Recommendations on negative pressure wound therapy with instillation and antimicrobial solutions - when, where and how to use: what does the evidence show?

Negative Pressure Level and Effects on Bacterial Growth Kinetics in an in vitro Wound Model

Negative Pressure Wound Therapy (NPWT) has been widely adopted in wound healing strategies due to its multimodal mechanism of action. While NPWT's positive impression on wound healing is well-established, its effect on bacterial load reduction remains equivocal. This study investigates NPWT's efficacy in reducing bioburden using an in vitro porcine skin model, focusing on the impact of Staphylococcus aureus and Staphylococcus epidermidis. Custom-made negative pressure chambers were employed to apply varying negative pressures. Porcine skin was cut into 5 × 5 cm squares and three standardized wounds of 6 mm each were created using a biopsy punch. Then, wounds were infected with S. aureus and S. epidermidis bacterial suspensions diluted 1:10,000 to obtain a final concentration of 1.5 × 104 CFU/ml and were placed in negative pressure chambers. After incubation, bacterial counts were expressed as colony-forming units (CFU) per ml. For S. aureus at 120 hours, the median CFU, mean area per colony, and total growth area were notably lower at -80 mmHg when compared to -250 mmHg and -50 mmHg, suggesting an optimal negative pressure for the pressure-dependent inhibition of the bacterial proliferation. While analyzing S. epidermidis at 120 hours, the response to the negative pressure was similar but less clear, with the minor CFU at -100 mmHg. The influence of intermittent negative pressure on the S. epidermidis growth showed notably lower median CFU with the interval therapy every hour compared to the S. aureus control group. This study contributes valuable insights into NPWT's influence on the bacterial load, emphasizing the need for further research to reformulate its role in managing contaminated wounds.

Assessment between antiseptic and normal saline for negative pressure wound therapy with instillation and dwell time in diabetic foot infections

Negative pressure wound therapy with instillation and dwell time (NPWTi-d) is increasingly used for a diverse range of wounds. Meanwhile, the topical wound irrigation solution consisting of polyhexamethylene biguanide and betaine (PHMB-B) has shown efficacy in managing wound infections. However, the effectiveness of this solution as a topical instillation solution for NPWTi-d in patients with diabetic foot infections (DFIs) has not been thoroughly studied. The objective of this retrospective study was to evaluate the impact of using PHMB-B as the instillation solution during NPWTi-d on reducing bioburden and improving clinical outcomes in patients with DFIs. Between January 2017 and December 2022, a series of patients with DFIs received treatment with NPWTi-d, using either PHMB-B or normal saline as the instillation solution. Data collected retrospectively included demographic information, baseline wound characteristics, and treatment outcomes. The study included 61 patients in the PHMB-B group and 73 patients in the normal saline group, all diagnosed with DFIs. In comparison to patients treated with normal saline, patients with PHMB-B exhibited no significant differences in terms of wound bed preparation time (P = 0.5034), length of hospital stay (P = 0.6783), NPWTi-d application times (P = 0.1458), duration of systematic antimicrobial administration (P = 0.3567), or overall cost of hospitalization (P = 0.6713). The findings of the study suggest that the use of either PHMB-B or normal saline as an instillation solution in NPWTi-d for DFIs shows promise and effectiveness, yet no clinical distinction was observed between the two solutions.

Negative pressure wound therapy with instillation and dwell time in debridement of fibrinous leg ulcers

OBJECTIVE

In conjunction with appropriate wound care, negative pressure wound therapy with instillation and dwell time (NPWTi-d) may be used as an adjunct therapy for acute or hard-to-heal (chronic) wounds, especially when infected. However, there are very few data on the use of NPWTi-d in the treatment of fibrinous wounds that are difficult to debride mechanically. The main objective of this study was to describe changes in the fibrin area of such wounds, before and after treatment with NPWTi-d.

METHOD

This was a monocentric, observational, prospective pilot study evaluating the NPWTi-d medical device. Eligible patients included in the study were those with hard-to-heal lower limb ulcers who had previously undergone unsuccessful specific debridement treatment for their wound, with failure of manual mechanic debridement for at least six weeks' duration, and whose wounds had a fibrinous surface area of >70% of the total wound surface area. The primary endpoint was the difference in the percentage of fibrinous surface area before and after treatment.

RESULTS

A total of 14 patients who received treatment for lower limb ulcers between October 2017 and August 2019 were included in the study. There was a significant shrinkage rate of the fibrinous wound surface between the start and end of treatment (83.6±14.5% and 32.2±19.7%, respectively; p<0.001).

CONCLUSION

This study showed a significant decrease in fibrin area in wounds treated with NPWTi-d, with good tolerance. We believe that NPWTi-d has its place in the multidisciplinary management of patients with hard-to-heal ulcers. Additional randomised studies are required to confirm these findings.

DECLARATION OF INTEREST

The authors have no conflicts of interest.

