Topical antimicrobial toxicity

Wound infection, dressings and pain, is there a relationship in the chronic wound?

The focus on quality of life issues in wound care has justly taken a far greater importance. With the acceptance that pain can be a major factor to the patient, and in particular, pain at dressing change comes the opportunity for avoidance and/or reduction strategies. Whilst pain has been associated with wound infection for millennia, it is only much more recently that this has received due attention from research and clinical practice. In this study, the nature of pain, changes in pain and pain associated with infection are the focal points. A Delphi approach, now a frequently used tool in wound care research, has been used to obtain expert opinion on these aspects of management.

Proper care of early wounds to optimize healing and prevent complications

Proper wound care has broad applications for all clinicians. Much of the future direction for enhancing wound repair focuses on key cells and growth factors, which is why possessing a strong understanding of the basic physiology of wound healing is imperative. This article first provides a thorough review of the phases of wound healing followed by a discussion on the latest wound management strategies. Wound conditions and surgical techniques are important components for optimizing wound healing and preventing complications. Special consideration has been given to the unique settings of contaminated wounds, open wounds, or avulsed tissue.

Wound healing through synergy of hyaluronan and an iodine complex

Hyaluronan, a glycosaminoglycan (GAG), is a polysaccharide found in many locations in the human body, such as eye, skin and soft tissue. It is also found in other mammals and bacteria. As a component of the extracellular matrix, its role in wound repair, among others, is that of providing a temporary structure to support new tissue formation. Harnessing the therapeutic action of hyaluronan into a topical application of proven clinical benefit has proved challenging. A new development in hyaluronan technology, comprising sodium hyaluronate and iodine complex, offers a novel approach in exploiting the benefits of hyaluronan and delivering real clinical benefits for a wide range of wound types.

Evaluation of wound-healing formulation against sulphur mustard-induced skin injury in mice

Sulphur mustard (SM) is a bifunctional alkylating agent that causes cutaneous blisters in human and animals. Remedies to SM-induced dermatotoxicity are still in experimental stage. Due to inevitable requirement of a wound-healing formulation against SM-induced skin lesions, efficacy of formulations including povidone iodine, Aloe vera gel, betaine or framycetin sulphate was evaluated in present study. SM was applied percutaneously (5 mg/kg) once on back region of Swiss albino mice; and after 24 hours, DRDE/WH-02 (Defence Research and Development Establishment/ Wound Healant- 02, containing polyvinylpyrrolidone [PVP], A. vera gel and betaine), Ovadine, Soframycin or A. vera gel were applied topically, daily for 3 or 7 days in different groups. Skin sections were subjected to histopathology, histomorphologic grading, tissue leukocytosis, terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) assay and immunohistochemistry of inflammatory-reparative biomarkers. DRDE/WH-02 treated mice received highest score on the basis of histomorphologic scale and lowest number of TUNEL-positive cells compared to other groups. DRDE/WH-02 showed better wound healing as evidenced by widespread re-epithelialization, homogenous fibroplasias well supported by the expression of transforming growth factor-α, endothelial nitric oxide synthase (eNOS) and fibroblast growth factor. Upregulation of interleukin 6 in DRDE/WH-02-treated mice skin resulted in increased tissue leukocytosis and an early removal of tissue debris that initiated reparative process at faster rate compared to other groups. In conclusion, DRDE/WH-02 provided better healing effect and can be recommended as an effective wound healant against SM-induced skin injury.

Silver nanoparticles as real topical bullets for wound healing

Nanotechnology is on the threshold of providing a host of new materials and approaches, revolutionizing the medical and pharmaceutical fields. Several areas of medical care are already profiting from the advantage that nanotechnology offers. Recently, silver nanoparticles are attracting interest for a clinical application because of its potential biological properties such as antibacterial activity, anti-inflammatory effects, and wound healing efficacy, which could be exploited in developing better dressings for wounds and ulcers. This article reviews the role of silver nanoparticles in wound healing.

Hydrogen Peroxide – A Party Trick from the Past?

Hydrogen peroxide solutions are found in almost every operating theatre and are used by many surgical specialties, often with little knowledge of their inherent risk. We reviewed the literature and evidence related to the use of hydrogen peroxide in surgery. We found little evidence supporting the use of hydrogen peroxide solutions intraoperatively, a large number of reports of sometimes-fatal oxygen embolism and other evidence of tissue toxicity. We conclude that the use of hydrogen peroxide as an antiseptic has no direct benefit, but is associated with significant risk, and therefore should be reconsidered.

