Transcript

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Managing Wound Infection

Negative Pressure Wound Therapy with Instillation

Faculty

John C. Lantis, II, MD Vice Chairman, Department of Surgery

Professor of Surgery Icahn School of Medicine

Vice Chairman, Department of Surgery Mount Sinai, St. Luke’s, and Roosevelt Hospitals

New York, New York

Learning Objectives

•  Discuss the impact of biofilms and bacteria on wound healing

•  Review the current wound treatment practice for infected wounds

•  Recognize the impact of different topical wound treatment solutions on the infected wound

•  Focus on the needs of the patient vs the needs of the healthcare provider

Bacteria in Chronic vs Acute Wounds

Chronic vs Acute Wounds

•  A chronic, nonhealing wound has been defined as a wound that fails to proceed through the orderly and timely series of events required to produce a durable structural, functional, and cosmetically acceptable closure

Lazarus GS, et al. Arch Dermatol. 1994;130(4):489-493.

Biochemical Differences

Healing Wounds

•  High cell mitosis

•  Low inflammatory cytokines

•  Low proteases (MMPs)

•  Increased growth factors

•  Cells capable of rapid response

•  Synergistic relationship with bacteria

Chronic Ulcers •  Low cell mitosis

•  High inflammatory cytokines

•  High proteases (MMPs)

•  Decreased response to growth factors

•  Senescent cells

•  Hostile relationship with bioburden

MMPs = matrix metalloproteinases.

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The Items to Deal with…

•  Necrotic burden –  MMPs: breakdown extracellular matrix, growth factors

–  Harbor resident bacteria

•  Edema –  Uncontrolled inflammation

•  Poorly vascularized wound bed –  Senescent cells that do not respond to stimuli

•  Bacterial burden (bioburden) –  Generate oxygen-free radicals and serine proteases

•  Wound exudate –  Overexpressed MMPs

Bioburden

•  Critical colonization –  Replicating bacteria in

the wound bed

•  Infection stimulates –  Prostaglandin E2 and

thromboxane

–  Thrombosis and vasoconstriction

–  Wound hypoxia

•  Absence of classical signs of infection; bacteria that –  Alter their phenotype and immune expression

–  Development of “immune tolerance”

–  Evade detection

Infection

•  Replicating organisms within a wound that stimulates a host response with; erythema, warmth, swelling, pain, loss of function; ± leukocytosis

•  Initiate parenteral antibiotics –  Course determined by tissue infected

–  Perfusion

•  Ideally planktonic bacteria culture focused antibiotics OR based on known local epidemiology

•  May also be influenced by “bad actors”

•  Initially treat the wound bed with an antibacterial, as well

Bioburden Challenges

Planktonic Bacteria •  Strain(s) •  Resistance •  Cross contamination •  Nosocomial •  Hospital-acquired infection •  Host susceptibility

Biofilm •  Strain(s) •  Resistance •  Extracellular polymeric substances

–  Penetration –  Disruption

•  Anaerobes

The Impact of Biofilms and Bacteria on Wound Healing

What is a biofilm?

•  Traditionally, microbiologists have studied bacterial structure, function, and susceptibility using cells that have been cultured in liquid medium

•  In this state, bacteria exist as free-floating planktonic cells

•  However, it is increasingly being recognized that in their natural habitat, most bacteria grow attached to a surface

Percival SL, et al. Wounds. 2004;16(7).

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What is a Biofilm?

•  The growth of large aggregates of cells on a surface encased within a three-dimensional matrix of extracellular polymers (otherwise known as extracellular polymeric substance or EPS)

•  Produced by the sessile bacteria is known as a biofilm

•  In man, the surfaces that are available for attachment are many and varied and include skin, teeth, the respiratory tract, and intestinal mucosa

Percival SL, et al. Wounds. 2004;16(7).

Why are biofilm a problem?