Ex vivo comparison of V.A.C.® Granufoam Silver™ and V.A.C.® Granufoam™ loaded with a first-in-class bis-dialkylnorspermidine-terphenyl antibiofilm agent

Implementation of negative pressure wound therapy (NPWT) as a standard of care has proven efficacious in reducing both the healing time and likelihood of nosocomial infection among pressure ulcers and traumatic, combat-related injuries. However, current formulations may not target or dramatically reduce bacterial biofilm burden following therapy. The purpose of this study was to determine the antibiofilm efficacy of an open-cell polyurethane (PU) foam (V.A.C.® Granufoam™) loaded with a first-in-class compound (CZ-01179) as the active release agent integrated via lyophilized hydrogel scaffolding. An ex vivo porcine excision wound model was designed to perform antibiofilm efficacy testing in the presence of NPWT. PU foam samples loaded with a 10.0% w/w formulation of CZ-01179 and 0.5% hyaluronic acid were prepared and tested against current standards of care: V.A.C.® Granufoam Silver™ and V.A.C.® Granufoam™. We observed statistically significant reduction of methicillin-resistant Staphylococcus aureus (MRSA) and Acinetobacter baumannii biofilms with the CZ-01179 antibiofilm foam in comparison to current standard of care foams. These findings motivate further development of an antibiofilm PU foam loaded with CZ-01179.

Clinical effect analysis of using medical glue versus conventional suturing to treat dog bite in children's maxillofacial region after negative pressure sealing drainage: A randomized trial

BACKGROUND

To compare the clinical effectiveness of applying medical glue versus conventional suturing after primary suturing and continuous vacuum sealing drainage (VSD) technology in the treatment of facial wounds caused by dog bites in children's maxillofacial region, with respect to operation time, wound infection rate, treatment effect, and patient satisfaction.

METHODS

From May 2020 to July 2022, 68 children with a dog bite in the maxillofacial region were randomly divided into medical glue and conventional suturing groups. The patients in both groups were treated with conventional debridement, tetanus and/or rabies immunization, and antibiotic therapy. The medical glue group was treated with VSD after the first-stage of the loose suture of the wound. After 5 days, the suture was removed, and the wound was tightly bonded with medical glue again. The conventional suturing group was treated with VSD after the first-stage of loose suture of the wound. The primary outcomes were the operation time and satisfaction of the 2 groups, and the secondary outcomes was the wound infection rate.

RESULTS

The operation time of the medical glue group was significantly lower than that of the conventional suturing group. However, there was no significant difference between the 2 groups in the wound infection rate. Still, the patient satisfaction was significantly better in the medical glue group than the conventional suturing group with statistically significant difference (P < .05).

CONCLUSION

In conclusion, applying medical glue after using negative pressure sealing drainage in treating maxillofacial dog bites can reduce surgeons work intensity, lessen children's pain, and improve the clinical treatment effect.

Influence of 4 drain configurations on fluid dispersal and retrieval in an instillation model

OBJECTIVE

To describe and compare the pattern of fluid dispersal and retrieval in a novel instillation therapy system.

STUDY DESIGN

In vitro experimental study.

METHODS

A 10 cm² square model was constructed using plastic sheeting secured to plexiglass, with a wound infusion catheter and Jackson-Pratt (JP) active suction drain positioned in 4 configurations: parallel, perpendicular, diagonal, and opposite. Fluid was instilled using the wound infusion catheter, allowed to dwell for 10 min, and retrieved using the JP drain. Two surface area calculations were made using imaging software: coloration with diluted methylene blue (MB) on photos, and filling with diluted contrast on fluoroscopic images. Fluid retrieval was recorded. Statistical analysis was performed using a mixed-effects linear model (p < .05).

RESULTS

Configuration influenced fluid dispersion within the model (p = .0001); the diagonal configuration had the greatest surface area coverage (mean ± SD; 94.5 ± 2.4%) and the parallel configuration had the lowest surface area coverage (60.2 ± 2.9%). A dwell period increased fluid dispersal by an average of 4.0 ± 0.8% (p < .0001). Fluid retrieval exceeded 16.7 ± 1.5 mL (83.5 ± 7.5% volume instilled) for all configurations and was 0.5 ± 0.1 mL (2.5 ± 0.5% volume instilled) greater for MB than contrast agent (p < .0001).

CONCLUSION

Perpendicular or diagonal configurations and low-viscosity fluid maximized fluid dispersion and retrieval.

CLINICAL SIGNIFICANCE

Wound instillation therapy involves delivering lavage fluid or medications to a closed wound space. This is feasible using a wound-infusion catheter and active suction drain. Configuration should be considered to optimize fluid dispersal and retrieval when planning instillation therapy.

Continuous local antibiotic perfusion: A treatment strategy that allows implant retention in fracture-related infections

PURPOSE

Fracture-related infections are difficult to treat because of the formation of biofilms around implants. Systemic antibiotics are notoriously ineffective against biofilms due to their insufficient penetration of tissues with poor vascularity. The goal of treating fracture-related infections is to achieve bone union while retaining the implant. Our proposal of continuous local antibiotic perfusion is a sustained local delivery system of sufficient antibiotics to bone and soft tissue infection sites, including to bone marrow via needles as intra-medullary antibiotics perfusion and to soft-tissue via double-lumen subcutaneous tubes as intra-soft tissue perfusion.