Wound healing effect of Haruan (Channa striatus) spray

Haruan (Channa striatus) is a type of fresh water fish in Malaysia that is known to promote wound healing. Haruan water extract has been formulated in an aerosol system which can produce a film for wound dressing. As topical preparation, Haruan spray needs to be evaluated in terms of the possibility to cause irritation reaction or toxic response. Three experiments were carried out to evaluate the safety of Haruan spray which are Primary Skin Irritation test, Intracutaneous test and Systemic Injection test. The result shows that Haruan spray gave no significant responses to all the above tests. The investigation of the effect of Haruan spray as wound dressing in the healing process was performed in Sprague-Dawley rats where 6-cm long full-thickness incision wound and burn wound were made on the back of the animals. Haruan spray was tested and compared with blank formula as control. Tensile strength test of treated wound was carried out at the 3rd, 6th, 9th and 12th day after wounding and treatment. The burn wounds contraction was measured daily for 21 days. Results showed that haruan water extract spray formula is not only effective but also safe for application to both incision and burn wounds.

Evaluation of LHP® (1% hydrogen peroxide) cream versus petrolatum and untreated controls in open wounds in healthy horses: a randomized, blinded control study

Background

Treatment and protection of wounds in horses can be challenging; protecting bandages may be difficult to apply on the proximal extremities and the body. Unprotected wounds carry an increased risk of bacterial contamination and subsequent infection which can lead to delayed wound healing. Topical treatment with antimicrobials is one possibility to prevent bacterial colonization or infection, but the frequent use of antimicrobials ultimately leads to development of bacterial resistance which is an increasing concern in both human and veterinary medicine.

Methods

Standardized wounds were created in 10 Standardbred mares. Three wounds were made in each horse. Two wounds were randomly treated with LHP^® or petrolatum and the third wound served as untreated control. All wounds were assessed daily until complete epithelization. Protocol data were recorded on day 2, 6, 11, 16, 21 and 28. Data included clinical scores for inflammation and healing, photoplanimetry for calculating wound areas and swab cytology to assess bacterial colonization and inflammation. Bacterial cultures were obtained on day 2, 6 and 16.

Results

Mean time to complete healing for LHP^® treated wounds was 32 days (95%CI = 26.9-37.7). Mean time to complete healing for petrolatum and untreated control wounds were 41.6 days (95%CI = 36.2-47.0) and 44.0 days (95%CI = 38.6-49.4) respectively. Wound healing occurred significantly faster in LHP^® wounds compared to both petrolatum (p = 0.0004) and untreated controls (p < 0.0001). There was no significant difference in time for healing between petrolatum and untreated controls. Total scores for bacteria and neutrophils were significantly (p < 0.0001) lower for LHP^® treated wounds compared to petrolatum from day 16 and onwards. Staphylococcus aureus and Streptococcus zooepidemicus were only found in cultures from petrolatum treated wounds and untreated controls.

Conclusions

Treatment with LHP^® reduced bacterial colonization and was associated with earlier complete wound healing. LHP^® cream appears to be safe and effective for topical wound treatment or wound protection.

Evolution in the treatment of mediastinitis: single-center experience

This study aimed to evaluate our 30-year experience in the treatment of deep sternal wound infection after cardiac surgery. Between 1979 and 2009, deep sternal wound infections occurred in 200 of 22,366 (0.89%) patients who underwent sternotomy. The study population was divided into 3 groups. In group A (62 patients; 1979–1994), an initial attempt at conservative antibiotic therapy was the rule, followed by surgery in case of failure. In group B (83 patients; 1995–2002), the treatment was in 3 steps: wound debridement and closed irrigation for 10 days; in case of failure, open dressing with sugar and hyperbaric treatment; delayed healing and negative wound cultures mandated plastic reconstruction. In group C (2002–2009), the treatment was based on early surgical debridement, vacuum application, and reconstruction using pectoralis muscle flap. Hospital mortality in group A was significantly higher than that in groups B and C. Hospital stay, time for normalization of white blood cell count and C reactive protein, and time for defervescence were significantly shorter in group C. In our experience, early surgical debridement and vacuum application followed by plastic reconstruction provided a satisfactory rate of healing and a good survival rate.

