The combined use of NPWT and instillation using an octenidine based wound rinsing solution: a case study

Negative Pressure Wound Therapy for Chronic Wounds

ABSTRACT

Chronic wounds, including those caused by venous and arterial insufficiency, diabetic complications, and pressure-induced ulcers, pose significant treatment challenges. Negative pressure wound therapy has been increasingly used for managing these wounds. This treatment aims to promote wound healing, prepare the wound bed for further surgical intervention, minimize the risk of infection, and potentially shorten the time to wound healing. Considering variances in techniques applied in different regions globally, there is an emerging need to comprehensively evaluate the effectiveness of negative pressure wound therapy on chronic wounds. Unfortunately, detailed descriptions of the techniques applied to achieve negative pressure are often lacking in existing literature abstracts, posing challenges for direct comparisons. This review aims to analyze the application of negative pressure wound therapy in the treatment of chronic wounds, summarize its advantages and disadvantages, and further explore the potential value and future research direction of negative pressure wound therapy in the repair of chronic wounds.

Chronic wounds and novel therapeutic approaches

In the past decade, the frequency of chronic wounds in older population has increased, and their impact on quality of life is substantial. Chronic wounds are a public health problem associated with very high economic and psychosocial costs. These wounds result from various pathologies and comorbidities, such arterial and venous insufficiency, diabetes mellitus and continuous skin pressure. Recently, the role of infection and biofilms in the healing of chronic wounds has been the subject of considerable research. This paper presents an overview of various methods and products used to manage chronic wounds and discusses recent advances in wound care. To decide on the best treatment for any wound, it is crucial to holistically assess the patient and the wound. Additionally, multiple strategies could be used to prevent or treat chronic wounds.

Limb salvage procedure in immunocompromised patients with therapy-resistant leg ulcers-The value of ultra-radical debridement and instillation negative-pressure wound therapy

The purpose of this study was to analyse the outcome of our established triple treatment strategy in therapy‐resistant deep‐thickness chronic lower leg ulcers. This limb salvage approach consists of ultra‐radical surgical debridement, negative‐pressure wound therapy (NPWT) with or without instillation, and split‐thickness skin grafting. Between March 2003 and December 2019, a total of 16 patients and 24 severe cases of lower leg ulcers were eligible for inclusion in this highly selective population. A total of seven patients received immunosuppressive medication. Complete wound closure was achieved in 25% and almost 90% of included lower leg ulcer cases after 3 and 24 months of our triple treatment strategy, respectively. The overall limb salvage rate was 100%. Bacterial colonisation of these wounds was significantly reduced after multiple surgical debridements and NPWT. Fasciotomy and radical removal of devitalised tissue such as deep fascia, tendons, and muscles combined with NPWT showed promising results in terms of the overall graft take rate. This treatment strategy was considered as last resort for limb salvage in such a critically ill and immunocompromised patient population. Surgeons should be aware of its efficacy and consider the triple treatment strategy especially if no other limb salvage option remains.

Wound-Healing Following Negative-Pressure Wound Therapy with Use of a Locally Developed AquaVac System as Compared with the Vacuum-Assisted Closure (VAC) System

BACKGROUND

Negative-pressure wound therapy (NPWT) gained widespread clinical use after its introduction in the 1990s because of its many beneficial effects on the wound environment. However, high treatment costs have limited its use in third-world countries. The present study compares a low-cost, locally developed NPWT system with a commercially available system in terms of efficacy, reliability, ease of application, and safety.

METHODS

This prospective, randomized controlled trial involved 36 patients who were managed with NPWT with either a low-cost, locally developed system (AquaVac) or a commercially available Vacuum-Assisted Closure Advanced Therapy System (VAC ATS; KCI). The low-cost NPWT system described consists of a converted aquarium pump as a reusable vacuum source and a dressing system that can be found in the hospital supply room: food plastic wrap as an occlusive drape, surgical gauze as wound filler, nasogastric tubes as tubing, and used intravenous (IV) bottles as effluent canisters. The purpose of the study was to compare the 2 systems in terms of (1) time to apply the dressing, (2) exudate levels, (3) amount of granulation tissue, (4) wound size reduction, (5) average cost of treatment, (6) visual analog scale (VAS) pain scores, and (7) complications.

