Negative pressure wound therapy for treating pressure ulcers

Osteomyelitis in Late-Stage Pressure Sore Patients: A Retrospective Analysis

BACKGROUND

Late-stage pressure sore (PS) patients are particularly susceptible to osteomyelitis (OM), as bony prominences commonly constitute the focal point of the ulcer. There are lack of data regarding the associated factors and the clinical relevance of this diagnosis in the context of PS treatment.

METHODS

This retrospective analysis investigated the clinical characteristics, blood markers indicative of infection in PS patients, and development of histologically evident OM. A total of 125 patient were included from 2014 to 2019. The patient records were especially scanned for histological diagnosis of OM.

RESULTS

OM was detected in 39% (37/96) of the samples taken during the index procedure. OM prevalence increased to 56% (43/77) at the second and 70% (41/59) at the third debridement. Therefore, the diagnosis of OM was acquired during treatment in 35 cases. Patients diagnosed with initial OM presented significantly higher blood markers, indicative of infection upon admission. Only patients with consistent OM (three positive biopsies) showed higher flap revision rates.

CONCLUSION

This study found no compelling evidence linking OM to worse clinical outcomes in PS patients. In the absence of elevated inflammatory markers, reducing bone biopsy frequency and adopting a less aggressive bone debridement approach may help prevent OM in PS patients.

Negative pressure wound therapy for treating pressure ulcers

BACKGROUND

Pressure ulcers, also known as bedsores, pressure sores, or pressure injuries, are localised damage to the skin and underlying soft tissue, usually caused by intense or long-term pressure, shear, or friction. Negative pressure wound therapy (NPWT) has been widely used in the treatment of pressure ulcers, but its effect needs to be further clarified. This is an update of a Cochrane Review first published in 2015.

OBJECTIVES

To evaluate the effectiveness of NPWT for treating adult with pressure ulcers in any care setting.

SEARCH METHODS

On 13 January 2022, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase, and EBSCO CINAHL Plus. We also searched ClinicalTrials.gov and the WHO ICTRP Search Portal for ongoing and unpublished studies and scanned reference lists of relevant included studies as well as reviews, meta-analyses, and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication, or study setting.

SELECTION CRITERIA

We included published and unpublished randomised controlled trials (RCTs) comparing the effects of NPWT with alternative treatments or different types of NPWT in the treatment of adults with pressure ulcers (stage II or above).

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted study selection, data extraction, risk of bias assessment using the Cochrane risk of bias tool, and the certainty of the evidence assessment using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. Any disagreement was resolved by discussion with a third review author.

MAIN RESULTS

This review included eight RCTs with a total of 327 randomised participants. Six of the eight included studies were deemed to be at a high risk of bias in one or more risk of bias domains, and evidence for all outcomes of interest was deemed to be of very low certainty. Most studies had small sample sizes (range: 12 to 96, median: 37 participants). Five studies compared NPWT with dressings, but only one study reported usable primary outcome data (complete wound healing and adverse events). This study had only 12 participants and there were very few events; only one participant was healed in the study (risk ratio (RR) 3.00, 95% confidence interval (CI) 0.15 to 61.74, very low-certainly evidence). There was no evidence of a difference in the number of participants with adverse events in the NPWT group and the dressing group, but the evidence for this outcome was also assessed as very low certainty (RR 1.25, 95% CI 0.64 to 2.44, very low-certainty evidence). Changes in ulcer size, pressure ulcer severity, cost, and pressure ulcer scale for healing (PUSH) sores were also reported, but we were unable to draw conclusions due to the low certainly of the evidence. One study compared NPWT with a series of gel treatments, but this study provided no usable data. Another study compared NPWT with 'moist wound healing',  which did not report primary outcome data. Changes in ulcer size and cost were reported in this study, but we assessed the evidence as being of very low certainty; One study compared NPWT combined with internet-plus home care with standard care, but no primary outcome data were reported. Changes in ulcer size, pain, and dressing change times were reported, but we also assessed the evidence as being of very low certainty. None of the included studies reported time to complete healing, health-related quality of life, wound infection, or wound recurrence.