METHODS

In this study, we examined the outcomes of 40 patients treated for fracture-related infections using continuous local antibiotic perfusion between 2015 and 2021 at Steel Memorial Hirohata Hospital, Himeji, Japan.

RESULT

The antibiotic used for continuous local antibiotic perfusion was gentamicin in all cases. Implant removal was required in five patients. Two patients required toe amputation and knee arthrodesis, while the remaining 38 patients achieved fracture union. Only one case of transient acute renal injury as a systemic side effect was observed, but it soon resolved. The blood concentration of gentamicin could be adjusted to less than the trough level.

CONCLUSIONS

Continuous local antibiotic perfusion is a novel local drug delivery system that has the potential of delivering sufficient concentrations of antibiotics with few systemic side effects; it is a useful option for the treatment of fracture-related infections.

[Blast injuries part 2 : Principles of medical treatment]

Explosions can cause severe injuries, which affect multiple organ systems and leave extensive soft tissue defects. In unstable patients, damage control surgery initially focuses exclusively on controlling bleeding and contamination with the aim of preserving life and limbs. The excision of all necrotic tissue, extensive wound irrigation with antiseptic solutions and a calculated antibiotic prophylaxis, which is subsequently adapted to the microbiological findings, are the basis for sufficient infection control. As the tissue damage caused by the pressure surge can regenerate over time as well as become secondarily necrotic (developing wounds), several revision operations are often necessary to assess the viability of tissue in the sense of serial debridement. In the case of extensive soft tissue injuries temporary vacuum-assisted closure (VAC) techniques can bridge the time to the earliest possible definitive plastic surgical wound closure; however, this must not delay the closure of the defect.

Clinical Uses of NPWT with Irrigation of Normal Saline in Diabetic Foot Ulcer: Outcome Assessed by DEPA Score

Introduction

Diabetic foot ulcer (DFU) is a common complication of uncontrolled diabetes. Negative pressure wound therapy (NPWT) with irrigation of normal saline is one of the methods for wound care and dressing techniques in DFU. Wound assessment is another aspect of DFU management for deciding whether the wound is prepared or not for coverage. The present study uses DEPA score as a wound assessment tool in DFU.

Materials and Methods

This case series include 11 patients with DFU who were treated using NPWT with simultaneous irrigation of normal saline.

Results

All 11 patients were male and age more than 60. Most patients have duration of diabetes for less than 10 years. Staphylococcus aureus (n = 5, 45.4%) was most common bacterial flora. Most patients in series presented with DEPA score more than 7 and after application of NPWT instillation therapy significant improvement seen with score in most of the patient with DEPA score below 6. Mean time for NPWT (irrigation) application was 15 days. Mean time of wound preparation was 18.7 days. Final surgical procedures executed in all patients, split skin grafting performed in 7 patients. 4 patients had wound coverage by reverse sural flap (2), medial plantar flap (1) and local flap coverage (1).

Conclusion

NPWT with normal saline irrigation is an effective method of wound preparation in DFU. DEPA score is an important tool for assessment of wound preparation which gives exact information for timing of wound coverage once diabetic foot wound is prepared.

Evidence-Based Wound Irrigation: Separating Fact from Fiction

SUMMARY

The relationship between wound irrigation and healing has been recognized for centuries. However, there is little evidence and no official recommendations from any health care organization regarding best wound irrigation practices. This is the first review of wound irrigation that systematically summarizes the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and distills the evidence into a practical format. In this comprehensive review, the authors outline the irrigation fluids and delivery methods used in the identified studies, analyze reported treatment outcomes, summarize irrigation effectiveness, and propose evidence-based guidelines to improve wound healing outcomes and enhance the consistency of wound irrigation. Thirty-one high-quality studies with a combined total of 61,808 patients were included. Based on the current evidence provided by this review, the authors propose the following guidelines: (1) acute soft-tissue wounds should receive continuous gravity flow irrigation with polyhexanide; (2) complex wounds should receive continuous negative-pressure wound therapy with instillation with polyhexanide; (3) infected wounds should receive continuous negative-pressure wound therapy with instillation with silver nitrate, polyhexanide, acetic acid, or povidone-iodine; (4) breast implant wounds should receive gravity lavage with povidone-iodine or antibiotics; and (5) surgical-site infection rates can be reduced with intraoperative povidone-iodine irrigation.