•  Biofilm bacteria are less susceptible to our immune defense system, and consequently, a biofilm-associated infection can persist for a long period of time (i.e., progress from an acute to a chronic infection)

•  Biofilms display innate resistance to antimicrobial agents, thus protecting associated bacteria. The reasons for this are not clear, but it is likely that antimicrobial agents are readily inactivated or fail to penetrate into the biofilm. Bacteria within biofilms may be up to 1,000 times more resistant to antimicrobial agents than those in a planktonic state

•  Biofilms increase the opportunity for gene transfer between and among bacteria. This is important, since bacteria resistant to antibiotics may transfer the genes for resistance to neighboring susceptible bacteria

Biofilms are resistant to antibiotics…

•  Impaired penetration of an antibiotic into the biofilm matrix

•  Reduced growth rate of bacteria in biofilms, which renders them less susceptible to antibiotics (they change from being physiologically active in the planktonic state to sessile in the biofilm state)

•  Altered micro-environment within the biofilm (e.g., pH, oxygen content), which reduces the activity of an antimicrobial agent

•  Altered gene expression

•  Quorum sensing (QS)

Percival SL, et al. Wounds. 2004;16(7).

How do biofilms inhibit healing?

•  Biofilms have a negative effect on wound healing as evidenced by their ability to induce keratinocyte apoptosis in vitro

•  Inhibit re-epithelialization in an in vivo animal wound model

•  In addition, biofilms may also augment the inflammatory response characteristic of chronic wounds, thus promoting tissue damage and further contributing to the nonhealing phenotype

Organisms that Probably Need to Be Covered No Matter What…

•  Beta hemolytic strep

•  Mycobacteria

•  Bacillus anthracis

•  Yersinia pestis

•  Corynebacterium diphtheriae

•  Erysipelothrix

•  Leptospira

•  Treponema

•  Brucella

•  Histoplasma

•  Blastomyces

•  Coccidioides

•  Leishmaniasis

Current Treatment Best Practices for Infected Wounds

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To Put the Patient First…

•  Efficacy

•  Availability/affordability

•  Concordance/compliance

•  Must follow the WUWHS consensus guidelines – Must address/take into consideration WRP

WUWHS = World Union of Wound Healing Societies; WRP = wound-related pain. WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.

WUWHS Guidelines

•  Identify and treat the cause of the chronic wound and address concerns expressed by the patient, including a pain assessment at each visit

•  Evaluate and document pain intensity and characteristics on a regular basis (before, during, and after dressing-related procedures)

•  Cleanse wound gently, avoid the use of abrasive wipes and cold solutions

•  Select an appropriate method of wound debridement and include the potential for causing WRP

•  Choose dressings that minimize trauma/pain during application and removal

WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.

WUWHS Guidelines (continued)

•  Treat infections that may cause WRP and inhibit healing

•  Treat local factors that may induce WRP (eg, inflammation, trauma, pressure, maceration)

•  Select an appropriate dressing to minimize WRP based on wear time, moisture balance, healing potential, and periwound maceration

•  Evaluate each patient’s need for pharmacologic (eg, topical/systemic agents) and nonpharmacologic strategies to minimize WRP

•  Involve and empower patients to optimize pain management

•  Healthcare providers should ensure WRP control for every patient

WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.

Local Infection

NERDS

• Nonhealing

• Exudate (increased)

• Red friable granulation tissue

• Debris

• Smell

WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.

Critical Colonization, Increased Bacterial Burden, Covert Infection

NERDS

•  Nonhealing

•  Exudate (increased)

•  Red friable granulation tissue

•  Debris

•  Smell

May be painful

Deep and Surrounding Skin Infection

•  New areas of breakdown

•  Erythema and/or edema

•  Exudate (increased)

•  Smell WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.

STONEES

•  Size increasing

•  Temperature increased (surrounding skin)

•  Os (probes or exposed bone)

Increased pain most reliable symptom and

may be clinically more useful than any one individual sign

Clinical Presentation

Acute Wound Infection

or

Severe Chronic Wound Infection

•  Advancing erythema

•  Fever

•  Warmth

•  Edema/swelling

•  Pain

•  Purulence

“Classic” Signs and Symptoms of Infection

Gardner SE, et al. Wound Repair Regen. 2001;9(3):178-186.