Mediastinitis in pediatric cardiac surgery: Prevention, diagnosis and treatment

In spite of advances in the management of mediastinitis following sternotomy, mediastinitis is still associated with significant morbidity. The prognosis is much better in pediatric surgery compared to adult surgery, but the prolonged hospital stays with intravenous therapy and frequent required dressing changes that occur with several therapeutic approaches are poorly tolerated. Prevention includes nasal decontamination, skin preparation, antibioprophylaxis and air filtration in the operating theater. The expertise of the surgical team is an additional factor that is difficult to assess precisely. Diagnosis is often very simple, being made on the basis of a septic state with wound modification, while retrosternal puncture and CT scan are rarely useful. Treatment of mediastinitis following sternotomy is always a combination of surgical debridement and antibiotic therapy. Continued use of numerous surgical techniques demonstrates that there is no consensus and the best treatment has yet to be determined. However, we suggest that a primary sternal closure is the best surgical option for pediatric patients. We propose a simple technique with high-vacuum Redon's catheter drainage that allows early mobilization and short term antibiotherapy, which thus decreases physiological and psychological trauma for patients and families. We have demonstrated the efficiency of this technique, which is also cost-effective by decreasing intensive care and hospital stay durations, in a large group of patients.

Treatment with chlorhexidine modifies the healing of colon anastomosis in rats

PURPOSE

To investigate the effects of chlorhexidine on the healing of colon anastomosis in the presence of peritonitis.

METHODS

Peritonitis was induced in male Wistar rats by cecal ligation and puncture (CLP). The abdominal cavities of experimental animals were irrigated with warm solutions containing 0.9% saline (SAL group; n = 8) or 0.05% chlorhexidine (CHD group; n = 8), following which colon anastomosis was performed. Rats of the control group (n = 8) were submitted to colon anastomosis but not to CLP. Animals were euthanized seven days after surgery, and healing was assessed by histopathological examination and by measuring anastomotic burst pressure.

RESULTS

Post-operative survival rates were 100, 87.5 and 75% for the control, SAL, and CHD groups, respectively. The degree of inflammation was significantly lower (ρ = 0.01) in the CHD group compared with the other groups, whilst the anastomotic burst pressure within the CHD group (156.7 ± 53.2 mmHg) was lower than, but not significantly different from, those of the control and SAL groups (196.3 ± 49.8, 208.6 ± 72.7 mmHg, respectively).

CONCLUSIONS

Peritoneal irrigation with chlorhexidine solution is effective in the control of inflammation promoted by peritonitis but does not improve healing of colon anastomosis in rats.

An update on pharmacological interventions for diabetic foot ulcers

Diabetic foot ulcers are the most common lower extremity complications of diabetes. Peripheral neuropathy and peripheral vascular disease are the underlying risk factors for diabetic foot ulcers, subsequently leading to infections and requiring antimicrobial therapy for the management of the disease. Each risk factor is a target for clinical intervention, with the intent to delay or prevent disease progression to amputation. The effective therapy includes interdisciplinary care, which involves optimized pharmacological interventions in concert with other treatments such as debridement strategies and specialized wound dressings. The pharmacological therapy alone cannot lead to successful therapy, and therefore, these supplementary techniques/modalities should not be overlooked. It is therefore the aim of this report to review various pharmacological interventions, specific to the diabetic foot and wound healing, along with incorporation of advanced therapies required to achieve a multifaceted treatment of diabetic foot ulcers and provide basis for superior drugs as well as drug delivery systems.

Acute wound pain: gaining a better understanding

PURPOSE

To provide the wound care practitioner with an overview of research and knowledge about the causes, mechanisms, contributing factors, and management of acute wound pain.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.

OBJECTIVES

After reading this article and taking this test, the reader should be able to: 1. Describe the causes of acute wound pain. 2. Discuss research findings related to the physiology of wound pain. 3. Identify current concepts in the management of acute wound pain.

Topical antimicrobials for burn wound infections

Throughout most of history, serious burns occupying a large percentage of body surface area were an almost certain death sentence because of subsequent infection. A number of factors such as disruption of the skin barrier, ready availability of bacterial nutrients in the burn milieu, destruction of the vascular supply to the burned skin, and systemic disturbances lead to immunosuppression combined together to make burns particularly susceptible to infection. In the 20th century the introduction of antibiotic and antifungal drugs, the use of topical antimicrobials that could be applied to burns, and widespread adoption of early excision and grafting all helped to dramatically increase survival. However the relentless increase in microbial resistance to antibiotics and other antimicrobials has led to a renewed search for alternative approaches to prevent and combat burn infections. This review will cover patented strategies that have been issued or filed with regard to new topical agents, preparations, and methods of combating burn infections. Animal models that are used in preclinical studies are discussed. Various silver preparations (nanocrystalline and slow release) are the mainstay of many approaches but antimicrobial peptides, topical photodynamic therapy, chitosan preparations, new iodine delivery formulations, phage therapy and natural products such as honey and essential oils have all been tested. This active area of research will continue to provide new topical antimicrobials for burns that will battle against growing multidrug resistance.

