title: Sample procurement for cultures of infected wounds: a systematic review.
abstract: OBJECTIVE
  Identifying the responsible pathogen is required in order to select optimum antimicrobial therapy for infected wounds, but the best techniques to use remain the subject of debate. Our aim was to assess the evidence on the value of wound swabs compared with biopsies.
  
  
  METHODS
  We conducted a systematic literature review with the terms 'wound infection', 'wound swab', 'wound swab technique', 'wound biopsy', 'wound culture', 'wound swab comparison', 'Levine swab technique', 'microbiological technique', 'specimen handling', 'bacterial load', 'perioperative care', 'swab', and 'culture'. We examined yields in identifying relevant pathogens, summarised salient features of qualifying studies, and defined knowledge gaps and endpoints that future studies should address.
  
  
  RESULTS
  Studies have been inconsistent, lacking specificity regarding wound types, clinical features, and sampling methods. We found moderate quality evidence that punch biopsies provide qualitative and quantitative information about the bacterial load and tissue reaction with nearly 100% sensitivity, 90% specificity and 95% accuracy for predicting wound closure. Biopsies are relatively invasive, costly, require skilled operators, and potentially exacerbate infection. Needle aspiration samples a limited portion and may enter uninfected tissue and extend infection. Wound swabs are minimally invasive, easier to perform and widely employed in clinical practice, but techniques vary. In comparative studies, the Levine technique was superior to the Z-swab techniques, and biopsies were more sensitive for antibiotic-resistant wounds than Levine or Levine-like swabs, suggesting that swabs may be useful for initial wound monitoring, but biopsies are preferred when antibiotic resistance is suspected.
  
  
  CONCLUSIONS
  The Levine swab is superior to the Z-swab technique and may be useful for initial wound monitoring, but quantitative biopsies are preferred for evaluation of antibiotic-resistant wounds and to monitor the response to treatment. There is limited evidence on the role of wound swabs for detecting wound colonisation versus infection and the impact of culture-guided therapy on such clinical outcomes as eradication of infection and accelerated healing. Future studies should specify patient populations, wound types, sampling protocols, and outcomes based on culture yield and treatment results, using rigorous statistical methodology.
authors.affiliation: Inova Fairfax Hospital.
authors.forename: L R
authors.initials: LR
authors.lastname: Copeland-Halperin
authors.affiliation: Inova Fairfax Hospital.
authors.forename: A J
authors.initials: AJ
authors.lastname: Kaminsky
authors.affiliation: Inova Fairfax Hospital.
authors.forename: N
authors.initials: N
authors.lastname: Bluefeld
authors.affiliation: Inova Fairfax Hospital.|Virginia Commonwealth University and Georgetown University.
authors.forename: R
authors.initials: R
authors.lastname: Miraliakbari
mesh_terms: D001706:Biopsy / Q000379:methods*; D006801:Humans; D008828:Microbiological Techniques / Q000379:methods*; D013048:Specimen Handling / Q000379:methods*; D014946:Wound Infection / Q000175:diagnosis* / Q000382:microbiology
keywords: Levine; anti-bacterial agents; bacterial load; biofilms; biopsy; microbe; swab; wound healing; z-swab