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Clinical Presentation

Gardner SE, et al. Wound Repair Regen. 2001;9(3):178-186.

Critically colonized –

τ Bacterial burden –

Local wound infection

•  Delayed healing

•  Change in color of wound bed

•  Friable granulation tissue

•  Absent or abnormal granulation tissue

•  τ or abnormal odor

•  τ Serous drainage

•  τ Pain at wound site

Secondary Signs and Symptoms of Infection

Identify and Treat the Cause of the Chronic Wound and Address Concerns Expressed by the Patient,

Including a Pain Assessment at Each Visit

–  Pain assessment is a required field

–  Not yet part of meaningful use

•  Diagnose –  Vascular supply –  Venous outflow –  Pressure surface –  Nutrition –  Bioburden

•  Electronic medical • Intervene record/JCAHO –  Debride within context of

patient acceptance –  Cleanse within context of

patient acceptance –  Treat bioburden within

context of patient acceptance

–  Reduce pressure/offload –  Improve blood flow –  Maximize nutrition –  Compress as necessary

JCAHO = Joint Commission on Accreditation of Healthcare Organizations.

The Playing Field

“Perhaps the most deceptively simple

of all therapeutic procedures is the treatment of

cutaneous infection with topical medication.

Despite the unique accessibility of the skin

to scientific investigation, it has for too long been

the playground of crude empiricism.”

Selwyn S. Microbial interactions and antibiosis. In: Maibach H, Aly R, eds. Skin microbiology: relevance to clinical infection. New York, NY: Springer-Verlag; 1981:63-74.

Instillation with NPWT Can be a Very Effective Way to Do This…

NPWT = negative-pressure wound therapy. Raad W, et al. Int Wound J. 2010;7(2):81-85.

A Pilot Study Comparing Sharp Debridement and Hydrodebridement:

Episodic Debridement Alone Does Not Adequately Reduce Planktonic Bioburden in Chronic Lower Extremity Wounds

•  Twelve patients, corresponding to 14 wounds, underwent debridement with either hydrodebridement (HD) or sharp steel (SS) with pulse irrigation

•  Wound quantitative tissue cultures were taken pre- and post- debridement

•  The bacterial counts prior to debridement were 1x107 CFU/gm (HD) versus 1.4 x107 CFU/gm (SS) and 2.5 x106 CFU/gm (HD) versus 7.5 x105 CFU/gm (SS) after debridement (p=0.41)

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A Pilot Study Comparing Sharp Debridement and Hydrodebridement:

Episodic Debridement Alone Does Not Adequately Reduce Planktonic Bioburden in Chronic Lower Extremity Wounds

•  The total bacteria reduction was 7.5 x106 CFU/gm (HD) versus 1.3 x107 CFU/gm (SS) after debridement (P=0.37)

•  The mean percentage of bacteria eradicated from baseline was 75% by HD and 93% killed by SS (P<0.05)

•  Extensive operative debridement using either modality does not provide adequate immediate reduction in wound planktonic bioburden

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Topical Wound Treatment Solutions

Do we have any hard data?

Cleanse Wound Gently, Avoid the Use of Abrasive Wipes and Cold Solutions

•  Irrigation: the practice of washing out or flushing a wound or body opening with a stream of a liquid solution

–  High 50 psi (jet) vs low pressure 4 to 15 psi (gravity or bulb syringe)

–  Continuous vs pulsatile

–  Low vs high volume

–  Solution (water, saline, antiseptics, or combinations)

•  Lavage: the process of washing/irrigating out an organ, usually the bladder, bowel, paranasal sinuses, or stomach, for therapeutic purposes with a liquid solution

•  Instillation: a procedure in which a liquid solution is slowly introduced into a cavity or passage of the body and allowed to remain for a specific length of time before being drained or withdrawn