Diluted povidone-iodine versus saline for dressing metal-skin interfaces in external fixation

PURPOSE

To compare infection rates associated with 2 dressing solutions for metal-skin interfaces.

METHODS

60 patients who underwent distraction osteogenesis with external fixators were equally randomised into 2 dressing solution groups (diluted povidone-iodine vs. saline). Fixations were attained using either rigid stainless steel 5-mm diameter half pins or smooth stainless steel 1.8-mm diameter wires. Half-pin fixation had one metal-skin interface, whereas wire fixation had 2 interfaces. Patients were followed up every 2 weeks for 6 months.

RESULTS

Of all 788 metal-skin interfaces, 143 (18%) were infected: 72 (19%) of 371 in the diluted povidone-iodine group and 71 (17%) of 417 in the saline group. Dressing solution and patient age did not significantly affect infection rates. Half-pin fixation was more likely to become infected than wire fixation (25% vs 15%).

CONCLUSION

Saline is as effective as diluted povidone-iodine as a dressing solution for metal-skin interfaces of external fixators. Saline is recommended in view of its easy availability and lower costs.

Topical antimicrobial therapy of chronic wounds healing by secondary intention using iodine products

All open wounds healing by secondary intention are contaminated by bacteria and in chronic wounds this can progress through colonisation to invasive infection. Iodine products reduce bacterial load and are active against most species of micro-organisms, and certainly those encountered in chronic wound care. This review evaluates the use of iodine products in chronic wound care including povidone-iodine solutions and cadexomer iodine. Antiseptics containing iodine are relatively cheap, resistance is unknown and concerns about systemic toxicity are probably overstated. More widespread use of these agents as topical anti-microbials in chronic wound care should be considered to reduce the need for systemic antibiotics when colonisation has progressed to invasive infection with systemic signs.

Negative pressure wound therapy with instillation: a pilot study describing a new method for treating infected wounds

This data review reports the results of 15 patients who were treated with Vacuum-Assisted Closure (VAC) negative pressure therapy system in addition to the timed, intermittent delivery of an instilled topical solution for management of their complex, infected wounds. Prospective data for 15 patients treated with negative pressure wound therapy (NPWT)-instillation was recorded and analysed. Primary endpoints were compared to a retrospective control group of 15 patients treated with our institution's standard moist wound-care therapy. Culture-specific systemic antibiotics were prescribed as per specific patient need in both groups. All data were checked for normality of distribution and equality of variance and appropriate parametric and non parametric analyses were conducted. Compared with the standard moist wound-care therapy control group, patients in the NPWT-instillation group required fewer days of treatment (36.5 +/- 13.1 versus 9.9 +/- 4.3 days, P < 0.001), cleared of clinical infection earlier (25.9 +/- 6.6 versus 6.0 +/- 1.5 days, P < 0.001), had wounds close earlier (29.6 +/- 6.5 versus 13.2 +/- 6.8 days, P < 0.001) and had fewer in-hospital stay days (39.2 +/- 12.1 versus 14.7 +/- 9.2 days, P < 0.001). In this pilot study, NPWT instillation showed a significant decrease in the mean time to bioburden reduction, wound closure and hospital discharge compared with traditional wet-to-moist wound care. Outcomes from this study analysis suggest that the use of NPWT instillation may reduce cost and decrease inpatient care requirements for these complex, infected wounds.

Hydrogen peroxide and wound healing: a theoretical and practical review for hair transplant surgeons

BACKGROUND

In most hair restoration practices, hydrogen peroxide has been routinely used to remove blood during and after hair transplant surgery. In other specialties, hydrogen peroxide is also used in these ways: wound cleaning, prevention of infection, hemostasis, and removal of debris. Despite its widespread use, there are still concerns and controversy about the potential toxic effect of hydrogen peroxide.

OBJECTIVE

The objective was to review all available literature including in vivo and in vitro effects of hydrogen peroxide, as well as general wound healing research.

MATERIAL AND METHODS

Literature up to and including the past three decades was investigated.

RESULTS

Two pilot studies were found, and there are not enough data examining the real impact of using hydrogen peroxide in hair transplant surgery. In other specialties, H(2)O(2) appears to have positive effects, such as stimulation of vascular endothelial growth factor, induction of fibroblast proliferation, and collagen, or negative effects, such as cytotoxicity, inhibition of keratinocyte migration, disruption of scarless fetal wound repair, and apoptosis.

