present in the wound.
ACKNOWLEDGMENTS
This work was supported by Seventh Framework program: FP7-NMP-2013-SME-7 (INFACT project, Grant agreement no.: 609198) and by Qualizyme Diagnostics GmbH.
CONFLICT OF INTEREST No conflict.
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