Trevelyan J. Nurs Times. 1996;92(16):46-48. Fletcher J. Prof Nurse. 1997;12(11):793-796. Williams C. Br J Nurs. 1999;8(21):1460-1462. Oliver L. Nurs Stand. 1997;11(20):47-56. Davies C. Nurs Times. 1999; 95(43):71-72, 75. Bergstrom N, et al. Treatment of pressure ulcers. Clinical Practice Guideline, No. 15. 1994. AHCPR Publication No. 95-0652. Rockville, MD: U.S. Department of Health and Human Services. Public Health service, Agency for Health Care Policy and Research. Chisholm CD, et al. Ann Emerg Med. 1992;21(11):1364-1367.

Role of Topical Antimicrobials

•  Many wounds support relatively stable mixed communities of microorganisms, often without signs of infection

•  In chronic wounds, reduction of certain microbial species, such as anaerobic bacteria, to limit undesirable odors

•  Mixed communities of 4 or more bacterial species that impede healing is to be justified

•  The eradication of beta hemolytic streptococci or staphylococci and Pseudomonas before grafting is essential

•  Intervention to prevent the development of systemic infection in critically colonized or locally infected wounds is reasonable

Bowler PG, et al. Clin Microbiol Rev. 2001;14(2): 244-269. Hansson C, et al. Acta Derm Venereol. 1995;75(1):24-30. Bowler PG, et al. Wounds. 1999;11:72-78. Trengove NJ, et al. J Wound Care. 1996;5(6):277-80. Schraibman IG. Ann R Coll Surg Engl. 1990;72(2):123-124. Gilliland EL, et al. Ann R Coll Surg Engl. 1988;70(2):105-108.

Choose Dressings that Minimize Trauma/Pain during Application and Removal

•  Cadexomer iodine dressings

–  72-hour wear times

•  Silver-containing foams –  Minimal pain

•  NPWT with instillation 72-hour wear times

•  Others

•  Maintenance of moist wound healing

•  Atraumatic to the wound and surrounding skin

•  Absorbency capacity (fluid handling/retention capacity)

•  Allergy potential •  Select dressings that stay

in situ for a longer period to avoid frequent removal

Schwartz JA, et al. Int Wound J. 2013;10(2):193-199. Lantis JC II, et al. J Wound Care. 2011;20(2): 90-96. Raad W, et al. Int Wound J. 2010;7(2):81-85.

Treat Local Factors that May Induce WRP (eg, inflammation, trauma, pressure, maceration)

•  ↑ MMPs; tissue damage; immune complex deposition; bradykinin, and related substance activation

•  Activated inflammatory mediators and tissue injury associated with nerve damage

•  Ischemic injury with tissue damage and nerve fiber irritation, reperfusion injury

•  ↑ Local interstitial pressure leading to tissue injury (impaired nutrient exchange: accumulation of waste products)

•  Topical and systemic anti- inflammatory

•  Protect exposed nerve fibres (eg, moist wound healing dressings)

•  Pressure redistribution

•  Venous, lymphatic: compression, mechanical pumps congestive heart failure, ↓ albumin; treat the cause

WUWHS. Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd, 2004.

NPWT with instillation (NPWTi) better reduces post debridement bioburden in chronically infected lower extremity wounds than NPWT alone

J Schwartz, J Lantis et al.

•  Single center, prospective study of 16 patients with heavy bioburden laden (quantitative tissue cultures > 105 bacteria) chronic lower extremity wounds

•  All patients received operative sharp surgical debridement. Wound tissue biopsy for quantitative tissue culture performed at day 0, 4, and 7

•  Patients were randomized to receive 1 week of post- debridement therapy with NPWT or NPWTi with 0.25% Dakins solution

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Bacterial bioburden change over time with NPWTi vs. NPWT

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Do we need to keep bacteria down post operatively?

•  Thirteen patients, corresponding to 16 chronic lower leg and foot wounds were taken to the operating room for debridement.

