Role of an acidic environment in the treatment of diabetic foot infections: A review

The efficacy and safety of acids as topical antimicrobial agents: a review

OBJECTIVE

Infected wounds, refractory to conventional therapy, are a major burden on the healthcare system. Available data show that many commonly used antiseptic agents may be toxic to the cells involved in the healing process and may affect the normal tissue repair. The topical use of different acids to control wound infections effectively and promote healing is well known. The present review aims to summarise the safety and efficacy of various acids as topical agents for treating wound infections.

METHOD

A literature search was performed in PubMed and manually from other sources (cross references and journal sites).

RESULTS

We reviewed 116 articles, from which data from 86 relevant articles were analysed. The studies showed that various organic acids were clinically effective in treating wound infections.

CONCLUSION

This study found that various organic acids can act as a substitute for antiseptics to control wound infections refractory to conventional antibiotic therapy and local wound care. Various organic acids differ in efficacy, safety and limitations as topical agents to control wound infections and promote healing. Some acids deliver better results than others, particularly in those cases in which antibiotics and routine antiseptic agents yield little lasting success, especially in controlling hospital strains with multiple antibiotic resistance. Among topically used acids, citric acid and acetic acid are associated with better results.

Zeolite-Loaded Hydrogels as Wound pH-Modulating Dressings for Diabetic Wound Healing

Wound pH has emerged as a promising therapeutic target in diabetic foot ulcers (DFU). Here, we aimed to develop a microparticle-loaded hydrogel for pH modulation in wound fluid. In a screen of polymeric and inorganic microparticles, zeolites were identified as pH-modulating microparticles. Zeolites were encapsulated in a calcium cross-linked alginate hydrogel, a biocompatible matrix clinically used as a wound dressing. This hydrogel potently neutralized hydroxide ions in serum-containing simulated wound fluid. These findings encourage a further development of this pH-modulating device as a molecular therapeutic system for DFUs.

Psychological stress level surveys in patients with diabetic foot ulcers and the application effect of using loofah sponges during VSD treatment

OBJECTIVE

To investigate the psychological stress levels in patients with diabetic foot ulcer (DFU) and evaluate the effects of using a luffa sponge in vacuum sealing drainage (VSD) treatment.

METHODS

This retrospective study analyzed the clinical data from 110 DFU patients treated with VSD at The First People's Hospital of Zunyi (The Third Affiliated Hospital of Zunyi Medical University) between September 2021 and October 2023. Patients were categorized into two groups based on psychological stress levels: an observation group (with psychological stress, n=42) and a control group (without psychological stress, n=68). Baseline data were analyzed to identify factors influencing psychological stress. The observation group was further divided into the conventional care group and the loofah fiber care group, each with 21 patients, to evaluate the effect of using a loofah sponge during VSD treatment.

RESULTS

Logistic regression analysis identified Wagner classification and diabetes-related distress levels as significant factors influencing psychological stress (P<0.05). Post-intervention, the loofah fiber care group showed significantly lower scores on HQ-9, GAD-7, and SRSS (all P<0.05). Additionally, the loofah fiber care group showed lower frequencies of ASD dressing changes, shorter wound healing times, shorter hospital stays, and lower VAS pain scores (all P<0.05). Quality of life scores were significantly higher in the loofah fiber care group across all dimensions (P<0.05), and DASS-21 scores were significantly lower post-intervention (P<0.05). The loofah fiber care group also demonstrated significantly better outcomes in Wagner classification and diabetes-related distress levels, with higher patient satisfaction (all P<0.05).

CONCLUSION

This study highlights significant factors influencing psychological stress in patients with DFU and demonstrates that loofah fiber nursing interventions during VSD treatment improve psychological stress, wound healing, and quality of life. This method provides a promising approach to enhance patient outcomes and satisfaction.