Experience with negative-pressure wound therapy with instillation in complex infected orthopaedic wounds

Chronic exudative wounds are frequently seen in hospitalised patients, consuming hospital resources and leading to increased morbidity. Negative‐pressure therapy (NPWT) with topical instillation “NPWTi” may be used to improve the wound healing process, with the unique features (removal of wound exudate, edema reduction, promotion of tissue perfusion and granulation tissue formation, as well as drawing the edges of the wound to facilitate, in addition to the cyclic cleansing mechanism). This report is a descriptive study of our experience with NPWTi on complex infected orthopaedic wounds as a potential method to decrease the need for multiple surgical debridements required for the closure of such wounds. A prospective observational study was conducted. Twenty patients with complex infected orthopaedic wounds were enrolled in our study. These patients were consulted by the Bone and Joint Infection Service and enrolled to receive NPWTi intraoperatively and to be used during their inpatient stay. Twenty patients with 20 complex infected lower limb wounds were included in our study. Of all the 20 wounds, the etiology was post‐surgical in 80% (n = 16) and post‐traumatic in 20% (n = 4). None of the patients received previous treatment with conventional NPWT before participation in the study. There were 11 males (55%) and 9 females (45%) with an average age of 57 years (22‐83). All wounds were located in the lower limbs, with 25% leg (n = 5), 20% thigh (n = 4), 20% knee (n = 4), 20% foot (n = 4), 10% heel (n = 2), and 5% ankle (n = 1). The average length of treatment with NPWTi was 5.2 days (2‐10). Successful wound closure within 6 weeks was achieved in 65% of the cases (n = 13). Of the closed wounds (n = 13), 54% (n = 7) were closed primarily and 46% (n = 6) were closed by secondary procedures (skin graft or skin flap). NPWTi is still considered a novel technique that can be used in the management of complex wounds, and the goal of this prospective study is to report our experience with NPWTi in the management of complex infected orthopaedic lower limb wounds. Randomised control studies with optimally matched wounds comparing NPWTi to the conventional methods of treatment are warranted.

Efficacy of delayed primary closure with intrawound continuous negative pressure and irrigation treatment after surgery for colorectal perforation

AIM

Surgical-site infections (SSIs) often occur after surgery for colorectal perforation. We introduced delayed primary closure (DPC) after intrawound continuous negative pressure and irrigation treatment (IW-CONPIT) to prevent SSIs. We aimed to evaluate the efficacy of DPC after IW-CONPIT compared with primary closure (PC) after surgery for colorectal perforation.

METHODS

We undertook a retrospective study including 22 patients who underwent DPC (DPC group) and 18 patients who underwent PC (PC group) at our hospital between April 2015 and January 2017. The primary outcome was the SSI rate. The secondary outcomes were other complications (<30 days), length of hospital stay, and costs.

RESULTS

The SSI rate was significantly lower in the DPC group than in the PC group (40% vs. 94%, P = 0.0006). Moreover, superficial and deep incisional SSIs, infectious complications, and Clavien-Dindo classification grade ≥ 2 complications were also significantly diminished in the DPC group. Conversely, the length of hospital stay and costs were not significantly different between the two groups. Multivariate analyses revealed that the significant independent protective factor against SSI after surgery for colorectal perforation was DPC after IW-CONPIT (odds ratio 0.04; 95% confidence interval, 0.002-0.25).

CONCLUSION

Delayed primary closure after IW-CONPIT reduced SSIs after surgery for colorectal perforation compared with PC.

The impact of negative-pressure wound therapy with instillation on wounds requiring operative debridement: Pilot randomised, controlled trial

Presence of bacteria in wounds can delay healing. Addition of a regularly instilled topical solution over the wound during negative‐pressure wound therapy (NPWT) may reduce bioburden levels compared with standard NPWT alone. We performed a prospective, randomised, multi‐centre, post‐market trial to compare effects of NPWT with instillation and dwell of polyhexamethylene biguanide solution vs NPWT without instillation therapy in wounds requiring operative debridement. Results showed a significantly greater mean decrease in total bacterial counts from time of initial surgical debridement to first dressing change in NPWT plus instillation (n = 69) subjects compared with standard NPWT (n = 63) subjects (−0.18 vs 0.6 log₁₀ CFU/g, respectively). There was no significant difference between the groups in the primary endpoint of required inpatient operating room debridements after initial debridement. Time to readiness for wound closure/coverage, proportion of wounds closed, and incidence of wound complications were similar. NPWT subjects had 3.1 times the risk of re‐hospitalisation compared with NPWT plus instillation subjects. This study provides a basis for exploring research options to understand the impact of NPWT with instillation on wound healing.

Negative Pressure Wound Therapy in Pyoderma Gangrenosum Treatment

Patient: Male, 83-year-old

Final Diagnosis: Pyoderma gangrenosum

Symptoms: Infection

Medication: —

Clinical Procedure: Negative pressure wound therapy

Specialty: Dermatology • Geriatrics • Palliative Medicine • Surgery

Surgical Site Infections Complicating the Use of Negative Pressure Wound Therapy in Renal Transplant Recipients

Surgical site infections (SSI) of the abdominal wall in renal transplant recipients can on occasion require management with negative pressure wound therapy (NPWT). This is often successful, with a low risk of further complications. However, we describe three cases in which persistent or recurrent surgical site sepsis occurred, whilst NPWT was being deployed in adults with either wound dehiscence or initial SSI. This type of complication in the setting of NPWT has not been previously described in renal transplant recipients. Our case series demonstrates that in immunosuppressed transplant recipients, there may be ineffective microbial or bacterial bioburden clearance associated with the NPWT, which can lead to further infections. Hence recognition for infections in renal transplant patients undergoing treatment with NPWT is vital; furthermore, aggressive management of sepsis control with early debridement, antimicrobial use, and reassessment of the use of wound dressing is necessary to reduce the morbidity associated with surgical site infections and NPWT.