CONCLUSIONS

There are not enough data in hair restoration surgery about the use of hydrogen peroxide, and it is unknown and unclear what the optimum dilution should be. Positive and negative effects were found in other specialties. Further studies are recommended. The authors have indicated no significant interest with commercial supporters.

Incorporating wound healing strategies to improve palliation (symptom management) in patients with chronic wounds

BACKGROUND

Palliative wound care should be centered on symptom management and is a viable option for patients whose chronic wounds do not respond to standard interventions, or when the demands of treatment are beyond the patient's tolerance or stamina. Palliative wound care is the incorporation of strategies that prioritize symptomatic relief and wound improvement ahead of wound healing (total closure). Palliative wound care strategies must also work in conjunction with curative treatment objectives as wounds often heal completely in spite of serious illness and advanced disease. Palliative wound care is much more than pain, exudate and odor management. Common curative treatment goals such as physical correction of the underlying pathology, addressing nutrition and other supportive aspects of care, and sensible (nonharmful) local wound treatments should never be ignored.

OBJECTIVE

(1) To provide a fresh and effective approach to palliative wound care by integrating individual clinical expertise with clinical and laboratory evidence from the (curative) wound healing literature and (2) to share our (Calvary Hospital) experience and approach to palliative wound care in an inpatient, home, and outpatient setting. This approach can be summarized with the mnemonic S-P-E-C-I-A-L (S = stabilizing the wound, P = preventing new wounds, E = eliminate odor, C = control pain, I = infection prophylaxis, A = advanced, absorbent wound dressings, L = lessen dressing changes). Throughout this paper we will offer rationale, principles and recipes, for each of the steps of the "SPECIAL" approach in an effort to facilitate the caring for chronic wounds in palliative medicine.

CONCLUSIONS

A practical marriage of wound palliation (symptom management) with current wound healing concepts to provide options for the palliative care provider and improve the practice of palliative medicine.

The influence of 3% hydrogen peroxide on the survival rate of hair grafts when used as an antiseptic solution for surgical wound care: experience with five patients

BACKGROUND

A solution of 3% hydrogen peroxide is one of the most widely used antiseptics to decrease bacterial colonization.

OBJECTIVE

We performed this study to evaluate influence of 3% hydrogen peroxide on the survival rate of hair grafts.

METHODS

We designed two templates on both frontoparietal recesses of five patients with male pattern alopecia. Follicular units containing single hairs were obtained from occiput. We grafted approximately 50 follicular units on each template. The gauze with normal saline was applied on the left template and the gauze with 3% hydrogen peroxide on the right template for 5 minutes. This procedure was repeated four times at 30-minute intervals. The number of surviving hairs of each template was counted 3 and 10 months after hair transplantation.

RESULTS

There was no statistically significant difference in the mean survival rate of the grafts between hydrogen peroxide and normal saline 3 and 10 months after transplantation (Mann-Whitney test, p>.05).

CONCLUSION

We think surgical wound care with 3% hydrogen peroxide during hair restoration surgery does not affect the survival rate of hair grafts when compared with normal saline. We also need further evaluation with larger participants to overcome small sample size and to gather other information.

Topical diphenylhydantoin sodium can improve healing in a diabetic incisional animal wound model

OBJECTIVE

Anecdotally, topical application of diphenylhydantoin sodium (DpH) (phenytoin) has been shown to aid wound healing. We previously reported improved healing following topical infiltration of DpH in a healthy animal wound model. This study evaluates its effect on an incisional wound model in diabetic animals.

METHOD

Twenty-five male Sprague-Dawley rats were rendered diabetic by a single intraperitoneal injection of streptozotocin. Two caudal and two cephalad wounds were made on the dorsal surface. A polyvinyl alcohol sponge was placed in a subcutaneous pocket created proximal to both cephalad wounds. Each wound was either treated topically with 10mg DpH in a 200microl carrier or an equal volume of the saline vehicle (control) on the day of wounding and days 3 and 6 post-incision. The animals were sacrificed on day 10. The breaking strength of fresh and fixed wounds was determined by tensiometry, and the hydroxyproline content was determined spectrophotometrically.

RESULTS

There was a significant overall increase in both fresh (24%) and fixed (18%) wound-breaking strength of the DpH-treated wounds when compared with the controls (p<0.05). This was associated with an increase in collagen synthesis as indicated by the increased hydroxyproline content in the DpH-infiltrated sponges when compared with the controls.

CONCLUSION

Our data suggest that topical DpH improves healing in a diabetic wound model. Topical administration of DpH has the potential to accelerate diabetic wound healing and should be evaluated in human diabetic wounds.