AUTHORS' CONCLUSIONS

The efficacy, safety, and acceptability of NPWT in treating pressure ulcers compared to usual care are uncertain due to the lack of key data on complete wound healing, adverse events, time to complete healing, and cost-effectiveness.  Compared with usual care, using NPWT may speed up the reduction of pressure ulcer size and severity of pressure ulcer, reduce pain, and dressing change times. Still, trials were small, poorly described, had short follow-up times, and with a high risk of bias; any conclusions drawn from the current evidence should be interpreted with considerable caution. In the future, high-quality research with large sample sizes and low risk of bias is still needed to further verify the efficacy, safety, and cost-effectiveness of NPWT in the treatment of pressure ulcers. Future researchers need to recognise the importance of complete and accurate reporting of clinically important outcomes such as the complete healing rate, healing time, and adverse events.

Cost analysis of negative-pressure wound therapy versus standard treatment of acute conflict-related extremity wounds within a randomized controlled trial

Background

Clinical outcomes after negative-pressure wound therapy (NPWT) and standard treatment of conflict-related extremity wounds are similar. In resource-limited settings, cost affects the choice of treatment. We aimed to estimate treatment-related costs of NPWT in comparison with standard treatment for conflict-related extremity wounds.

Methods

We derived outcome data from a randomized, controlled superiority trial that enrolled adult (≥ 18 years) patients with acute (≤ 72 h) conflict-related extremity wounds at two civilian hospitals in Jordan and Iraq. Primary endpoint was mean treatment-related healthcare costs (adjusted to 2019 US dollars).

Results

Patients were enrolled from June 9, 2015, to October 24, 2018. A total of 165 patients (155 men [93.9%]; 10 women [6.1%]; and median [IQR] age, 28 [21–34] years) were included in the analysis. The cost per patient treated with NPWT was $142 above that of standard treatment. Overall, results were robust in a sensitivity analysis.

Conclusions

With similar clinical outcomes compared to standard care, our results do not support the use of NPWT in routine treatment of conflict-related extremity wounds at civilian hospitals in resource scarce settings.

Trial registration NCT02444598.

Simple and Efficient Pressure Ulcer Reconstruction via Primary Closure Combined with Closed-Incision Negative Pressure Wound Therapy (CiNPWT)—Experience of a Single Surgeon

Background: In this study, we aimed to analyze the clinical efficacy of closed-incision negative pressure wound therapy (CiNPWT) when combined with primary closure (PC) in a patient with pressure ulcers, based on one single surgeon’s experience at our medical center. Methods: We retrospectively reviewed the data of patients with stage III or IV pressure ulcers who underwent reconstruction surgery. Patient characteristics, including age, sex, cause and location of defect, comorbidities, lesion size, wound reconstruction methods, operation time, debridement times, application of CiNPWT to reconstructed wounds, duration of hospital stay, and wound complications were analyzed. Results: Operation time (38.16 ± 14.02 vs. 84.73 ± 48.55 min) and duration of hospitalization (36.78 ± 26.92 vs. 56.70 ± 58.43 days) were shorter in the PC + CiNPWT group than in the traditional group. The frequency of debridement (2.13 ± 0.98 vs. 2.76 ± 2.20 times) was also lower in the PC + CiNPWT group than in the traditional group. The average reconstructed wound size did not significantly differ between the groups (63.47 ± 42.70 vs. 62.85 ± 49.94 cm²), and there were no significant differences in wound healing (81.25% vs. 75.38%), minor complications (18.75% vs. 21.54%), major complications (0% vs. 3.85%), or mortality (6.25% vs. 10.00%) between the groups. Conclusions: Our findings indicate that PC combined with CiNPWT represents an alternative reconstruction option for patients with pressure ulcers, especially in those for whom prolonged anesthesia is unsuitable.