Antipathogenic Activity of Betainized Polyethyleneimine Sprays Without Toxicity

Background/Objectives: The design of alternative antipathogenic sprays has recently attracted much attention due to the limitations of existing formulations, such as toxicity and low and narrow efficacy. Polyethyleneimine (PEI) is a great antimicrobial polymer against a wide range of pathogens, but toxicity limits its use. Here, betainized PEI (B-PEI) was synthesized to decrease the toxicity of PEI and protonated with citric acid (CA), boric acid (BA), and HCl to improve antimicrobial activity. Methods: Cytotoxicity of the PEI-based solutions was determined on L929 fibroblast cells. Antibacterial/fungal activity of PEI-based antipathogenic sprays was investigated by microtiter and disc diffusion assays, in addition to bacterial viability and adhesion % of common bacteria and fungi on the PEI-treated masks. Furthermore, the antiviral effect of the PEI-based solutions was determined against SARS-CoV-2 virus. Results: The biosafe concentration of PEI was determined as 1 μg/mL with 75 ± 11% cell viability, but B-PEI and its protonated forms had great biocompatibility even at 1000 μg/mL with more than 85% viability. The antibacterial/fungal effect of non-toxic B-PEI was improved by protonation with BA and HCl with 2.5-10 mg/mL minimum bactericidal/fungicidal concentrations (MBCs/MFCs). Bacterial/fungal viability and adhesion on the mask was almost eliminated by using 50 μL with 5-10 mg/mL of B-PEI-BA. Both protonated bare and betainized PEI show potent antiviral activity against SARS-CoV-2 virus. Conclusions: The toxicity of PEI was overcome by using betainized forms of PEI (B-PEI). Furthermore, the antimicrobial and antiviral efficacy of PEI and B-PEI was improved by protonation with CA, BA, and HCl of amine groups on B-PEI. B-PEI-BA spray solution has great potential as an antipathogenic spray with broad-spectrum antimicrobial potency against harmful bacteria, fungi, and viruses without any toxicity.

Antibacterial properties of photo-crosslinked chitosan/methacrylated hyaluronic acid nanoparticles loaded with bacitracin

The current treatments for wounds often fail to induce adequate healing, leaving wounds vulnerable to persistent infections and development of drug-resistant microbial biofilms. New natural-derived nanoparticles were studied to impair bacteria colonization and hinder the formation of biofilms in wounds. The nanoparticles were fabricated through polyelectrolyte complexation of chitosan (CS, polycation) and hyaluronic acid (HA, polyanion). UV-induced photo-crosslinking was used to enhance the stability of the nanoparticles. To achieve this, HA was methacrylated (HAMA, degree of modification of 20 %). Photo-crosslinked nanoparticles obtained from HAMA and CS had a diameter of 478 nm and a more homogeneous size distribution than nanoparticles assembled solely through complexation (742 nm). The nanoparticles were loaded with the antimicrobial agent bacitracin (BC), resulting in nanoparticles with a diameter of 332 nm. The encapsulation of BC was highly efficient (97 %). The BC-loaded nanoparticles showed significant antibacterial activity against gram-positive bacteria Staphylococcus aureus, Methicillin-resistant S. aureus and S. epidermidis. Photo-crosslinked HAMA/CS nanoparticles loaded with BC demonstrated inhibition of biofilm formation and a positive effect on the proliferation of mammalian cells (L929). These crosslinked nanoparticles have potential for the long-term treatment of wounds and controlled antibiotic delivery at the location of a lesion.

Wound pH-Modulating Strategies for Diabetic Wound Healing

Significance: Chronic diabetic wounds on the lower extremities (diabetic foot ulcers, DFU) are one of the most prevalent and life-threatening complications of diabetes, responsible for significant loss of quality of life and cost to the health care system. Available pharmacologic treatments fail to achieve complete healing in many patients. Recent studies and investigational treatments have highlighted the potential of modulating wound pH in DFU. Recent Advances: Data from in vitro, preclinical, and clinical studies highlight the role of pH in the pathophysiology of DFU, and topical administration of pH-lowering agents have shown promise as a therapeutic strategy for diabetic wounds. In this critical review, we describe the role of pH in DFU pathophysiology and present selected low-molecular-weight and hydrogel-based pH-modulating systems for wound healing and infection control in diabetic wounds. Critical Issues: The molecular mechanisms leading to pH alterations in diabetic wounds are complex and may differ between in vitro models, animal models of diabetes, and the human pathophysiology. Wound pH-lowering bandages for DFU therapy must be tested in established animal models of diabetic wound healing and patients with diabetes to establish a comprehensive benefit-risk profile. Future Directions: As our understanding of the role of pH in the pathophysiology of diabetic wounds is deepening, new treatments for this therapeutic target are being developed and will be tested in preclinical and clinical studies. These therapeutic systems will establish a target product profile for pH-lowering treatments such as an optimal pH profile for each wound healing stage. Thus, controlling wound bed pH could become a powerful tool to accelerate chronic diabetic wound healing.

