Validity of Diagnosis of Superficial Infection of Laparotomy Wounds Using Digital Photography
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Abstract: Background. The use of digital photography to assess and document the wound healing process has become increasingly popular. One of the most common complications of wound healing is infection, but the validity of digital photography for the diagnosis of wound infection is unknown. We intended to measure the degree of inter and intra-observer agreement on the diagnosis of superficial wound infection using digital photography. Methods. In a prospective, observational clinical study, abdominal wounds were photographed daily and signs of infection were documented in a standard manner. Four surgeons independently assessed photographs of 50 wounds opened for infection within hours after photography and 50 normally healed wounds (n = 50). Wound pain scores, morning temperature, and postoperative day were noted. Surgeons recorded the presence of infection and treatment for each wound. Paired kappa (κ) values were calculated and intra-observer agreement was measured after 4–6 weeks. Results. Mean specificity with regard to infection was 97% (94%–100%) and mean sensitivity was 42% (32%–48%). Paired κ-values with regard to wound infection were: 0.54, 0.67, 0.68, 0.63, 0.58, and 0.61. Agreement on treatment was present in 76 of 100 wounds (κ values: 0.15, 0.17, 0.20, 0.72, 0.63, 0.68). Kappa values for intra-observer agreement on infection were: 0.66, 0.43, 0.74, and 0.76 for surgeons A, B, C, and D, respectively. Conclusion. Inter- and intra-observer agreement on the diagnosis of superficial infection with digital photography are moderate, but specificity is high. Physical examination findings should also be reported.
Address correspondence to:
Gabriëlle H. van Ramshorst, MD
Department of Surgery, Erasmus University Medical Center
Room Z-836
PO Box 2040, 3000 CA
Rotterdam, The Netherlands
Email:
g.vanramshorst@erasmusmc.nl
Recently, the use of digital photography has become increasingly popular and highlighted in literature for documentation and evaluation of wound healing progression in addition to its usefulness in telemedicine for diagnosis in dermatology and vascular surgery.1–3 For chronic and burn wounds in particular, photography can be used to assess treatment results and support continuation or alteration of treatment strategy.4 One of the most common complications of surgery is wound infection, as approximately 10% of all abdominal wounds are affected.5,6 Although the validity of digital photography has been reported for a number of indications, its validity of diagnosing infection in surgical wounds remains unclear.3
The diagnosis of infection of the acute wound has been based on symptoms such as rubor, dolor, calor, tumor, and functio laesa, which have been around since the time of Hippocrates. Physicians diagnose wound infection based on subjective and objective criteria and experience. The international gold standard for diagnosis of surgical wound infection is represented by the criteria for surgical site infection (SSI) as defined by the Centers for Disease Control and Prevention (CDC).7 According to the CDC, the surgeon’s judgment is very important in the diagnosis of superficial SSI. In several studies where wound photography was used to assess healed lacerations and incisions, moderate to good inter- and intra-observer agreement was found on wound appearance scales.8–10 Few reports exist on agreement among surgeons with regard to wound assessment.
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