Evidence-based wound management: a systematic review of therapeutic agents to enhance granulation and epithelialization

Successful management of open wounds in dogs requires knowledge of the physiology of wound healing and application of that knowledge to choose appropriate therapeutic intervention. The authors' objective was to investigate whether or not there are any available therapeutic agents that enhance granulation or epithelialization of open wounds in dogs. Based on the literature identified in the authors' review, there is insufficient evidence to make a recommendation for or against any of the topical wound agents or procedures studied.

The effect of intravitreally injected povidone-iodine on Staphylococcus epidermidis in rabbit eyes

PURPOSE

Firstly, the aim of this study was to determine the maximally tolerated dose of intravitreally injected povidone-iodine (PVP-I). A second aim was to test the efficacy of PVP-I on rabbit eyes infected intravitreally with Staphylococcus epidermidis.

METHODS

Phase I of the study used 16 New Zealand albino rabbits, divided into 4 groups (n=4 each). Animals were anesthetized and intravitreally injected with 0.1 mL of 50, 100, 200, or 400 micrograms (microg) of PVP-I in 1 eye, and with saline in the other. The animals were examined at days 1, 7, and 14, using indirect ophthalmoscopy and slit-lamp biomicroscopy; electroretinography (ERG) was performed before treatment and prior to euthanization. Histological preparations were examined to determine retinal damage. Phase II of the study divided 20 New Zealand albino rabbits into 4 groups (n=5 each). Animals were anesthetized and injected with 0.1 mL of S. epidermidis containing 3030 colony forming units (CFU) in 1 eye and saline in the other. Seven (7) h later, animals were treated with 0.1 mL of 20, 50, and 100 microg of PVP-I, or no treatment. Bacterial concentrations from extracted vitreous were determined 2 days following infection. Results were analyzed for statistical significance, using the Student t test and analysis of variance, and histologic preparations assessed the presence of endophthalmitis.

RESULTS

Phase I of the study observed no retinal damage at any of the concentrations studied, as noted by indirect ophthalmoscopy, slit-lamp biomicroscopy, ERG, and histologic exam. Phase II of the study showed no statistical difference in bacterial counts between treatment and control groups. All infected eyes went on to develop endophthalmitis, as observed by indirect ophthalmoscopy and histologic preparations.

CONCLUSIONS

These results suggest that 400_g of PVP-I can be tolerated intravitreally in rabbit eyes with no noticeable damage over a 14-day period. Results further showed that 100 microg of intravitreally injected PVP-I has no statistically significant effect on rabbit eyes injected intravitreally with 3030 CFU of S. epidermidis.

Bactericidal and Cytotoxic Effects of Chloramine-T on Wound Pathogens and Human Fibroblasts In Vitro

OBJECTIVES

To evaluate cytotoxicity and bactericidal effects of chloramine-T.

METHODS

In vitro study of various concentrations and exposure times to preparations containing human fibroblasts or 1.5 x 10 colony forming units per milliliter (CFU/mL) of 3 gram-positive bacteria-Staphylococcus aureus, methicillin-resistant S aureus, and vancomycin-resistant Enterococcus faecalis-and 2 gram-negative bacteria-Escherichia coli and Pseudomonas aeruginosa-with and without fetal bovine serum present.

MAIN OUTCOME MEASURES

Percentage reduction of bacterial growth and percentage of viable fibroblasts 48 hours after exposure.

RESULTS

All gram-positive growth was reduced by 95% to 100%, regardless of dose, with or without serum. E coli (gram-negative; with/without serum) was reduced 94% to 100% at antiseptic concentrations of 300 and 400 ppm. At 200 ppm, E coli growth was fully inhibited without serum present and by 50% with serum. P aeruginosa (gram-negative) was not significantly affected under any conditions. At 100 and 200 ppm, cell viability remained greater than 90% under all experimental conditions. A 300-ppm, 3-minute exposure to chloramine-T resulted in cell viability of up to 70%, with longer exposures producing lower viabilities. Serum did not affect cell viability in any condition.

CONCLUSIONS

In vitro, chloramine-T at 200 ppm for 5 to 20 minutes was effective against 3 virulent gram-positive bacteria without fibroblast damage. At 300 ppm and 3 and 5 minutes, 30% of fibroblasts were damaged and 95% to 100 % of E coli were inhibited, respectively.