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.

Randomized clinical study to compare negative pressure wound therapy with simultaneous saline irrigation and traditional negative pressure wound therapy for complex foot infections

The aim of this study was to compare the efficacy of different negative pressure wound therapy (NPWT) devices and NPWT with and without simultaneous irrigation in patients admitted to hospital with moderate and severe foot infections. Ninety patients were randomized in a 12‐week prospective, randomized noninferiority trial to compare wound healing in patients with moderate and severe infected foot wounds treated with NPWT after surgery. Inclusion criteria included ABI > 0.5 or toe pressures >30 PVR/mmHg, >18 years of age and exclusion included active Charcot arthropathy, collagen vascular disease, HIV, and hypercoagulable state. We compared two different traditional devices, NPWT‐K (KCI, VAC Ulta) and NPWT‐C (Cardinal, PRO), and NPWT‐I with saline irrigation (Cardinal, PRO). All patients had therapy delivered at 125 mmHg continuous pressure. In patients who received simultaneous saline irrigation (NPWT‐I), the administration rate was 15 ml per hour. The primary outcome was the proportion of healed wounds in 12 weeks. Secondary outcomes included surgical wound closure, number of surgeries, length of stay, and time to wound healing. Continuous data was presented as mean ± standard deviation. Analysis of variance was used to compare continuous variables and chi‐square to compare dichotomous variables with an alpha of 0.05. There were no differences in outcomes among NPWT‐I, NPWT‐C, and NPWT‐K groups in proportion of healed wounds (63.3%, 50.0%, 46.7% p = 0.39), surgical wound closure (83.3%, 80.0%, 63.3%, p = 0.15), number of surgeries (2.0 ± 0.49, 2.4 ± 0.77, 2.4 ± 0.68, p = 0.06), length of stay (16.3 ± 15.7, 14.7 ± 7.4, 15.3 ± 10.5 days, p = 0.87), time to wound healing (46.2 ± 22.8, 40.9 ± 18.8, 45.9 ± 28.3 days, p = 0.78). We did not identify any significant differences in clinical outcomes or adverse events between patients treated with different NPWT devices or NPWT with and without irrigation.

Fundamental aspects of the local approach to cutaneous ulcers

Ulcers or wounds can be classified as acute or chronic. Their treatment involves overall assessment of the patient and choice of suitable local therapy, and the appropriate indication and use of products. Technological progress in the field of wound treatment has increased rapidly. Constant updating, with emphasis on available scientific evidence, is necessary to offer the best approaches to patients with acute and chronic wounds. A qualitative analysis of literature was conducted to identify scientific publications that update the concepts involved in local wound treatment, to present some resources that can aid the healing process and describe the different types of dressings available. This review includes wound assessment using the acronym TIME (tissue, infection/inflammation, moisture balance and edge of wound), cleaning and debridement, infection/inflammation control, exudate control, dressing types and main indications.

[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.

Negative pressure wound treatment with computer-controlled irrigation/instillation decreases bacterial load in contaminated wounds and facilitates wound closure

Microbial wound contamination is known to be a hindrance to wound healing. Negative pressure wound therapy (NPWT) with or without irrigation is known to optimise conditions in problem wounds. The aim of this study was to investigate the influence of computer-controlled wound irrigation with NPWT on the bacterial load in contaminated wounds. A total of 267 patients were treated with NPWT with automated instillation because of problematic wounds using an antiseptic instillation solution. In 111 patients, a minimum of 4 operative procedures were necessary, and swabs were taken at least at the first and at the fourth operation in a standardised procedure. The number of different bacteria and the amount of bacteria were analysed during the course. In a subgroup of 51 patients, swabs were taken at all 4 operative procedures and analysed separately. In an overall analysis, the number of different bacteria and the amount of bacteria significantly decreased independent of wound localisation and diagnosis. NPWT with automated instillation demonstrates a positive influence in the reduction of bacterial load in problem wounds. Thus, it may help to optimise wound conditions before definite wound closure.

On the significance of negative-pressure wound therapy with instillation in dermatology

Methods used in the treatment of acute and chronic wounds undergo constant evolution, reevaluation, and innovation. While negative-pressure wound therapy (NPWT) is an established treatment modality, the combination of NPWT and instillation of normal saline as well as solutions with active antiseptic components for topical treatment of the wound bed represents a novel approach. The well-known effects of NPWT may thus be combined with those of local antisepsis. They include a decrease in wound area, induction of granulation tissue, and reduction in bacterial colonization. To date, studies have focused on NPWT with instillation for orthopedic/surgical indications, whereas clinical data in dermatosurgery is limited to case reports or small case series. There are as yet no randomized prospective studies investigating NPWT with instillation in the treatment of skin disorders. The goal of this review is to present the method of NPWT with instillation, to highlight its mode of action as well as possible complications and contraindications, and to review the recent literature. In summary, there is increasing evidence that both simple and complicated wounds may be effectively treated with NPWT with instillation, resulting in markedly accelerated tissue granulation and thus earlier defect closure.