International study to develop the WOUND-Q patient-reported outcome measure for all types of chronic wounds

Patient‐reported outcome measures (PROMs) for chronic wounds mainly focus on specific types of wounds. Our team developed the WOUND‐Q for use with all types of wounds in any anatomic location. We conducted 60 concept elicitation interviews with patients in Canada, Denmark, the Netherlands, and the United States. Analysis identified concepts of interest to patients and scales were formed and refined through cognitive interviews with 20 patients and input from 26 wound care experts. Scales were translated into Danish and Dutch. An international field‐test study collected data from 881 patients (1020 assessments) with chronic wounds. Rasch measurement theory (RMT) analysis was used to refine the scales and examine psychometric properties. RMT analysis supported the reliability and validity of 13 WOUND‐Q scales that measure wound characteristics (assessment, discharge, and smell), health‐related quality of life (life impact, psychological, sleep impact, and social), experience of care (information, home care nurses, medical team, and office staff), and wound treatment (dressing and suction device). The WOUND‐Q can be used to measure outcomes in research and clinical practice from the perspective of patients with any type of wound.

Negative pressure wound therapy in patients with wounds healing by secondary intention: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Negative pressure wound therapy (NPWT) is a widely used method of wound treatment. We performed a systematic review of randomised controlled trials (RCTs) comparing the patient-relevant benefits and harms of NPWT with standard wound therapy (SWT) in patients with wounds healing by secondary intention.

METHODS

We searched for RCTs in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and study registries (last search: July 2018) and screened reference lists of relevant systematic reviews and health technology assessments. Manufacturers and investigators were asked to provide unpublished data. Eligible studies investigated at least one patient-relevant outcome (e.g. wound closure). We assessed publication bias and, if feasible, performed meta-analyses, grading the results into different categories (hint, indication or proof of a greater benefit or harm).

RESULTS

We identified 48 eligible studies of generally low quality with evaluable data for 4315 patients and 30 eligible studies with missing data for at least 1386 patients. Due to potential publication bias (proportion of inaccessible data, 24%), we downgraded our conclusions. A meta-analysis of all wound healing data showed a significant effect in favour of NPWT (OR 1.56, 95% CI 1.15 to 2.13, p = 0.008). As further analyses of different definitions of wound closure did not contradict that analysis, we inferred an indication of a greater benefit of NPWT. A meta-analysis of hospital stay (in days) showed a significant difference in favour of NPWT (MD - 4.78, 95% CI - 7.79 to - 1.76, p = 0.005). As further analyses of different definitions of hospital stay/readmission did not contradict that analysis, we inferred an indication of a greater benefit of NPWT. There was neither proof (nor indication nor hint) of greater benefit or harm of NPWT for other patient-relevant outcomes such as mortality and adverse events.

CONCLUSIONS

In summary, low-quality data indicate a greater benefit of NPWT versus SWT for wound closure in patients with wounds healing by secondary intention. The length of hospital stay is also shortened. The data show no advantages or disadvantages of NPWT for other patient-relevant outcomes. Publication bias is an important problem in studies on NPWT, underlining that all clinical studies need to be fully reported.

ALGINATE versus NPWT in the Preparation of Surgical Excisions for an STSG: ATEC Trial

Supplemental Digital Content is available in the text.

A calcium alginate dressing (ALGINATE) and negative pressure wound therapy (NPWT) are frequently used to treat wounds which heal by secondary intention. This trial compared the healing efficacy and safety of these 2 treatments.

Heel Pressure Injuries: Consensus-Based Recommendations for Assessment and Management

Significance: A systematic approach to develop experts-based recommendations could have a favorable impact on clinical problems characterized by scarce and low-quality evidence as heel pressure ulcers. Recent Advances: A systematic approach was used to conduce a formal consensus initiative. A multidisciplinary panel of experts identified relevant clinical questions, performed a systematic search of the literature, and created a list of statements. GRADE Working Group guidelines were followed. An independent international jury reviewed and voted recommendations for clinical practice. Consent was developed according to Delphi rules and GRADE method was used to attribute grade of strength. Critical Issues: The extensive search of the literature retrieved 42 pertinent articles (26 clinical studies, 7 systematic reviews or meta-analysis, 5 other reviews, 2 consensus-based articles, and 2 in vitro studies). Thirty-five recommendations and statements were created. Only 1 of 35, concerning ankle-brachial pressure index reliability in diabetic patients, was rejected by the panel. No sufficient agreement was achieved on toe brachial index test to rule out the orphan heel syndrome, removing dry eschar in adult patients without vascular impairment, and using an antimicrobial dressing in children with infected heel pressure injuries. Eleven recommendations were approved with a weak grade of strength. Experts strongly endorsed 20 recommendations. Offloading, stages I and II pressure injuries, and referral criteria were areas characterized by higher level of agreement. Future Directions: We believe that the results of our effort could improve practice, especially in areas where clear and shared opinions emerged. Barriers and limits that could hinder implementation are also discussed in the article.