Comparing conventional gauze therapy to vacuum-assisted closure wound therapy: A prospective randomised trial

BACKGROUND

Vacuum-assisted closure wound therapy (vacuum therapy) has been used in our department since 1997 as a tool to bridge the period between debridement and definite surgical closure in full-thickness wounds. We performed a prospective randomised clinical trial to compare the efficacy of vacuum therapy to conventional moist gauze therapy in this stage of wound treatment.

METHODS

Treatment efficacy was assessed by semi-quantitative scoring of the wound conditions (signs of rubor, calor, exudate and fibrinous slough) and by wound surface area measurements. Tissue biopsies were performed to quantify the bacterial load. Besides this, the duration until 'ready for surgical therapy' and complications encountered during therapy and postoperatively were recorded.

RESULTS

Fifty-four patients were included (vacuum n=29, conventional n=25). With vacuum therapy, healthier wound conditions were observed. Furthermore, a tendency towards a shorter duration of therapy was found, which was most prominent in late-treated wounds. In addition, the wound surface area reduced significantly faster with vacuum therapy. Surprisingly, these results were obtained without a decrease in the number of bacteria colonising the wound. Complications were minor, except for one case of septicaemia and one case of increased tissue necrosis, which compelled us to stop vacuum therapy. For the treatment of full-thickness wounds, vacuum therapy has proven to be a valid wound healing modality.

Iodine revisited

Iodine is an antiseptic that has been used in wound care for more than 150 years. Traditional formulations of iodine had serious limitations that were reduced in later products. Much has been written about iodine and opinions on its clinical efficacy are divided. There have been reviews of the chemical properties of iodine, its antimicrobial activity, human physiology, cytotoxicity and its clinical effectiveness, but few have addressed all these aspects. With the recent development of iodine-containing wound care products and the continued publication of laboratory and clinical studies, it seems timely to reassess the evidence relating to the effectiveness of iodine for treating wounds. This literature review attempts to provide an appropriate chemical and physiological background of the characteristics of iodine in order to provide a sound basis for understanding the available microbiological and clinical data. It will show that understanding the factors that contribute to the activity and potential cytotoxicity of iodine are important in evaluating the clinical evidence. Although definitive studies are needed, the sustained delivery of low doses of free iodine offers the potential to inhibit a broad range of microbial species without selecting for resistant strains or inducing cytotoxic effects.

Postcare Recommendations for Emergency Department Wounds

Diligent posttreatment wound care management undoubtedly will improve wound outcome and patient satisfaction. There are limited recommendations in the literature to guide management plans. Nevertheless patients must receive specific instructions to complete wound care. These instructions should include whether a dressing is indicated, which dressing should be used, the duration of use, and the method of application. The plan must explain clearly the reasons for returning for further medical attention, for follow-up, for routine removal of sutures/staples, and an earlier return for possible concerns of infection or dehiscence. Preprinted discharge instruction sheets are useful, and illustrations can be helpful.

The Role of Betadine Irrigation in Breast Augmentation

BACKGROUND

In the spring of 2000, the U.S. Food and Drug Administration issued a ban on the use of Betadine (povidone-iodine; Purdue Frederick, Stamford, Conn.) in association with saline breast implants, because data seemed to indicate a higher rate of implant deflation in association with Betadine. Betadine has been used for many years because studies have shown a decrease in the rate of capsular contracture when the breast pocket is irrigated with Betadine at the time of augmentation.

METHODS

Breast augmentations performed from January of 1998 through September of 2005 were reviewed. The review included an analysis of how Betadine was used at the time of each augmentation, along with the incidences of implant deflation and capsular contracture. Findings were compared with data used by the Food and Drug Administration in their breast implant literature.

RESULTS

The deflation rate was significantly lower than that reported in the data from the Food and Drug Administration and the Institute of Medicine (0.24 percent versus 7 to 10 percent). The capsular contracture rate was lower than that in the Food and Drug Administration data, especially when Betadine was used as indicated in the final phase (0.5 to 2.2 percent versus 10 to 11 percent).

CONCLUSIONS

This article confirms other studies reporting that the use of Betadine has no effect on the rate of deflation of a saline breast implant. It also shows that the incidence of capsular contracture is significantly decreased with the proper use of Betadine.

Treatment of postoperative sternal dehiscence with mediastinitis: twenty-four-year use of a single method

OBJECTIVE

Postoperative deep sternal wound infection with dehiscence carries a high mortality rate, a high morbidity rate, and a poor cure rate. We developed a standard protocol of care to treat this complication, achieving primary closure and cure of the infection.