Implementación de buenas prácticas clínicas: serie de casos de heridas de difícil cicatrización con tratamiento en extremidades inferiores

Introducción:

El estándar de manejo de heridas de difícil cicatrización basado en buenas prácticas clínicas incluye la identificación adecuada y el tratamiento de factores de riesgo que influyen en el mal pronóstico de cicatrización de las heridas en los pacientes, como carga microbiana en biopelículas, inflamación crónica y presencia de tejido desvitalizado y senescente.

Objetivo:

Describir el estándar de manejo implementado en un policlínico para tratar usuarios con heridas de difícil cicatrización en extremidades inferiores y evaluar los resultados clínicos de los protocolos utilizados.

Método:

Se identificaron y se analizaron los factores de riesgo presentes en los usuarios. Se utilizó una escala de valoración de pronóstico según la etiología de la úlcera y se valoró integralmente al paciente. Se determinó el objetivo terapéutico a través de la guía TIMERS y se definió el protocolo de tratamiento en el policlínico, que incluyó la limpieza terapéutica de la herida con ácido hipocloroso estabilizado pH 5.5, el uso de apósitos bactericidas-antibiopelícula y distintas estrategias de desbridamiento en heridas con signos de infección. Luego, se instauró un tratamiento local para la disminución de marcadores inflamatorios persistentes a través del uso de apósitos con octasulfato de sacarosa en las heridas sin signos de infección local, y se llevó a cabo un seguimiento de la evolución de las heridas.

Resultados:

Todos los pacientes con heridas de difícil cicatrización derivados al policlínico y tratados con el protocolo actualizado en buenas prácticas clínicas lograron la cicatrización de las heridas. Los tiempos reportados (90–120 días) fueron concordantes con protocolos homólogos reportados en la literatura, y resultaron menores en relación con un grupo de pacientes categorizados en la misma escala de clasificación de pronóstico y gravedad. No se observaron complicaciones durante el tratamiento. Se alcanzó la cicatrización en todos los casos.

Conclusión:

El abordaje sistemático y el uso de estrategias terapéuticas adecuadas pueden promover la cicatrización de heridas en extremidades inferiores, mejorar los resultados clínicos y la calidad de vida de los pacientes.

Asiaticoside-nitric oxide promoting diabetic wound healing through the miRNA-21-5p/TGF-β1/SMAD7/TIMP3 signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Centella asiatica (L.) Urban is an ethnobotanical herb. The main bioactive components of Centella asiatica are pentacyclic triterpenoid glycosides, namely asiaticoside and hydroxyasiaticoside. Asiaticoside possess a diverse array of pharmacological properties, such as wound-healing, anti-inflammatory, antioxidant, anti-allergic, antidepressant, anxiolytic, anti-fibrotic, antibacterial, anti-arthritic, anti-tumor, and immunomodulatory activities.

AIM OF THE STUDY

The purpose of this investigation is to explore potential therapeutic interventions for the delayed healing of wounds in diabetic patients (DW) facilitated by Asiaticoside-Nitric Oxide. To clarify the key molecular mechanism of miRNA-21-5p in DW wound repair and to deepen the understanding of DW disease pathogenesis.

MATERIALS AND METHODS

Firstly, miRNA microarray technology, bioinformatics, and RT-qPCR were used to analyze DW patients' and normal controls' skin tissue samples. Secondly, in order to investigate the role of miRNA-21-5p, a hyperglycemic model was established using HaCaT cells. Overexpressing as well as interfering HaCaT cell lines were constructed by lentiviral infection to further explore the proliferative and migratory effects of Asiaticoside-Nitric Oxide. The next step was to search for potential target genes of miRNA-21-5p and verify them with dual-luciferase reporter assay. Finally, the expression levels of target genes and proteins were detected through the utilization of RT-qPCR and Western blotting under the influence of Asiaticoside-Nitric Oxide.