Vakuumassistierte Wundbehandlung (Negative Pressure Wound Therapy, NPWT) in der Kleintiermedizin

Die Behandlung offener Wunden gehört zu den alltäglichen Herausforderungen in der Tiermedizin. In den letzten Jahren hat sich mit der vakuumassistierten Wundbehandlung (Negative Pressure Wound Therapy, NPWT) eine neue Therapieform entwickelt. Durch ihren Einsatz lassen sich die Heilung offener Wunden und die Einheilungsrate freier Hauttransplantate beim Kleintier signifikant verbessern. In diesem Überblick werden Wirkweise, Indikationen sowie Komplikationen der Negative Pressure Wound Therapy dargestellt.

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.

5th Congress of WUWHS Abstract book Florence, Italy September 25–29 2016

The abstract book contains the abstracts of keynote lectures, focus sessions, symposia, workshops, AIUC annual meeting, AISLEC annual meeting, EPUAP annual meeting, ETRS special session, sponsor symposia, oral presentations, poster presentations and the subject index.

[Acute therapeutic measures for limb salvage Part 2 : Debridement, lavage techniques and anti-infectious strategies]

The quality of the primary care of Gustilo-Anderson (GA) type IIIB and IIIC extremity injuries is crucial to the success of the limb salvage procedure. This article provides a compilation of consistent, but often controversially discussed aspects of initial debridement, modern techniques of lavage and wound closure, in addition to current issues on the application of antibiotics and antiseptics, based on our own experiences and the latest literature. The following points should be stressed. Severe extremity injuries with gross contamination (GA IIIA, B, and C) will still be associated with an infection rate of up to 60 %. The initial debridement should be performed as soon as an experienced trauma surgeon is available. Tissue that is definitely avital will have to be removed, whereas traumatized but potentially surviving tissue will have to be re-evaluated during a second-look operation after 36-48 h. Given a high enough level of contamination, biofilms will form after as few as 6 h. The perioperative antibiotic prophylaxis has to be initiated early and should be continued for at least 24 h (GA I/II) or up to 5 days (GA III). In cases of bacterial contamination, wound irrigation will be useful with additives such as polyhexanide, octenidine or superoxidized water. Rinsing of the wound should be performed with 3-9 L and only slight manual pressure (no jet lavage). The definitive primary closure of a wound should be achieved in the initial operation, but only in the case of certain "decontamination" and overall vitality of the wound (GA I and II). In the presence of high-grade injuries, a temporary vacuum sealing technique can be used until the earliest possible definitive plastic surgical wound closure.

A comparative study of negative pressure wound therapy with and without instillation of saline on wound healing

OBJECTIVE

Negative pressure wound therapy (NPWT) has become an established treatment of traumatic and infected wounds. Negative pressure wound therapy with instillation (NPWTi) is a further development that combines the conventional NPWT with instillation of different fluids which continuously administer therapeutic reagents to the wound. The aim of this study was to compare the impact of additional saline instillation in NPWTi to NPWT alone.

METHOD

Between January and July 2014, consecutive patients with acute wounds of the lower limb were treated with NPWTi with saline instillation. The number of revision surgeries, length of hospital stay, and duration of treatment until final healing were recorded and compared with matched patients undergoing NPWT without instillation.

RESULTS

There were 10 patients recruited with 10 matched controls examined restrospectivley. Patients who received NPWTi were found to have decreased time of hospitalisation (21.5 versus 26.5 days, p=0.43), and accelerated wound healing (9.0 versus 12.5 days, p=0.36) than patients who received NPWT. However, the difference in the outcomes of the patients who received NPWTi and patients who received NPWT was not found to be statisticallly significant.

CONCLUSION

NPWTi with instillation of saline is a promising method and its effectiveness needs to be tested in a randomised controlled trial compared with NPWT alone.

DECLARATION OF INTEREST

This study obtained support by KCI (Wiebsaden, Germany) for the surgical material.

Treating Fasciotomy Wounds with Negative Pressure Wound Therapy with Instillation and Dwell Time (NPWTi-d)

Acute compartment syndrome (ACS) is a serious complication of lower-extremity trauma caused by accidents or post-procedure complications. ACS is characterized by increased pressure within the compartment, resulting in reduced blood flow, tissue hypoxia, and tissue necrosis. Fasciotomies to relieve pressure and debridement of necrotic tissue comprise primary treatment. My purpose is to present initial experience using negative pressure wound therapy with instillation and dwell time (NPWTi-d)* to treat fasciotomy wounds in two patients. NPWTi-d provides automated, volumetric control of instilled topical wound solutions with a dwell time in combination with negative pressure wound therapy (NPWT).