METHODS

From January 1, 1981, through May 31, 2005 (24 years 5 months), we treated 114 patients with dehiscence and mediastinitis. The diagnosis was made from 4 to 56 days (mean, 14.5 days) after surgery. Mean age was 64.3 years (range, 38-84 years); 79 (69%) were obese, and 48 (42%) had diabetes. Ten had previous attempts (1-4) of repair with other methods. Treatment entailed (1) debridement without removal of bone, (2) bilateral dissection of skin and subcutaneous tissue as one layer, (3) implantation of a staggered double-tube irrigation-suction system posterior and another one anterior to the sternum, (4) lateral reinforcement of the sternum and reclosure with a double wire, and (5) a single-layer closure of the subcutaneous tissue and skin.

RESULTS

Of 114 patients, 109 (96%) had mediastinitis, positive for Staphylococcus species in 101 (92.6%). The cure rate was 98% (112/114); hospital stay was 14 days (range, 12-16 days), with no deaths.

CONCLUSIONS

Use of this standard protocol is effective and highly recommended. It spares the sternum, cures the infection, and leaves the patient physically functional without the use of soft tissue flaps.

In vitro bactericidal efficacy of a new sun- and heat burn gel

We assessed the in vitro bactericidal efficacy of a new sunburn gel (Rescudermtrade mark; RESC) against planktonic and sessile Pseudomonas aeruginosa (PSEUD) and Staphylococcus epidermidis (STAPH). While PSEUD levels were 4log(10) lower than those of STAPH within 24h of adding RESC to contaminated nutrient broths, all bacterial counts were comparable by 48h. PSEUD and STAPH levels were then measured after applying either a single or three consecutive aliquots of RESC to polyurethane sponges. Gel was removed after 5 or 20min, or left on for 72h. Bacterial counts in placebo-treated sponges had plateaued by 24h to values above 9log(10)CFU/mL. In contrast, six out of seven of the RESC application modalities reduced bacterial levels below 4log(10)CFU/mL for 72h. RESC remained effective against STAPH despite up to a 24h treatment delay, irrespective of the number of applications. Repeated RESC applications were required to maintain PSEUD below 4log(10)CFU/mL when the delay exceeded 7h. These data demonstrate the differential susceptibility of planktonic and sessile bacteria to RescuDermtrade mark. This product might be a good candidate for reducing the opportunity for wound infection, especially in burns.

What is the evidence for tissue regeneration impairment when using a formulation of PVP-I antiseptic on open wounds?

Wound care and the use of antiseptics has long been the subject of much debate within the health professional's literature. This study was undertaken to determine the range of literature available on povidone-iodine (PVP-I) antiseptic use and the evidence supporting the outcomes reported. A range of articles was collected and divided into subgroups based on hierarchy of evidence and the five evidence dimensions [1]. Using the READER scoring tool, articles were evaluated and given a numerical award between 4 and 25 as a determinant of their quality in method, statistical analysis and outcome measures, with those scoring 12.5 or higher (from a possible 25) deemed as offering a satisfactory level of evidence. Statistical analysis on the results prior to applying the READER scoring tool found that overall 49% of articles did not support PVP-I use. However, this situation changed when the quality of evidence was limited to articles scoring >12.5. The higher-scored articles showed a 71% support for the continued use of PVP-I. The outcome of this study shows that there is reason for further debate over the use of PVP-I.

A toxicity index of skin and wound cleansers used on in vitro fibroblasts and keratinocytes

OBJECTIVE

To determine toxicity indexes of commercially available skin, wound, and skin/wound cleansers on in vitro fibroblasts and keratinocytes.

DESIGN

Seventeen cleansers and 3 liquid bath soaps were evaluated for cytotoxic effect on human infant dermal fibroblasts and epidermal keratinocytes. Both skin cell types were exposed to serial 10-fold dilutions of each cleanser until treated cell viability was comparable to untreated controls.

RESULTS

The experimental design allowed calculation of relative toxicity indexes ranging from 0 to 100,000. Shur-Clens, SAF-Clens, and saline were found to be the least toxic to fibroblasts (toxicity index 0); Dial Antibacterial Soap and Ivory Liqui-Gel were the most toxic (toxicity index 100,000). Biolex, Shur-Clens, and Techni-Care were the least toxic to keratinocytes (toxicity index 0); hydrogen peroxide, modified Dakin's solution, and povidone (10%) were found to be the most toxic (toxicity index 100,000).

CONCLUSIONS

Successful cutaneous tissue repair depends on the viability of the principal cell types involved (fibroblasts and keratinocytes). Toxicity indexes provide helpful guidelines for subsequent in vivo evaluations and clinical applications. The study findings also suggest that judicious use of these supposedly innocuous agents should be considered in a clinical setting.