RESULTS

The experimental low-cost system had a small but statistically insignificant advantage over the commercially available system in terms of application time, pain during dressing changes, and wound contraction percentage. The 2 systems were comparable in terms of the amount of exudate, granulation tissue coverage, and VAS scores during the course of treatment. No wound or periwound complications were observed. The systems were significantly different in terms of cost, with the AquaVac system being 7 times less expensive than the VAC ATS system ($63.75 compared with $491.38 USD).

CONCLUSIONS

The low-cost AquaVac system was shown to be comparable with the commercial VAC ATS system, suggesting that it is an effective and safe alternative method for NPWT in resource-challenged settings.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Non-antibiotic antimicrobial interventions and antimicrobial stewardship in wound care

Control of wound infection today relies largely on antibiotics, but the continual emergence of antibiotic-resistant microorganisms threatens a return to the pre-antibiotic era when physicians used antiseptics to prevent and manage infection. Some of those antiseptics are still used today, and others have become available. A diverse variety of non-antibiotic antimicrobial interventions are found on modern formularies. Unlike the mode of action of antibiotics, which affect specific cellular target sites of pathogens, many non-antibiotic antimicrobials affect multiple cellular target sites in a non-specific way. Although this reduces the likelihood of selecting for resistant strains of microorganisms, some have emerged and cross-resistance between antibiotics and antiseptics has been detected. With the prospect of a post-antibiotic era looming, ways to maintain and extend our antimicrobial armamentarium must be found. In this narrative review, current and emerging non-antibiotic antimicrobial strategies will be considered and the need for antimicrobial stewardship in wound care will be explained.

EWMA Document: Negative Pressure Wound Therapy

1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.¹ NPWT has been described as a effective treatment for wounds of many different aetiologies^2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,^4-6 dehisced sternal wounds following cardiac surgery^7,8 and as a valuable agent in complex non-healing wounds.^9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.¹¹ While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.^12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents^15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.

The Antiseptic Octenidine Inhibits Langerhans Cell Activation and Modulates Cytokine Expression upon Superficial Wounding with Tape Stripping

Ideal agents for the topical treatment of skin wounds should have antimicrobial efficacy without negative influence on wound healing. Octenidine (OCT) has become a widely used antiseptic in professional wound care, but its influence on several components of the wound healing process remains unclear. In the present study, we have used a superficial wound model using tape stripping on human full-thickness skin ex vivo to investigate the influence of OCT on epidermal Langerhans cells (LCs) and cytokine secretion pattern of skin cells during wound healing in a model without disruption of the normal skin structure. Histological and immunofluorescence studies showed that OCT neither altered human skin architecture nor the viability of skin cells upon 48 hours of culture in unwounded or wounded skin. The epidermis of explants and LCs remained morphologically intact throughout the whole culture period upon OCT treatment. OCT inhibited the upregulation of the maturation marker CD83 on LCs and prevented their emigration in wounded skin. Furthermore, OCT reduced both pro- and anti-inflammatory mediators (IL-8, IL-33, and IL-10), while angiogenesis and growth factor mediators (VEGF and TGF-β1) remained unchanged in skin explant cultures. Our data provide novel insights into the host response to OCT in the biologically relevant environment of viable human (wounded) skin.

[Importance of wound irrigation solutions and fluids with antiseptic effects in therapy and prophylaxis : Update 2017]

INTRODUCTION

Despite the use of modern antibiotics as well as complex perioperative, intraoperative and postoperative prophylactic measures, the rate of surgical site infections (SSI) could not be significantly reduced. The introduction of biocompatible antiseptic drugs with a high microbiocidal effect provided a successful alternative for infection prevention and therapy, particularly in a time of increasing occurrence of multi-drug resistant pathogens. Hence, questions about the risk-benefit ratio of antiseptic wound irrigation solutions, the prophylactic use of wound irrigation solutions for the reduction of SSI and the effect of negative pressure wound therapy combined with instillation (NPWTi) need to be answered.