International mixed methods study protocol to develop a patient-reported outcome measure for all types of chronic wounds (the WOUND-Q)

INTRODUCTION

Most patient-reported outcome measures (PROM) for chronic wounds are specific to a single wound type (eg, pressure ulcer) or part of the body. A barrier to outcome assessment in wound care and research is the lack of a rigorously designed PROM that can be used across wound types and locations. This mixed method study describes the protocol for an international collaboration to develop and validate a new PROM called the WOUND-Q for adults with chronic wounds.

METHODS AND ANALYSIS

In phase I, the qualitative approach of interpretive description is used to elicit concepts important to people with wounds regarding outcome. Participants from Canada, Denmark, the Netherlands, and the USA are aged 18 years and older and have a wound that has lasted 3 months or longer. Interviews are digitally recorded, transcribed and coded. A conceptual framework and preliminary item pool are developed from the qualitative dataset. Draft scales are formed to cover important themes in the conceptual framework. These scales are refined using feedback from people with chronic wounds and wound care experts. After refinement, the scales are translated into Danish and Dutch, following rigorous methods, to prepare for an international field-test study. In phase II, data are collected in Canada, Denmark, the Netherlands, and the USA. An international sample of people with a large variety of chronic wounds complete the WOUND-Q. Rasch Measurement Theory analysis is used to identify the best subset of items to retain for each scale and to examine reliability and validity.

ETHICS AND DISSEMINATION

This study is coordinated at Brigham and Women's Hospital (Boston, USA). Ethics board approval was received at each participating site for both study phases. Findings will be published in peer-reviewed journals and presented at national and international conferences and meetings.

The discovery and development of topical medicines for wound healing

INTRODUCTION

Chronic, nonhealing skin wounds claim >3% of the health-care budget in industrialized countries, and the incidence is rising. Currently, two parallel trends influence innovations within the field of wound healing: the need to reduce spread of antibiotic resistance and the emerging use of health economy and value-based models. Areas covered: This review focuses on the discovery of drug candidates and development of treatments aiming to enhance wound healing in the heterogeneous group of patients with nonhealing wounds. Expert opinion: Nonhealing wounds are multifaceted and recognized as difficult indications. The majority of products currently in use are medical device dressings, or concepts of negative pressure or hyperbaric oxygen treatment. Global best practice guidelines for the treatment of diabetic foot ulcers recommend debridement, redressing, as well as infection control, and are critical to the lack of coherent clinical evidence for many approved products in active wound care. To accelerate wound healing, there is an emerging trend toward biologics, gene therapy, and novel concepts for drug delivery in research and in the pipeline for clinical trials. Scientific delineation of the therapeutic mechanism of action is, in our opinion, vital for clinical trial success and for an increased fraction of medical products in the pharmaceutical pipeline.

Support surfaces for treating pressure ulcers

BACKGROUND

Pressure ulcers are treated by reducing pressure on the areas of damaged skin. Special support surfaces (including beds, mattresses and cushions) designed to redistribute pressure, are widely used as treatments. The relative effects of different support surfaces are unclear. This is an update of an existing review.

OBJECTIVES

To assess the effects of pressure-relieving support surfaces in the treatment of pressure ulcers.

SEARCH METHODS

In September 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included published or unpublished randomised controlled trials (RCTs), that assessed the effects of support surfaces for treating pressure ulcers, in any participant group or setting.

DATA COLLECTION AND ANALYSIS

Data extraction, assessment of 'Risk of bias' and GRADE assessments were performed independently by two review authors. Trials with similar participants, comparisons and outcomes were considered for meta-analysis. Where meta-analysis was inappropriate, we reported the results of the trials narratively. Where possible, we planned to report data as either risk ratio or mean difference as appropriate.

