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

[Trauma surgical relevance of bite injuries by animals and humans]

Bite injuries require differentiated treatment due to the deeply inoculated polymicrobial pathogen spectrum, possible concomitant injuries and pronounced soft tissue damage. Dog bites are the most common bite injuries but are less complicated to heal than human and cat bites. The location of the bite greatly depends on the age and the size of the bite victim as well as the type of bite perpetrator. In every case detection of the pathogen should be carried out to provide the best possible adapted treatment in the event of an exacerbation. The primary antibiotic treatment should be empirical with amoxicillin + clavulanic acid or ampicillin + sulbactam and, if necessary, adjusted according to the antibiogram. Depending on the findings, surgical treatment includes excision of the bite canal and a customized wound debridement. It is important to check the vaccination status of those involved and if indicated, to carry out postexposure prophylaxis for tetanus and rabies.

Safety and effectiveness of an antiseptic wound cleansing and irrigation solution containing polyhexamethylene biguanide

OBJECTIVE

There is currently a wide range of cleansing and irrigation solutions available for wounds, many of which contain antimicrobial agents. The aim of this study was to assess the safety of HydroClean Solution (HARTMANN, Germany), a polyhexamethylene biguanide (PHMB)-containing irrigation solution, in a standard cytotoxicity assay, and to assess its effect in a three-dimensional (3D) full-thickness model of human skin.

METHOD

A number of commercially available wound cleansing and irrigation solutions, including the PHMB-containing irrigation solution, were tested in a cytotoxicity assay using L929 mouse fibroblasts (ISO 10993-5:2009). The PHMB-containing irrigation solution was then assessed in an in vitro human keratinocyte-fibroblast 3D full-thickness wounded skin model to determine its effect on wound healing over six days. The effect of the PHMB-containing irrigation solution on tissue viability was measured using a lactate dehydrogenase (LDH) assay, and proinflammatory effects were measured using an interleukin-6 (IL-6) production assay.

RESULTS

The PHMB-containing irrigation solution was shown to be equivalent to other commercially available cleansing and irrigation solutions when tested in the L929 fibroblast cytotoxicity assay. When assessed in the in vitro 3D human full-thickness wound healing model, the PHMB-containing irrigation solution treatment resulted in no difference in levels of LDH or IL-6 when compared with levels produced in control Dulbecco's phosphate-buffered saline cultures. There was, however, a pronounced tissue thickening of the skin model in the periwound region.

CONCLUSION

The experimental data presented in this study support the conclusion that the PHMB-containing irrigation solution has a safety profile similar to other commercially available cleansing and irrigation solutions. Evidence also suggests that the PHMB-containing irrigation solution does not affect tissue viability or proinflammatory cytokine production, as evidenced by LDH levels or the production of IL-6 in a 3D human full-thickness wound healing model. The PHMB-containing irrigation solution stimulated new tissue growth in the periwound region of the skin model.

Bidirectional Irrigation System to Treat a Difficult Wound: A Case Series

AIMS

To date, there is no distinct principle determining whether to use irrigation under negative-pressure wound therapy (NPWT). We developed a new economical device to manage difficult wounds, employing 1 of 2 techniques depending on the wound condition.

METHODS

This case series study was conducted in 12 patients with difficult wound, from 2017 to 2018. Four patients were treated with Type A bidirectional irrigation system (wound irrigation), while 8 patients were treated with Type B bidirectional irrigation system (wound irrigation combined with NPWT).

RESULTS

In the Type A device group, inflammatory profiles in case I, case IV, and case VIII were not monitored due to the stability of their wound. The mean recovery period was 3.75 weeks (2-8 weeks), with decreases in 100% healing rate. In the Type B device group, we noted an average of 71% reduction in inflammatory profiles. All patients' infections were resolved or were healing, and 7 patients recovered satisfactorily. The recovery period ranged from 4 to 17 weeks, with a median value of 7 weeks.

CONCLUSION

Bidirectional irrigation system decreases secondary infections and complications, and increases the healing rate in patients with difficult wound.