•  Quantitative cultures were taken pre-operatively after sterile preparation and draping of the wound site (POD # 0, pre-op), post- operatively once debridement was completed (POD # 0, post-op), and on post-operative day 7 after operative debridement (POD # 7, post- op).

•  After operative debridement (post-operative day 0) there was a mean of 3 (±1) types of bacteria per wound.

•  At 7 days post debridment. The mean absolute reduction in bacteria for the NPWTi group was 10.6 × 106 bacteria per gram of tissue while there was a mean absolute increase in bacteria for the NPWT group of 28.7 × 106 bacteria per gram of tissue, therefore there was a statistically significant reduction in the absolute bioburden in those wounds treated with NPWTi (p = 0.016).

Goss SG, et al. J Am Coll Clin Wound Spec. 2012;4(4):74-80.

Georgetown Data

•  Protosan™ (Polyhexanide + Betaine)

•  6 minute dwell time (3.5 hours NPWT)

•  20 minute dwell time (2 hours NPWT)

•  Compared to NPWT without instillation

3 Powers KA, et al. Presented at: The Symposium on Advanced Wound Care. May 1-5, 2013; Denver, Colorado.

Georgetown Data

3 Powers KA, et al. Presented at: The Symposium on Advanced Wound Care. May 1-5, 2013; Denver, Colorado.

–  Foam –  Alginates

•  High – Alginates/hyrofibres plus… – Mini negative

pressure units •  Very high

– NPWT

Absorptive Capacity Therapeutic Effect •  Minimal • Can it deliver an agent?

– Starch molecules – Antibacterial •  Medium •  Iodine

•  Intrinsic to honey?? •  Silver-based •  Topical antseptic

– Analgesic/anti-inflammatory •  Intrinsic to honey?? •  Nonsteroidal anti-inflammatory drugs •  Topical anesthetic

– Growth enhancing •  Growth factors •  Extracellular matrix

Select an Appropriate Dressing to Minimize WRP Based on Wear Time, Moisture Balance,

Healing Potential, and Periwound Maceration

–  MMP binding •  ORC/collagen

ORC = origin recognition complex.

Other Factors to Remember

•  Evaluate each patient’s need for pharmacologic (topical/systemic agents) and nonpharmacologic strategies to minimize WRP

•  Involve and empower patients to optimize pain management

•  Healthcare providers should ensure WRP control for every patient

Clinical Considerations

•  Anatomical location •  Patient positioning

•  Relation to gravity •  Complexity

–  Tunnel –  Undermining

•  Infection •  Hardware

–  Size –  Areas

•  Volume •  Others

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Wound Closure Concept St. Luke’s – Roosevelt Hospital, Division of Vascular Surgery

•  We do not know the bioburden/do not recognize the burden

•  We do not know the proliferative capacity

•  We do not know the exact deficiencies

•  We have to regain balance

•  We have to manage bacterial burden…

•  …but we have to put the patient’s needs first

Wound Cleansing Concept St. Luke’s – Roosevelt Hospital, Division of Vascular Surgery

•  Obtain quantitative culture prior to debridement •  Debride—sharp or hydrotherapy

–  Debridement only reduces planktonic bacteria by 1 log

•  Pulse irrigate –  Debridement still only reduces planktonic bacteria by 1 log

•  Obtain quantitative culture postdebridement •  Decide on topical therapy

–  Needs of the patient •  Are they willing to be hospitalized?

•  Are they a candidate for near-immediate closure?

–  Based on goal of therapy –  Size of wound –  Amount and number of bacteria –  Duration and etiology of wound

Schwartz JA, et al. Presented at: SAWC Spring/WHS Symposium; May 1-5, 2013; Denver, Colorado.