MAIN RESULTS

For this update we identified one new trial of support surfaces for pressure ulcer treatment, bringing the total to 19 trials involving 3241 participants. Most trials were small, with sample sizes ranging from 20 to 1971, and were generally at high or unclear risk of bias.

PRIMARY OUTCOME

healing of existing pressure ulcersLow-tech constant pressure support surfacesIt is uncertain whether profiling beds increase the proportion of pressure ulcer which heal compared with standard hospital beds as the evidence is of very low certainty: (RR 3.96, 95% CI 1.28 to 12.24), downgraded for serious risk of bias, serious imprecision and indirectness (1 study; 70 participants).There is currently no clear difference in ulcer healing between water-filled support surfaces and foam replacement mattresses: (RR 0.93, 95% CI 0.63 to 1.37); low-certainty evidence downgraded for serious risk of bias and serious imprecision (1 study; 120 participants).Further analysis could not be performed for polyester overlays versus gel overlays (1 study; 72 participants), non-powered mattresses versus low-air-loss mattresses (1 study; 20 participants) or standard hospital mattresses with sheepskin overlays versus standard hospital mattresses (1 study; 36 participants).High-tech pressure support surfacesIt is currently unclear whether high-tech pressure support surfaces (such as low-air-loss beds, air suspension beds, and alternating pressure surfaces) improve the healing of pressure ulcers (14 studies; 2923 participants) or which intervention may be more effective. The certainty of the evidence is generally low, downgraded mostly for risk of bias, indirectness and imprecision.Secondary outcomesNo analyses were undertaken with respect to secondary outcomes including participant comfort and surface reliability and acceptability as reporting of these within the included trials was very limited.Overall, the evidence is of low to very low certainty and was primarily downgraded due to risk of bias and imprecision with some indirectness.

AUTHORS' CONCLUSIONS

Based on the current evidence, it is unclear whether any particular type of low- or high-tech support surface is more effective at healing pressure ulcers than standard support surfaces.

Pressure ulcer-related pelvic osteomyelitis: evaluation of a two-stage surgical strategy (debridement, negative pressure therapy and flap coverage) with prolonged antimicrobial therapy

Background

A two-stage surgical strategy (debridement-negative pressure therapy (NPT) and flap coverage) with prolonged antimicrobial therapy is usually proposed in pressure ulcer-related pelvic osteomyelitis but has not been widely evaluated.

Methods

Adult patients with pressure ulcer-related pelvic osteomyelitis treated by a two-stage surgical strategy were included in a retrospective cohort study. Determinants of superinfection (i.e., additional microbiological findings at reconstruction) and treatment failure were assessed using binary logistic regression and Kaplan-Meier curve analysis.

Results

Sixty-four pressure ulcer-related pelvic osteomyelitis in 61 patients (age, 47 (IQR, 36–63)) were included. Osteomyelitis was mostly polymicrobial (73%), with a predominance of S. aureus (47%), Enterobacteriaceae spp. (44%) and anaerobes (44%). Flap coverage was performed after 7 (IQR, 5–10) weeks of NPT, with 43 (68%) positive bone samples among which 39 (91%) were superinfections, associated with a high ASA score (OR, 5.8; p = 0.022). An increased prevalence of coagulase negative staphylococci (p = 0.017) and Candida spp. (p = 0.003) was observed at time of flap coverage. An ESBL Enterobacteriaceae spp. was found in 5 (12%) patients, associated with fluoroquinolone consumption (OR, 32.4; p = 0.005). Treatment duration was as 20 (IQR, 14–27) weeks, including 11 (IQR, 8–15) after reconstruction. After a follow-up of 54 (IQR, 27–102) weeks, 15 (23%) failures were observed, associated with previous pressure ulcer (OR, 5.7; p = 0.025) and Actinomyces spp. infection (OR, 9.5; p = 0.027).

Conclusions

Pressure ulcer-related pelvic osteomyelitis is a difficult-to-treat clinical condition, generating an important consumption of broad-spectrum antibiotics. The lack of correlation between outcome and the debridement-to-reconstruction interval argue for a short sequence to limit the total duration of treatment.