Negative Pressure Wound Therapy With Instillation-Dwell in Orthopaedic Trauma: How to Avoid Leaks and Frustration

Negative pressure wound therapy with instillation-dwell (NPWTi-d) is the natural evolution of NPWT. This therapy combines the benefits of instillation with negative pressure. Advancements in the drape and the foam dressing has further advanced the utility of this therapy for use in orthopaedic trauma wounds. The technique for drape application plays an important role in maximizing the benefits of NPWTi-d. This article provides tips and guidance to ensure a proper dressing seal and other helpful instructions to maximize the benefits of NPWTi-d.

Combined use of vancomycin powder and betadine irrigation lowers the incidence of postcraniotomy wound infection in low-risk cases: a single-center risk-stratified cohort analysis

PURPOSE

Postoperative surgical site infections (SSIs) constitute a significant source of morbidity for neurosurgical patients. Protocols that minimize postoperative wound infections are integral to improving outcomes and curtailing expenditures. The present study seeks to identify risk factors for infection and assess the efficacy of prophylactic betadine irrigation and vancomycin powder in addition to standard antibiotic irrigation.

METHODS

We reviewed craniotomies performed by THS at Weill Cornell/New York Presbyterian Hospital to treat neuro-oncologic pathology. Patients were divided into three groups: group 1 - antibiotic irrigation, group 2 - antibiotic irrigation and betadine irrigation, group 3 - antibiotic irrigation, betadine irrigation, and vancomycin powder. SSI was confirmed with bacterial culture. Risk factor identification and assessment of treatment paradigms was performed using chi-square tests and univariate logistic regression.

RESULTS

Among 1209 total patients, the 30- and 90-day SSI rates were 1.7% and 3.5%, respectively. Significant predictors of SSI included preoperative use of bevacizumab (OR 40.84; p < 0.0001), foreign body (OR 4.06; p < 0.0001), prior radiation (OR 2.20; p = 0.03), and prior operation/biopsy (OR 1.92; p = 0.04). Risk of infection was 2.1% in low-risk cases and 6.9% in high-risk cases. A significant, incremental decrement in SSIs was identified between the prophylaxis groups, although only among low-risk cases: group 1: 4.53%, group 2: 1.39%, group 3: 0.42% (p = 0.02). Neither vancomycin powder nor betadine significantly reduced the risk of SSI in patients with one or more risk factors.

CONCLUSION

Vancomycin powder with betadine irrigation decreased SSI rates following neuro-oncologic cranial procedures in patients at low risk of infection (i.e., no preoperative risk factors).

Antiseptic versus non-antiseptic solutions for preventing infection in acute traumatic wounds: a systematic review

OBJECTIVE

To compare the effectiveness of antiseptic solutions to that of non-antiseptic solutions in reducing wound infection rate, reducing bacterial load and improving wound healing.

METHOD

We searched PubMed MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), ProQuest Medical Database and medRxiv for randomised controlled trials (RCTs) comparing antiseptic solutions with non-antiseptic solutions in simple, uncomplicated acute traumatic wounds. Qualitative data synthesis was employed. Risk of bias was assessed and GRADE assessment was used to evaluate quality of evidence.

RESULTS

In this systematic review, four studies with a total of 875 participants were included, of which two studies showed a significant reduction of wound infection rate using povidone-iodine (p=0.001 and p=0.03). The use of non-antiseptic solutions significantly increased bacterial load on acute traumatic wounds (p=0.0001). The quality of evidence was very low. No studies reported on wound healing outcome.

CONCLUSION

No robust conclusions can be implemented in clinical practice. Future studies are needed to compare the use of antiseptic and non-antiseptic solutions in acute traumatic wounds.

Multifunctional Irrigation-Assisted Vacuum Drainage versus Traditional Drainage in the Treatment of Odontogenic Deep Fascial Infection: A Retrospective Cohort Study

Purpose

Odontogenic deep fascial space infection in the head and neck is a common potentially fatal clinical problem. Traditional drainage method is considered laborious and gravity-dependent. In this study, we aimed to evaluate the clinical effect of a modified multifunctional irrigation-assisted vacuum drainage (MIVD) by comparing it with the traditional drainage method in the treatment of odontogenic deep fascial infection.

Patients and Methods

Patients diagnosed with odontogenic deep fascial space infection in the Second Affiliated Hospital, Zhejiang University School of Medicine, China between March 2018 and March 2021 were studied. We divided the patients into two groups based on the drainage method they received: patients with the MIVD device were included in the MIVD group, patients with traditional drainage were included in the traditional group. Data were collected retrospectively including baseline characteristics and treatment outcome variables.