METHOD

Against the background of our own experiences with the use of antiseptic wound irrigation solutions, a literature analysis (e.g. computer-supported MEDLINE, EMBASE and Cochrane database research as of April 2017) was performed.

RESULTS

Antiseptic fluids can be used both prophylactically and therapeutically, in acute and chronic, clean, contaminated and infected wounds to reduce the posttraumatic and postoperative wound infection rates. The antiseptic solutions that are commonly used in orthopedic and trauma surgery (e.g. PVP-iodine, octenidine, polyhexanide, sodium hypochlorite/hypochlorous acid and acetic acid), have in common that no development of resistance has so far been shown and that when the contraindications are taken into account, the antiseptic effect can develop without any clinically significant local and systemic side effects. As a rule the biocompatibility index is higher than 1 for the substances mentioned. In addition, they show an antiseptic effect against biofilms and multi-drug resistant pathogens. These antiseptic solutions can also be used for NPWTi with some limitations for octenidine.

CONCLUSION

As the basic equipment in trauma surgery, a selection of three different antiseptic wound irrigation solutions for the reduction of the rates of posttraumatic and SSI can be recommended. The use of antiseptics should be reviewed on an ongoing basis in the daily clinical routine and particular attention should be paid to unwanted effects in the course of the healing process. After application of 7-14 days, the indications for continuing the use of the antiseptic solutions must be carefully re-evaluated.

Consensus on Wound Antisepsis: Update 2018

Wound antisepsis has undergone a renaissance due to the introduction of highly effective wound-compatible antimicrobial agents and the spread of multidrug-resistant organisms (MDROs). However, a strict indication must be set for the application of these agents. An infected or critically colonized wound must be treated antiseptically. In addition, systemic antibiotic therapy is required in case the infection spreads. If applied preventively, the Wounds-at-Risk Score allows an assessment of the risk for infection and thus appropriateness of the indication. The content of this updated consensus recommendation still largely consists of discussing properties of octenidine dihydrochloride (OCT), polihexanide, and iodophores. The evaluations of hypochlorite, taurolidine, and silver ions have been updated. For critically colonized and infected chronic wounds as well as for burns, polihexanide is classified as the active agent of choice. The combination 0.1% OCT/phenoxyethanol (PE) solution is suitable for acute, contaminated, and traumatic wounds, including MRSA-colonized wounds due to its deep action. For chronic wounds, preparations with 0.05% OCT are preferable. For bite, stab/puncture, and gunshot wounds, polyvinylpyrrolidone (PVP)-iodine is the first choice, while polihexanide and hypochlorite are superior to PVP-iodine for the treatment of contaminated acute and chronic wounds. For the decolonization of wounds colonized or infected with MDROs, the combination of OCT/PE is preferred. For peritoneal rinsing or rinsing of other cavities with a lack of drainage potential as well as the risk of central nervous system exposure, hypochlorite is the superior active agent. Silver-sulfadiazine is classified as dispensable, while dyes, organic mercury compounds, and hydrogen peroxide alone are classified as obsolete. As promising prospects, acetic acid, the combination of negative pressure wound therapy with the instillation of antiseptics (NPWTi), and cold atmospheric plasma are also subjects of this assessment.

Aseptic surgical preparation for upper eyelid blepharoplasty via full-face octenidine antiseptic without antibiotic medication shows effective prophylaxis against post-surgical wound infection