Review of the Current Management of Pressure Ulcers

Significance: The incidence of pressure ulcers is increasing due to our aging population and the increase in the elderly living with disability. Learning how to manage pressure ulcers appropriately is increasingly important for all professionals in wound care. Recent Advances: Many new dressings and treatment modalities have been developed over the recent years and the goal of this review is to highlight their benefits and drawbacks to help providers choose their tools appropriately. Critical Issues: Despite an increased number of therapies available on the market, none has demonstrated any clear benefit over the others and pressure ulcer treatment remains frustrating and time-consuming. Future Directions: Additional research is needed to develop products more effective in prevention and treatment of pressure ulcers.

Wound bed preparation: TIME for an update

While the overwhelming majority of wounds heal rapidly, a significant proportion fail to progress through the wound-healing process. These resultant chronic wounds cause considerable morbidity and are costly to treat. Wound bed preparation, summarised by the TIME (Tissue, Inflammation/infection, Moisture imbalance, Epithelial edge advancement) concept, is a systematic approach for assessing chronic wounds. Each of these components needs to be addressed and optimised to improve the chances of successful wound closure. We present an up-to-date literature review of the most important recent aspects of wound bed preparation. While there are many novel therapies that are available to the treating clinician, often, there are limited data on which to assess their clinical value, and a lack of appreciation for adequate wound bed preparation needed before expensive therapy is used to heal a wound.

Topical phenytoin for treating pressure ulcers

BACKGROUND

Pressure ulcers are common in clinical practice and pose a significant health problem worldwide. Apart from causing suffering to patients, they also result in longer hospital stays and increase the cost of health care. A variety of methods are used for treating pressure ulcers, including pressure relief, patient repositioning, biophysical strategies, nutritional supplementation, debridement, topical negative pressure, and local treatments including dressings, ointments and creams such as bacitracin, silver sulphadiazine, neomycin, and phenytoin. Phenytoin is a drug more commonly used in the treatment of epilepsy, but may play an important role in accelerating ulcer healing.

OBJECTIVES

To assess the effects of topical phenytoin on the rate of healing of pressure ulcers of any grade, in any care setting.

SEARCH METHODS

In September 2016, we searched the following electronic databases to identify relevant randomized clinical trials: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library); Ovid MEDLINE; Ovid Embase; and EBSCO CINAHL Plus. We handsearched conference proceedings from the European Pressure Ulcer Advisory Panel, European Wound Management Association and the Tissue Viability Society for all available years. We searched the references of the retrieved trials to identify further relevant trials. We also searched clinical trials registries to identify ongoing and unpublished studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) addressing the effects (both benefits and harms) of topical phenytoin on the healing of pressure ulcers of any grade compared with placebo or alternative treatments or no therapy, irrespective of blinding, language, and publication status.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted information on participants, interventions, methods and results and assessed risk of bias using Cochrane methodological procedures. For dichotomous variables, we calculated the risk ratio (RR) with 95% confidence interval (CI). For continuous variables, we calculated the mean difference with 95% CI. We rated the quality of the evidence by using Grading of Recommendations, Assessment, Development and Evaluation approach (GRADE).

MAIN RESULTS

Three small RCTs met our inclusion criteria and included a total of 148 participants. These compared three treatments with topical phenytoin: hydrocolloid dressings, triple antibiotic ointment and simple dressings. In the three RCTs, 79% of participants had grade II ulcers, and 21% of participants had grade I ulcers; no participants had grade III or IV ulcers. Two RCTs had a high risk of bias overall and the other RCT was at unclear risk of bias due to poor reporting. Two RCTs had three intervention arms and the other had two intervention arms.Two studies compared topical phenytoin with hydrocolloid dressing (84 participants analysed). The available data suggest that hydrocolloid dressings may improve ulcer healing compared to topical phenytoin (39.3% ulcers healed for phenytoin versus 71.4% ulcers healed for hydrocolloid dressings (RR 0.55, 95% CI 0.33 to 0.92; 56 participants, 1 study; low quality evidence). We downgraded the evidence twice: once due to serious limitations (high risk of bias) and once due to the small sample size and small number of events. Two studies compared topical phenytoin with simple dressings (81 participants analysed). From the available data, we are uncertain whether topical phenytoin improves ulcer healing compared to simple dressings (39.3% ulcers healed for phenytoin versus 29.6% ulcers healed for the simple dressing (RR 1.33, 95% CI 0.63 to 2.78; 55 participants, 1 study; very low quality evidence). This evidence was downgraded once due to serious limitations (high risk of bias) and twice due to the low number of outcome events and resulting wide CI which included the possibility of both increased healing and reduced healing. We therefore considered it to be insufficient to determine the effect of topical phenytoin on ulcer healing. One study compared topical phenytoin with triple antibiotic ointment, however, none of the outcomes of interest to this review were reported. No adverse drug reactions or interactions were detected in any of the three RCTs. Minimal pain was reported in all groups in one trial that compared topical phenytoin with hydrocolloid dressings and triple antibiotic ointment.