RESULTS

A library of miRNAs and target genes expressed explicitly in DW patients and rats was established. The study confirmed the upregulation of miRNA-21-5p in DW patients and identified its involvement in signaling pathways related to chronic ulcer wound repair. Overexpression of LV-miRNA-21-5p significantly promoted cell proliferation, while treatments of Asiaticoside-Low dose (AC-L) and Asiaticoside-Medium dose (AC-M) enhanced proliferation and migration, particularly when combined with nitroprusside (SNP). Further analysis revealed potential target genes of miRNA-21-5p, such as TGF-β1, SMAD7, and TIMP3. Their interaction with miRNA-21-5p was confirmed through dual luciferase assays. The study found that anti-DW drugs increased the expression of TGF-β1 and SMAD7 while inhibiting TIMP3 expression in a high-glucose environment.

CONCLUSIONS

The research concluded that miRNA-21-5p plays a crucial role in the delayed healing of diabetic wounds, and that the combination treatment of AC + SNP shows promise in promoting wound healing in DW rats. Target genes, including TGF-β1, SMAD7, and TIMP3, may contribute to the regulatory mechanisms involved in diabetic wound healing. These findings provide valuable insights for developing novel therapeutic approaches for DW.

Diabetic Foot Ulcer in India: Aetiological Trends and Bacterial Diversity

Diabetes is one of the most prevalent epidemic metabolic disorders, responsible for a significant amount of physical, psychological and economic loss in human society. Diabetic foot ulcer (DFU) is one of the extreme pathophysiological consequences of diabetes. Bacterial infection is the most important cause of chronic DFU. Bacterial species or their biofilms show multidrug resistance, which complicates DFU and consequently leads to amputation of the infected part. Since the Indian population comprises diverse ethnic and cultural groups, this could influence the aetiology of diabetic foot infections and bacterial diversity. We reviewed 56 articles published from 2005 to 2022 on the microbiology of DFU and extracted the data on study location, number of patients analysed in the study, pathophysiological complications, age of the patients, sex of the patient, type of bacteria, type of infection (mono or polymicrobial), predominant bacteria (Gram-positive or Gram-negative), predominant isolates and multiple drug resistance (tested or not). We analysed data and described aetiological trends in diabetic foot infections and bacterial diversity. The study revealed that Gram-negative bacteria are predominant as compared to Gram-positive bacteria in individuals with diabetes with DFU in India. Escherichia coli, Pseudomonas aeruginosa, Klebsiella sp. and Proteus sp. were the most predominant Gram-negative bacteria, while Staphylococcus aureus and Enterococcus sp. were the major Gram-positive bacteria in DFU. We discuss bacterial infections in DFU in the context of bacterial diversity, sampling methods, demography and aetiology.

Current scenario of traditional medicines in management of diabetic foot ulcers: A review

Diabetic foot infections and diabetic foot ulcers (DFU) cause significant suffering and are often recurring. DFU have three important pathogenic factors, namely, microangiopathy causing local tissue anoxia, neuropathy making the foot prone to injuries from trivial trauma, and local tissue hyperglycaemia favouring infection and delaying the wound healing. DFU have been the leading cause for non-traumatic amputations of part or whole of the limb. Western medicines focus mainly on euglycaemia, antimicrobials, debridement and wound cover with grafts, and off-loading techniques. Advances in euglycaemic control, foot care and footwear, systemic antimicrobial therapy, and overall health care access and delivery, have resulted in an overall decrease in amputations. However, the process of wound care after adequate debridement remains a major cost burden globally, especially in developing nations. This process revolves around two basic concerns regarding control/eradication of local infection and promotion of faster healing in a chronic DFU without recurrence. Wound modulation with various dressings and techniques are often a costly affair. Some aspects of the topical therapy with modern/Western medicines are frequently not addressed. Cost of and compliance to these therapies are important as both the wounds and their treatment are "chronic." Naturally occurring agents/medications from traditional medicine systems have been used frequently in different cultures and nations, though without adequate clinical base/relevance. Traditional Chinese medicine involves restoring yin-yang balance, regulating the 'chi', and promoting local blood circulation. Traditional medicines from India have been emphasizing on 'naturally' available products to control wound infection and promote all the aspects of wound healing. There is one more group of chemicals which are not pharmaceutical agents but can create acidic milieu in the wound to satisfy the above-mentioned basic concerns. Various natural and plant derived products (e.g., honey, aloe vera, oils, and calendula) and maggots are also used for wound healing purposes. We believe that patients with a chronic wound are so tired physically, emotionally, and financially that they usually accept native traditional medicine which has the same cultural base, belief, and faith. Many of these products have never been tested in accordance to "evidence-based medicine." There are usually case reports and experience-based reports about these products. Recently, there have been some trials (in vitro and in vivo) to verify the claims of usage of traditional medicines in management of DFU. Such studies show that these natural products enhance the healing process by controlling infection, stimulating granulation tissue, antimicrobial action, promoting fibroblastic activity and collagen deposition, etc. In this review, we attempt to study and analyse the available literature on results of topical traditional medicines, which are usually advocated in the management of DFU. An integrated and 'holistic' approach of both modern and traditional medicine may be more acceptable to the patient, cost effective, and easy to administer and monitor. This may also nevertheless lead to further improvement in quality of life and decrease in the rates of amputations for DFU.