Blepharoplasty is the third most common plastic surgical procedure in the USA. Due to the emergence of multiresistant bacteria, optimising the antiseptic procedure is crucial. Choice of antiseptics plays an important role as they may cause skin irritation and colouring of disinfected areas. In this study, the use of the aqueous antiseptic octenisept^® (octenidine) was evaluated in the outcome of blepharoplasties: incidence of wound dehiscence; haematoma; and infection in correlation with gender, medication, smoking habits and time of year. This retrospective surveillance study included 352 patients (median age 58·3 years). Skin disinfection was performed thrice prior to blepharoplasty. Sutures were removed on day 6. None of the patients suffered from wound infection. The total rate of wound dehiscence was 6·3%, with a higher ratio among male patients. Smokers and patients on anticoagulant medication showed a significantly higher incidence of wound dehiscence. Throughout the year, rates of wound dehiscence were highest in summer. Aseptic surgical preparation for blepharoplasty via full-face scrub with octenisept^® without oral antibiotic prophylaxis is well tolerated, with no report of wound infection, which may improve antibiotic stewardship as well as patient comfort. Elective upper eyelid blepharoplasty may ideally be performed in winter.

The effect of negative pressure wound therapy with antibacterial dressings or antiseptics on an in vitro wound model

OBJECTIVE

The aim of this study was to investigate the bacterial bioburden in experimental in vitro wounds during the application of conventional negative pressure wound therapy (NPWT), with and without antimicrobial dressings (polyhexanide, silver), against NPWT instillation of octenidine.

METHOD

Experimental wounds produced in an in vitro porcine wound model were homogenously contaminated with bacterial suspension and treated with NPWT and different options. Group A: non-antimicrobial polyurethane foam dressing; group B: antimicrobial polyurethane foam dressing containing silver; group C: antimicrobial gauze dressing containing polyhexanide; group D: non-antimicrobial polyurethane foam dressing intermittently irrigated with octenidine; group E: negative control (non-antimicrobial polyurethane foam dressing without NPWT). Standard biopsies were harvested after 24 and 28 hours.

RESULTS

This study demonstrated that the use of NPWT with intermitted instillation of octenidine (group D) or application of silver-based polyurethane foam dressings (group B) is significantly superior against Staphylococcus aureus colonisation in experimental wounds compared with non-antimicrobial polyurethane foam dressing (group A) after 48 hours. Surprisingly, the polyhexanide-based dressing (group C) used in this model showed no statistical significant effect compared with the control group (group E) after 24 or 48 hours of treatment.

CONCLUSION

Both intermitted instillation of octenidine and silver-based dressings in standard NPWT were significantly superior compared with non-antimicrobial polyurethane foam dressings or PHMB coated gauze dressing after 48 hours.

Peroxy Pyruvic Acid-Containing Topical Anti-Infective: A Potential Candidate for a Wound Instillation Solution

Objective: Evaluate the therapeutic properties of a peroxy pyruvic acid (PPA)-containing topical anti-infective in a human ex-vivo model that replicates the natural conditions of a human chronic wound. Approach: Wound material was extracted from patients with nonhealing diabetic ulcers, venous stasis ulcers, and arterial wounds. Microbial species were identified, and wound colonization was quantified. Extracted samples were then exposed to a PPA-containing topical anti-infective as an instillation solution with negative pressure wound therapy NPWT at concentrations of 1,000, 1,500, or 2,500 ppm for a period of 1, 5, or 10 min to determine the effect of exposure on isolated pathogens, including effect on proteins. Results: A total of 32 samples were collected from patients. Samples presented with a range of bacteria and fungi representing 14 genera and 22 species, many of which are or are evolving to be resistant to many, if not most, current systemic antibiotics. Thirteen of twenty-three samples (57%) from chronic wounds had bacteria counts ≥10⁵ and most were 6 logs or more. Seven of 10 samples (70%) from acute wounds had bacteria counts ≤10⁵ and most were much lower. Exposure to PPA-containing topical anti-infective at 1,000 ppm killed all bacteria and fungi in all samples within 1 min of exposure. Innovation: PPA-containing topical anti-infective is a potentially valuable clinical option for NPWT. Conclusion: PPA-containing topical anti-infective is a potential candidate for use as an NPWT instillation solution for the treatment of wound infections caused by susceptible pathogens.