Results

A total of 65 patients were included. All the patients were eventually cured. There were no significant differences in age, gender, diabetes, end stage renal disease, autoimmune diseases, other systemic diseases, tobacco use, number of the infected spaces, preoperative white blood cell count and C-reactive protein between the two groups. The number and frequency of manual irrigation by clinicians (MIC), time required for white blood cell count to return to normal levels (TWBC), time required for C-reactive protein to return to normal levels (TCRP), the length of hospitalization and the length and total cost of antibiotics use were significantly less in the MIVD group. There was no significant difference in the cost of hospitalization between the 2 groups.

Conclusion

The MIVD device significantly reduced the number and frequency of MIC, TWBC, TCRP, the length of hospitalization and the length and total cost of antibiotics use in comparison with the traditional drainage method. It provided a favorable treatment method for patients with odontogenic deep fascial space infection in the head and neck.

Sodium hypochlorite is more effective than chlorhexidine for eradication of bacterial biofilm of staphylococci and Pseudomonas aeruginosa

PURPOSE

Periprosthetic infection is a common reason for surgical revision. Given the increasing resistance of bacteria to antibiotics (e.g., VRE, 4-MRGN) local antiseptic treatment is gaining in importance. However, no standard guideline-based treatment recommendation is yet available. The aim of this study was to investigate the effectiveness of sodium hypochlorite and chlorhexidine against bacterial biofilms. Furthermore, the toxicity of both antiseptics towards human chondrocytes was examined.

METHODS

Human chondrocytes were isolated, cultivated and treated with sodium hypochlorite and chlorhexidine. The viability of cultures was assessed by determination of cell count, XTT and MTT ELISAs, and fluorescent staining with propidium iodide. Bacterial strains of Staphylococcus aureus, Staphylococcus epidermidis and Pseudomonas aeruginosa were added to liquid media and incubated overnight. After determination of bacterial concentrations polyethylene (PE) devices were inoculated with bacteria for 48 h until biofilms formed. The devices were then washed, treated with antiseptics for 2 and 5 min and subsequently spread on agar plates.

RESULTS

Sodium hypochlorite is more effective than chlorhexidine in penetrating biofilms of S. aureus, S. epidermidis and P. aeruginosa. Both antiseptics are chondrotoxic, but sodium hypochlorite damages human chondrocytes less than chlorhexidine in vitro.

CONCLUSIONS

The findings confirm the effectiveness of sodium hypochlorite and chlorhexidine against bacterial biofilms. Both antiseptics can be recommended for the treatment of periprosthetic infections. The toxic effects of sodium hypochlorite and chlorhexidine towards chondrocytes may mean there is a risk of damage to cartilage tissue.

LEVEL OF EVIDENCE

Controlled experimental study.

Evaluation of Necrotic, Edematous and Inflammatory Changes in Bone Marrow and Soft Tissue After Irrigation with Different Concentrations of NaOCl Solution: An Experimental Study in Rat Tibia

Objective

We aimed to investigate effects of different concentrations (0.5-5%) of Sodium Hypochlorite (NaOCl) solution on healthy tissues, and determine the optimal concentration that does not harm to tissue.

Materials and Methods

30 tibias of 15 male Wistar albino rats were used. The tibias were randomly divided into 5 groups (Salin, 0.5%, 1%, 2.5%, and 5% NaOCl). Tibias were reamed intramedullary, and irrigated with 20 ml of saline or increasing concentrations of (0.5-5%) NaOCl. The tibias were embedded in paraffin and the sections were stained with hematoxylin-eosin. All sections were assessed for edema, acute inflammation, or necrosis according to their density, in bone marrow and soft tissues.

Results

Pairwise comparisons revealed that irrigation of tibia with saline or 0.5% NaOCl solutions was not statistically significant in terms of necrosis in the bone marrows (p=0.320). However, irrigation of rat tibia with saline caused less necrosis in the bone marrows compared to high concentrations (1%, 2.5%, and 5%) of NaOCl (saline and 1% NaOCl, p=0.017; saline and 2.5% NaOCl, p=0.0007; saline and 5% NaOCl, p=0.001).