Wound Cleansing Choice St. Luke’s – Roosevelt Hospital, Division of Vascular Surgery

•  Ambulatory –  DFU: cadexomer/iodine

–  Venous/painful: silver-containing foams

–  Vasculitic painful: silver-containing foams

–  Others: honey-based products (as part of trials)

•  Larger wounds (>40 sq cm?) –  That can be hospitalized: NPWT with instillation

–  That need quick closure: •  Pain

•  Other surgery planned

–  Anatomically appropriate

–  Need jump start

NPWT with Instillation Protocol St. Luke’s – Roosevelt Hospital, Division of Vascular Surgery

•  Obtain quantitative culture prior to debridement

•  Debride

•  Pulse irrigate

•  Obtain quantitative culture postdebridement

•  Use NPWT with instillation—place directly in the operating room

•  Change 2 to 3 times in 7-day treatment course –  10-minute soak followed by 50-minute NPWT to 3.5-hour

NPWT

–  Quarter strength Dakin’s solution

How Do We Do This?

•  Algorithm

•  Decide size of the foam

–  L x W x D (2 cm) x .20 cc

•  Decide what solution

– Dakin’s 0.125??

•  Decide the time to dwell

–  Many factors

–  We are doing 10 minutes dwell/50 minutes NPWT

–  Have moved to 10 minutes dwell/3.5 hours NPWT

Clinical Questions

•  What agents? –  Different bacteria—different choices?

•  How long to dwell? –  Different agent—require different dwells

•  Dakin’s—very reactive, short dwell

•  PHMB—minimum 20-minute dwell

•  How long to provide negative pressure? –  What potentiates—macro and micro deformation?

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How Do I Choose a Solution?

•  Hypochlorite-based solutions –  Dakin’s solution, Dermacyn®, Microcyn®

•  Sulfur-based solutions –  Sulfamylon®, mafenide acetate solution

•  Silver nitrate solution –  Various

•  Biguanides (PHMB) –  Prontosan®

•  Cationic solutions –  Octenidine, benzalkonium chloride

•  Isotonic solutions –  Normal saline solution, Lactated Ringer’s solution

PHMB = polyhexanide.

In Vitro Biofilm Data NPWT with Instillation of the Appropriate Solution

May Control Bacteria Known to Form Biofilm

•  Mature biofilm starts to form within 4 to 10 hours, providing a window of opportunity during biofilm development where biofilm can be disrupted

•  Immature biofilms were exposed to antimicrobial solutions

–  0.1% PHMB

–  5% mafenide acetate

–  0.004% sodium hypochlorite + 0.003% hypochlorous acid

•  Intermittent exposure of developing biofilm to antimicrobial solutions reduced the number of mature biofilm bacteria by 1 to 2 log CFU

Control Saline 0.1% Poly-

5% Mafenide

haxanide Acetate

0.004% Sodium Hypo-

chlorite + 0.003%

1.00E+08

1.00E+07

1.00E+09

1.00E+06

1.00E+05

1.00E+04

1.00E+03

1.00E+02

1.00E+00

1.00E+01

Aver

age

CFU

/mL

Hypochlorous Acid

CFU = colony-forming unit. Cowan L, Philips P, Stechmiller J, et al. Antibiofilm Strategies and Antiseptics. In: Willy C, ed. Antiseptics in Surgery Update 2013. Berlin, Germany: Lundqvist Books; 23-30.

Sodium Hypochlorite Solutions

•  Device class –  Antimicrobial Agent

•  Commercially available names –  Dakin’s, Dermacyn®, Microcyn®

•  FDA cleared for topical application? –  Yes

•  FDA indication –  Wound cleansing

•  Common available forms –  Solution available in variety concentrations 0.5% (full strength), 0.25% (half strength), and

0.125% (quarter strength)

•  Common irrigation concentrations (%) –  Concentration commonly used 0.025% or 0.125%; NPWT instillation recommended –  Concentration max is 0.125% (quarter strength)

•  Common clinical usage –  Useful against nonsystemic infections due to drug-resistant microorganisms

Gerit D, et al. Wounds. 2007;19(7):173-182.