Patient 1, a 33-year-old male injured in a motorcycle accident, developed ACS within 24 hours of hospitalization. Prior treatments included wet-to-dry dressings and NPWT^†. In the latter course of treatment, NPWTi-d was applied; 40 ml of normal saline (NS) were instilled with a ten-minute dwell time, followed by four hours of NPWT at ‑125 mmHg. After five days of NPWTi‑d, granulation tissue covered the bone. Four days later, the patient was discharged home. The wound continued to improve and, at the last recorded visit, was completely closed.

Patient 2, a 44-year-old male, developed right lower extremity ACS due to complications post cardiac surgery. NPWT was initiated in the hospital and continued post-discharge to a nursing home. The patient was readmitted to the hospital with a right leg wound infection that was surgically debrided. NPWTi-d was then applied; 60 ml of NS were instilled with a ten-minute dwell time, followed by 3.5 hours of NPWT at -125 mmHg. After ten days of NPWTi-d, granulation tissue covered the bone. In Patient 2, NPWTi-d improved the likelihood of healing in a malnourished patient who had been critically ill by promoting granulation tissue over exposed bone. The use of NPWTi-d with NS contributed to positive outcomes for both patients.

*V.A.C. VeraFlo™ Therapy, ^†V.A.C.® Therapy (KCI, an Acelity company, San Antonio, TX)

Use of negative pressure wound therapy on malignant wounds - a case report and review of literature

The presence of malignancy is considered a contraindication to the use of negative pressure wound therapy (NPWT) because of concerns that it may promote tumourigenesis and expedite metastasis. This notion is extrapolated from studies evaluating NPWT in normal tissues. Despite the absence of direct evidence, the use of this technology in malignant wounds is widely considered a contraindication. We present the case of a patient with treatment-resistant metastatic colon cancer, who developed a chronic abdominal wound with positive margins. A staged reconstruction using NPWT was performed and wound closure allowed the patient to meet eligibility criteria and enrol in a clinical trial for treatment of his oncological disease. Skin closure remained intact until the patient expired 6 months after the wound closure. This case, as well as others in the literature, demonstrated that the use of NPWT should not be considered an absolute contraindication in malignancy. Individualised approaches taking into account the patient's clinical scenario, the available evidence, as well as the risks and benefits of this technology are recommended.

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.

Secondary infection of haematoma following closed acromioclavicular joint dislocation

An unusual case of a patient presenting with a large infected haematoma following a traumatic grade II acromioclavicular joint dislocation is reported. Diagnosis of this rare complication, of an otherwise common self-limiting injury, was delayed until 19 days postinjury despite several presentations during this time with worsening swelling and pain. The patient was found to have significant tissue destruction by the time washout was performed and required multiple procedures to treat the infection. This case highlights the need for a high index of suspicion for complications, even following common self-limiting injuries, when patients represent with symptoms that do not fit the usual natural history of the condition, particularly if they have risk factors for bleeding and infection.

Approach to chronic wound infections

Infection is the likeliest single cause of delayed healing in healing of chronic open wounds by secondary intention. If neglected it can progress from contamination to colonization and local infection through to systemic infection, sepsis and multiple organ dysfunction syndrome, and it can be life-threatening. Infection in chronic wounds is not as easy to define as in acute wounds, and is complicated by the presence of biofilms. There is, as yet, no diagnostic for biofilm presence, but it contributes to excessive inflammation - through excessive and prolonged stimulation of nitric oxide, inflammatory cytokines and free radicals - and activation of immune complexes and complement, leading to a delay in healing. Control of biofilm is a key part of chronic wound management. Maintenance debridement and use of topical antimicrobials (antiseptics) are more effective than antibiotics, which should be reserved for treating spreading local and systemic infection. The continuing rise of antimicrobial resistance to antibiotics should lead us to reserve their use for these indications, as no new effective antibiotics are in the research pipeline. Antiseptics are effective through many mechanisms of action, unlike antibiotics, which makes the development of resistance to them unlikely. There is little evidence to support the theoretical risk that antiseptics select resistant pathogens. However, the use of antiseptic dressings for preventing and managing biofilm and infection progression needs further research involving well-designed, randomized controlled trials.

Current concepts in negative pressure wound therapy

Negative pressure wound therapy (NPWT) is becoming recognized in veterinary medicine as a viable option for the management of complex wounds. NPWT has many advantages over traditional wound care and results in quicker and improved wound healing in many instances. This article discusses the art and science of NPWT, as well as the many current indications, complications, advantages and disadvantages, and future directions of NPWT in small animal veterinary medicine. This therapy will likely have a growing role in veterinary medical practice for complicated wound management and other usages in coming years.

Ozonated saline shows activity against planktonic and biofilm growing Staphylococcus aureus in vitro: a potential irrigant for infected wounds

Infections associated with deep wounds require extensive surgical and medical care. New adjunctive treatments are required to aid in the eradication of the bacterial biofilms found on infected wounds and, in particular, any underlying hardware. Ozone has been used as a safe and efficient disinfectant in water treatment plants for many years. The purpose of this study is to investigate the anti-biofilm potential of ozonated saline against biofilms of Staphylococcus aureus, a microorganism commonly implicated in wound infections. A custom-made bacterial biofilm bioreactor was used to grow S. aureus biofilms on discs of medical grade titanium alloy. An ozone generator was connected in-line and biofilms and planktonic bacteria were exposed to ozone in saline. Cytotoxicity was assessed against primary ovine osteoblasts in the same system. In tests against planktonic S. aureus, a 99% reduction in bacterial numbers was detected within 15 minutes of exposure. S. aureus biofilms were significantly more resistant to ozone, although complete eradication of the biofilm was eventually achieved within 5 hours. Ozonated saline was not found to be cytotoxic to primary ovine osteoblasts. Ozonated saline may be suitable as an adjuvant therapy to treat patients as an instillation fluid for wound irrigation and sterilisation.