AUTHORS' CONCLUSIONS

This review has considered the available evidence and the result shows that it is uncertain whether topical phenytoin improves ulcer healing for patients with grade I and II pressure ulcers. No adverse events were reported from three small trials and minimal pain was reported in one trial. Therefore, further rigorous, adequately powered RCTs examining the effects of topical phenytoin for treating pressure ulcers, and to report on adverse events, quality of life and costs are necessary.

Negative pressure wound therapy aids recovery following surgical debridement due to severe bacterial cellulitis with abdominal abscess post-cesarean: A case report (CARE-Compliant)

INTRODUCTION

Bacterial cellulitis post-Cesarean section is rare. Negative pressure wound therapy (NPWT) is widely used in various medical specialities; its effectiveness in obstetrics however remains the topic of debate-used predominantly as an adjunct to secondary intention specific to high-risk patient groups. Its application in the treatment of actively infected wounds post-Cesarean is not well documented. Here, we document NPWT in the treatment of an unusually severe case of bacterial cellulitis with abdominal abscess postpartum. We provide a unique photographic timeline of wound progression following major surgical debridement, documenting the effectiveness of 2 different NPWT systems (RENASYS GO and PICO, Smith & Nephew). We report problems encountered using these NPWT systems and "ad-hoc" solutions to improve efficacy and patient experience.A 34-year-old primiparous Caucasian female with no prior history or risk factors for infection and a normal body mass index (BMI) presented with severe abdominal pain, swelling, and extensive abdominal redness 7 days postemergency Cesarean section. Examination revealed extensive cellulitis with associated abdominal abscess. Staphylococcus aureus was identified in wound exudates and extensive surgical debridement undertaken day 11 postnatally due to continued febrile episodes and clinical deterioration, despite aggressive intravenous antibiotic therapy. Occlusive NPWT dressings were applied for a period of 3 weeks before discharge, as well as a further 5 weeks postdischarge into the community.NPWT was well tolerated and efficacious in infection clearance and wound healing during bacterial cellulitis. Wound healing averaged 1 cm per week before NPWT withdrawal; cessation of NPWT before full wound closure resulted in significantly reduced healing rate, increased purulent discharges, and skin irritation, highlighting the efficacy of NPWT. Five-month follow-up in the clinic found the wound to be fully healed with no additional scarring beyond the boundaries of the original Cesarean incision. The patient was pleased with treatment outcomes, reporting no lasting pain or discomfort from the scar.

CONCLUSIONS

This report represents the first documented use of NPWT to aid healing of an actively infected, open wound following extensive surgical debridement 10 days post-Cesarean section, confirming both the efficacy and tolerability of NPWT for the treatment of severe bacterial cellulitis in obstetric debridement.