Conclusion

As an irrigation solution, the effects of 0.5% NaOCl are similar to those of saline in terms of edema, inflammation, and necrosis. There is a need for evaluation of necrosis for extended periods such as one week or one month by immunohistochemical methods and flow cytometry.

Re-evaluation of polihexanide use in wound antisepsis in order to clarify ambiguities of two animal studies

OBJECTIVE

Due to classification of the agent polihexanide (PHMB) in category 2 'may cause cancer' by the Committee for Risk Assessment of the European Chemicals Agency in 2011, the users of wound antiseptics may be highly confused. In 2017, this statement was updated, defining PHMB up to 0.1% as a preservative safe in all cosmetic products. In the interest of patient safety, a scientific clarification of the potential carcinogenicity of PHMB is necessary.

METHODS

A multidisciplinary team (MDT) of microbiologists, surgeons, dermatologists and biochemists conducted a benefit-risk assessment to clarify the hazard of antiseptic use of PHMB.

RESULTS

In two animal studies, from which the assessment of a carcinogenic risk was derived, PHMB was administered orally over two years in extremely high concentrations far above the NO(A)EL (no-observed-(adverse-) effect level) in rats and mice. Feeding in the NO(A)EL range resulted in no abnormal effects. In one male in the highest dose group of 4000ppm PHMB, an adenocarcinoma was found, which the author attributed to chronic inflammation of the colon with systemic atypical exposure. The increasing incidence of hemangiosarcomas highly probably resulted from increased endothelial proliferation, triggered by the exceedingly high dosage fed, because PHMB is not genotoxic and there is no evidence for epigenetic effects.

DISCUSSION

It is well known that PHMB is not absorbed when applied topically. Considering the absence of genotoxicity and epigenetic effects together with the interpretation of the animal studies, it is the consensus of the multidisciplinary experts that a carcinogenic risk from PHMB-use for wound antisepsis can be ruled out.

CONCLUSION

On this basis and considering their effectiveness, tolerability and clinical evidence, the indications for PHMB based wound antiseptics are justified.

Negative pressure wound therapy with instillation: International consensus guidelines update

The use of negative pressure wound therapy with instillation and dwell time (NPWTi‐d) has gained wider adoption and interest due in part to the increasing complexity of wounds and patient conditions. Best practices for the use of NPWTi‐d have shifted in recent years based on a growing body of evidence and expanded worldwide experience with the technology. To better guide the use of NPWTi‐d with all dressing and setting configurations, as well as solutions, there is a need to publish updated international consensus guidelines, which were last produced over 6 years ago. An international, multidisciplinary expert panel of clinicians was convened on 22 to 23 February 2019, to assist in developing current recommendations for best practices of the use of NPWTi‐d. Principal aims of the meeting were to update recommendations based on panel members' experience and published results regarding topics such as appropriate application settings, topical wound solution selection, and wound and patient characteristics for the use of NPWTi‐d with various dressing types. The final consensus recommendations were derived based on greater than 80% agreement among the panellists. The guidelines in this publication represent further refinement of the recommended parameters originally established for the use of NPWTi‐d. The authors thank Karen Beach and Ricardo Martinez for their assistance with manuscript preparation.

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.

Evaluation of three experimental in vitro models for the assessment of the mechanical cleansing efficacy of wound irrigation solutions

The aim of this study was to compare different wound-rinsing solutions to determine differences in the efficiency and to evaluate three different in vitro models for wound cleansing. Different wound-rinsing solutions (physiological saline solution, ringer lactate solution for wound irrigation, water and a solution containing polihexanide and the surfactant undecylenamidopropyl-betain) were applied on standardised test models (one- and three-chamber model, flow-cell method and a biofilm model), each challenged with three different standardised wound test soils. In the one-chamber model saline showed a better effect on decontaminating proteins than the ringer lactate solution. In the flow-cell method, water performed better than physiological saline solution, whereas ringer lactate solution demonstrated the lowest cleansing effect. No obvious superiority between the two electrolyte-containing solutions was detectable in the biofilm model. Unfortunately, it was not possible to assess the protein decontamination qualities of the surfactant-containing solution because of the interference with the protein measurement. The flow-cell method was able to detect differences between different rinse solutions because it works at constant flow mechanics, imitating a wound-rinsing procedure. The three-chamber and the less-pronounced modified one-chamber method as well as the biofilm model had generated inhomogeneous results.