Microenvironment-Based Diabetic Foot Ulcer Nanomedicine

Diabetic foot ulcers (DFU), one of the most serious complications of diabetes, are essentially chronic, nonhealing wounds caused by diabetic neuropathy, vascular disease, and bacterial infection. Given its pathogenesis, the DFU microenvironment is rather complicated and characterized by hyperglycemia, ischemia, hypoxia, hyperinflammation, and persistent infection. However, the current clinical therapies for DFU are dissatisfactory, which drives researchers to turn attention to advanced nanotechnology to address DFU therapeutic bottlenecks. In the last decade, a large number of multifunctional nanosystems based on the microenvironment of DFU have been developed with positive effects in DFU therapy, forming a novel concept of "DFU nanomedicine". However, a systematic overview of DFU nanomedicine is still unavailable in the literature. This review summarizes the microenvironmental characteristics of DFU, presents the main progress of wound healing, and summaries the state-of-the-art therapeutic strategies for DFU. Furthermore, the main challenges and future perspectives in this field are discussed and prospected, aiming to fuel and foster the development of DFU nanomedicines successfully.

Advances in the Preparation of Nanofiber Dressings by Electrospinning for Promoting Diabetic Wound Healing

Chronic diabetic wounds are one of the main complications of diabetes, manifested by persistent inflammation, decreased epithelialization motility, and impaired wound healing. This will not only lead to the repeated hospitalization of patients, but also bear expensive hospitalization costs. In severe cases, it can lead to amputation, sepsis or death. Electrospun nanofibers membranes have the characteristics of high porosity, high specific surface area, and easy functionalization of structure, so they can be used as a safe and effective platform in the treatment of diabetic wounds and have great application potential. This article briefly reviewed the pathogenesis of chronic diabetic wounds and the types of dressings commonly used, and then reviewed the development of electrospinning technology in recent years and the advantages of electrospun nanofibers in the treatment of diabetic wounds. Finally, the reports of different types of nanofiber dressings on diabetic wounds are summarized, and the method of using multi-drug combination therapy in diabetic wounds is emphasized, which provides new ideas for the effective treatment of diabetic wounds.

More studies are necessary to establish the effectiveness of Jinhuang powder in the treatment of diabetic foot

Diabetes mellitus is a common global public health problem that can cause serious illness and premature death. Diabetic foot ulcer, one of the complications of diabetes, is a major cause of morbidity and mortality and is associated with many other devastating complications. Previous study found that a group of traditional Chinese medicine (TCM) can be used for treating diabetic foot ulcers. More and more attention is being paid to the use of Chinese medicine to heal diabetic feet. Under the guidance of relevant theories of traditional Chinese medicine, more studies are needed to reveal the key active components and related signal pathways of TCM in the treatment of diabetic foot ulcer. One clinical study explored the treatment of diabetic foot with infection combined moist exposed burn ointment with Jinhuang powder. However, large-scale multi-center, double blind, randomized, placebo-controlled clinical trials and animal studies are necessary to establish the effectiveness of Jinhuang powder in the treatment of diabetic foot.