Ten-year analyses of the German DRG data about negative pressure wound therapy

Exact data regarding the clinical role of negative pressure wound therapy (NPWT) for wound care in a specific country are not available. Thus, we analysed the use of NPWT in hospitalised patients in Germany. Detailed lists of all hospitalised cases treated with NPWT in Germany for each of the years from 2005 to 2014 were obtained from the Federal Statistical Office, as well as lists of the 15 most frequent principal and additional diagnoses documented with NPWT in 2014. Within the 10-year time period of the study, the number of cases treated with NPWT increased by 349%, from 37 053 in 2005 to 129 269 in 2014. The rate of all hospitalised cases treated with NPWT increased form 0·22% to 0·66% in Germany. In 2014, wounds affecting skin and subcutaneous tissue (5-916.a0) are the most frequent documented indication for NPWT followed by deep wounds involving bones and joints at the limbs (5-916.a1). Open abdomens (5-916.a3) count for higher numbers than deep wounds of the thorax, mediastinum and sternum (5-916.a2). Fifty percent of all cases hospitalised for stage IV pressure ulcers at sacrum or ischium and around one third (32.2%) of cases with pyothorax received NPWT. Every fourth to fifth case hospitalised for disruption of surgical wounds or infections following a procedure (24·1%), as well as for infections and inflammations because of internal joint prosthesis or because of an internal fixation device was treated with NPWT (22·9%). In cases with diabetic foot syndrome, it is still every tenth case (10·1%). This analysis shows a substantial increase in the use of NPWT in the last decade for hospitalised patients. NPWT has a fixed role in the treatment of stage IV pressure ulcers at sacrum or ischium, pyothorax, infection and inflammation because of internal joint prosthesis or an internal fixation device and diabetic foot syndrome.

Negative pressure wound therapy for treating leg ulcers

BACKGROUND

Leg ulcers are open skin wounds that occur between the ankle and the knee that can last weeks, months or even years and are a consequence of arterial or venous valvular insufficiency. Negative pressure wound therapy (NPWT) is a technology that is currently used widely in wound care and is promoted for use on wounds. NPWT involves the application of a wound dressing to the wound, to which a machine is attached. The machine applies a carefully controlled negative pressure (or vacuum), which sucks any wound and tissue fluid away from the treated area into a canister.

OBJECTIVES

To assess the effects of negative pressure wound therapy (NPWT) for treating leg ulcers in any care setting.

SEARCH METHODS

For this review, in May 2015 we searched the following databases: the Cochrane Wounds Group Specialised Register (searched 21 May 2015); the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2015, Issue 4); Ovid MEDLINE (1946 to 20 May 2015); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 20 May 2015); Ovid EMBASE (1974 to 20 May 2015); EBSCO CINAHL (1982 to 21 May 2015). There were no restrictions based on language or date of publication.

SELECTION CRITERIA

Published or unpublished randomized controlled trials (RCTs) comparing the effects of NPWT with alternative treatments or different types of NPWT in the treatment of leg ulcers.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction.

MAIN RESULTS

We included one study, with 60 randomized participants, in the review. The study population had a range of ulcer types that were venous arteriolosclerotic and venous/arterial in origin. Study participants had recalcitrant ulcers that had not healed after treatment over a six-month period. Participants allocated to NPWT received continuous negative pressure until they achieved 100% granulation (wound preparation stage). A punch skin-graft transplantation was conducted and the wound then exposed to further NPWT for four days followed by standard care. Participants allocated to the control arm received standard care with dressings and compression until 100% granulation was achieved. These participants also received a punch skin-graft transplant and then further treatment with standard care. All participants were treated as in-patients until healing occurred.There was low quality evidence of a difference in time to healing that favoured the NPWT group: the study reported an adjusted hazard ratio of 3.2, with 95% confidence intervals (CI) 1.7 to 6.2. The follow-up period of the study was a minimum of 12 months. There was no evidence of a difference in the total number of ulcers healed (29/30 in each group) over the follow-up period; this finding was also low quality evidence.There was low quality evidence of a difference in time to wound preparation for surgery that favoured NPWT (hazard ratio 2.4, 95% CI 1.2 to 4.7).Limited data on adverse events were collected: these provided low quality evidence of no difference in pain scores and Euroqol (EQ-5D) scores at eight weeks after surgery.

AUTHORS' CONCLUSIONS

There is limited rigorous RCT evidence available concerning the clinical effectiveness of NPWT in the treatment of leg ulcers. There is some evidence that the treatment may reduce time to healing as part of a treatment that includes a punch skin graft transplant, however, the applicability of this finding may be limited by the very specific context in which NPWT was evaluated. There is no RCT evidence on the effectiveness of NPWT as a primary treatment for leg ulcers.