Zum Stellenwert der Unterdruck-Instillationstherapie in der Dermatologie

Die Methoden zur Behandlung akuter und chronischer Wunden unterliegen einer steten Weiterentwicklung, Reevaluierung und Anwendung innovativer Therapieformen. Die Vakuumtherapie zur Wundbehandlung gehört zu den etablierten Behandlungsmodalitäten. Ein innovatives Verfahren kombiniert die Vakuumtherapie mit der automatisierten, kontrollierten Zufuhr und Drainage wirkstoffhaltiger Lösungen zur topischen Wundbehandlung im Wundbett und auch wirkstofffrei durch Instillation physiologischer Kochsalzlösung (Unterdruck-Instillationstherapie). Hierdurch können die Effekte der konventionellen Vakuumtherapie mit denen der lokalen Antisepsis kombiniert werden. Hierdurch kommt es zu einer Reduktion der Wundfläche, einer Induktion von Granulationsgewebe sowie einer Reduktion der Keimbesiedelung der Wunden. Bisher publizierte Studien konzentrieren sich auf die Anwendung dieses Therapieverfahrens zur Behandlung orthopädisch-chirurgischer Krankheiten. Die Datenlage bezüglich der Vakuum-Instillationstherapie in der Dermatochirurgie beschränkt sich derzeit auf Fallberichte und Einzelfallerfahrungen. Randomisierte, prospektive Studien zum Vergleich der Vakuum-Instillationstherapie zur Behandlung dermatologischer Krankheitsbilder existieren bislang nicht. Ziele des vorliegenden Artikels sind die Vorstellung der Vakuumtherapie mit Instillation einschließlich ihres Wirkprinzips, deren mögliche Komplikationen, die Diskussion erdenklicher Kontraindikationen sowie eine Übersicht über die aktuell verfügbare Datenlage. Zusammenfassend scheint sich die Evidenz zu verdichten, dass mittels Unterdruck-Instillationstherapie sowohl einfache als auch komplizierte Wunden effizient behandelt werden können, was sich in einer deutlichen Beschleunigung der Wundgranulation mit konsekutiv früher möglichem Defektverschluss äußert.

Management of post-operative fistula in head and neck surgery: Sweeping it under the carpet?

The most dreaded complication in head and neck surgery is the development of fistula. Fistulas are common and devastating. The prevalence and the risk factors that contribute to fistula formation after head and neck procedures were discussed briefly. The main goal of this manuscript is to discuss current management of head and neck fistula. We believed that the best management strategy for head and neck fistulas is prevention. We recommend a holistic preventive approach during the perioperative period. The roles of different types of wound products and hyperbaric oxygen therapy were also discussed and highlighted. We also discussed the operative repair of fistulas, which relies on the tenet of providing well-vascularized tissue to an area of poor wound healing. Most often, the surgeon’s preference and range of operative skills dictate the timing and the type of repair. We highlighted the use of the pectoralis major, a well-known flap, as well as a novel technique in the surgical repair of complex, difficult-to-heal head and neck fistula.

Non-invasive treatment for severe complex pressure ulcers complicated by necrotizing fasciitis: a case report

Introduction

Pressure ulceration is a common problem for long-term bedridden patients and individuals with traumatic paraplegia. Necrotizing fasciitis can be a life-threatening complication caused by pressure ulcers, especially for debilitated elderly patients. In this report, we describe the successful use of negative pressure wound therapy with instillation to treat severe complex pressure ulcers complicated with peri-anal necrotizing fasciitis.

Case presentation

A 58-year-old Chinese woman was admitted to our hospital with severe complex pressure ulcers on her bilateral ischial tuberosities, left hip, perineum, and left sacrococcygeal region. The wounds had been present for nearly 2 years. Her seventh and eighth thoracic vertebrae had been traumatically injured; she had been bedridden for 5 years. She was also diabetic. Her medical history and laboratory investigations confirmed severe complex pressure ulcers complicated with necrotizing fasciitis. Antibiotic therapy was initiated. Following negative pressure wound treatment with instillation, the topical infection subsided and final closure of the wound occurred after 130 days.

Conclusions

Negative pressure wound treatment with instillation is an effective treatment protocol. It can reduce healing time, and promote long-term functional and cosmetic outcomes in debilitated patients with severe complex pressure ulcers complicated with necrotizing fasciitis.