In Vitro Biofilm Data NPWT with Instillation of the Appropriate Solution

May Control Bacteria Known to Form Biofilm

•  In vitro biofilm model using pig skin

•  Instilled 6 times in 24 hours with 10-minute soak time using V.A.C. Instill® wound therapy

•  Solutions used

•  0.9% sodium chloride (normal saline)

•  0.1% polyhexamethylene biguanide (PHMB or polyhexanide)

•  Instillation therapy with antimicrobial solutions reduced biofilm bacteria by 3 log CFU Untreated V.A.C.®

Therapy V.A.C.

VeraFlo™ Therapy

With 0.1%

PHMB

V.A.C. VeraFlo™ Therapy

With Normal Saline

1.00E+07

1.00E+08

1.00E+06

1.00E+05

1.00E+04

1.00E+03

1.00E+02

1.00E+00

1.00E+01

Aver

age

CFU

/mL

Cowan L, Philips P, Stechmiller J, et al. Antibiofilm Strategies and Antiseptics. In: Willy C, ed. Antiseptics in Surgery Update 2013. Berlin, Germany: Lundqvist Books; 23-30.

PHMB Solutions

•  Device class –  Wound cleanser

•  Commercially available name –  Prontosan®

•  FDA cleared for topical application? –  Yes

•  FDA indication –  Intended for cleaning wounds and for moistening and lubricating absorbent wound

dressings for ulcers, burns, postsurgical wounds, and abrasions •  Common available forms

–  0.1% solution

•  Common irrigation concentrations (%) –  0.1% solution

•  Common clinical usage –  Aids in the removal of dirt and debris from chronic wounds, skin ulcers, and abrasions,

even when surfaces are difficult to access, such as skin folds, fissures, and wound pockets

Gerit D, et al. Wounds. 2007;19(7):173-182.

Cases

•  DFU with bone resection

•  Infected venous leg ulcer

•  Traumatic amputation

•  Necrotizing fasciitis of sacral wound

•  Open abdominal wound

•  Acute postoperative dressings

•  Other lower-extremity wounds

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Diabetic Charcot Foot

Postdebridement 12x106 Coagulase

negative staphylococci

Postoperative Day 4 Rare—Gram-positive cocci in pairs,

rare gram-negative rods

Postdebridement and initiation of NPWT with instillation Quarter strength Dakin’s solution

10-minute soak followed by 50-minute NPWT

Infected DFU

April 16

May 25 September 10

April 2 Initial application of NPWT

ORC/Collagen as an Adjunct to NPWT Wound Closure

Week 1 Week 2

Week 5 Week 8

Use of NPWT and Instillation to Prepare Pseudomonas-Infected Wound for STSG

10 days later with Debride in OR NPWT with instillation

STSG in OR 30 days post-STSG STSG = split-thickness skin graft.; OR = operating room. Raad W, et al. Int Wound J. 2010;7(2):81-85.

Sacral Wound Necrotizing Fasciitis Follow Same Standards for Postoperative Dressings?

•  Decrease frequency of dressing changes

•  Decrease edema

•  Maintain moist wound environment

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Other Wound Types and Transitions

•  Infected saphenectomy site –  >105 S. aureus –  Debride in OR –  4 days NPWT with instillation –  Discharge to skilled nursing facility

on NPWT system –  Planned STSG –  Also has open transmetatarsal

amputations with NPWT

•  Medial thigh ischemic wound •  Now revascularized

– >105 MRSA; 25,000 CFUs of Pseudomonas; 25,000 CFUs of corynebacterium

–  4 days of NPWT with Dakin’s instillation

–  Discharged on NPWT –  Planned STSG

MRSA = methicillin-resistant Staphylococcus aureus.

Techniques to Facilitate Closure of Complex Abdominal Wounds Summary

•  We assume most chronic wounds are infected/critically colonized

•  Minor colonizations can be treated with debridement; then—

–  Topical antimicrobial

•  Major colonizations can be treated with debridement; then—

–  Irrigation and NPWT


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