Clinical and microbiological aspects of biofilm-associated surgical site infections

While microbial biofilms have been recognized as being ubiquitous in nature for the past 40 years, it has only been within the past 20 years that clinical practitioners have realized that biofilm play a significant role in both device-related and tissue-based infections. The global impact of surgical site infections (SSIs) is monumental and as many as 80 % of these infections may involve a microbial biofilm. Recent studies suggest that biofilm- producing organisms play a significant role in persistent skin and soft tissue wound infections in the postoperative surgical patient population. Biofilm, on an organizational level, allows bacteria to survive intrinsic and extrinsic defenses that would inactivate the dispersed (planktonic) bacteria. SSIs associated with biomedical implants are notoriously difficult to eradicate using antibiotic regimens that would typically be effective against the same bacteria growing under planktonic conditions. This biofilm-mediated phenomenon is characterized as antimicrobial recalcitrance, which is associated with the survival of a subset of cells including "persister" cells. The ideal method to manage a biofilm-mediated surgical site wound infection is to prevent it from occurring through rational use of antibiotic prophylaxis, adequate skin antisepsis prior to surgery and use of innovative in-situ irrigation procedures; together with antimicrobial suture technology in an effort to promote wound hygiene at the time of closure; once established, biofilm removal remains a significant clinical problem.

VAWCM-Instillation Improves Delayed Primary Fascial Closure of Open Septic Abdomen

Background. Failure to achieve delayed primary fascial closure (DPFC) is one of the main complications of open abdomen (OA), certainly when abdominal sepsis is present. This retrospective cohort study aims to evaluate the effect of combined therapy of vacuum-assisted mesh-mediated fascial traction and topical instillation (VAWCM-instillation) on DPFC in the open septic abdomen. Methods. The patients with abdominal sepsis who underwent OA using VAWCM were included and divided into the instillation and noninstillation (control) groups. The DPFC rate and other outcomes were compared between the two groups. Results. Between 2007 and 2013, 73 patients with open septic abdomen were treated with VAWCM-instillation and 61 cases with VAWCM-only. The DPFC rate in the instillation group was significantly increased (63% versus 41%, P = 0.011). The mortality with OA was similar (24.6% versus 23%, P = 0.817) between the two groups. However, time to DPFC (P = 0.003) and length of stay in hospital (P = 0.022) of the survivals were significantly decreased in the instillation group. In addition, VAWCM-instillation (OR 1.453, 95% CI 1.222–4.927, P = 0.011) was an independent influencing factor related to successful DPFC. Conclusions. VAWCM-instillation could improve the DPFC rate but could not decrease the mortality in the patients with open septic abdomen.

Use of negative pressure wound therapy with automated, volumetric instillation for the treatment of extremity and trunk wounds: clinical outcomes and potential cost-effectiveness

OBJECTIVE

A growing body of literature supports use of negative pressure wound therapy (NPWT) with instillation and dwell time (NPWTi-d) with positive clinical outcomes and potential cost savings. A retrospective analysis was performed to compare clinical outcomes of wounds treated with NPWTi-d versus NPWT and to estimate cost-differences between treatments based on clinical outcomes.

METHODS

Data were extracted from records of patients with extremity or trunk wounds treated with NPWT (n = 34) or NPWTi-d using saline or polyhexanide (n = 48). On the basis of outcomes data, a hypothetical economic model using cost assumptions was created to calculate cost savings for NPWTi-d (related to) number of debridements and length of therapy. Operating room debridement cost was $3393 according to Granick et al. Daily therapy cost for each modality was $194.80 (NPWTi-d) and $106.08 (NPWT) based on internal company information.

RESULTS

RESULTS showed significant differences (P < 0.0001) between NPWTi-d and NPWT patients, respectively, for the following: mean operating room debridements (2.0 vs 4.4), mean hospital stay (8.1 vs 27.4 days), mean length of therapy (4.1 vs 20.9 days), and mean time to wound closure (4.1 vs 20.9 days). Hypothetical economic model showed potential average reduction of $8143 for operating room debridements between NPWTi-d ($6786) and NPWT ($14,929) patients. There was a $1418 difference in average therapy costs between groups ($799/NPWTi-d vs $2217/NPWT).

CONCLUSIONS

In this study, NPWTi-d appeared to assist in wound cleansing and exudate removal, which may have allowed for earlier wound closure compared to NPWT. Hypothetical economic model findings illustrate potential cost-effectiveness of NPWTi-d compared to NPWT.

Recommendations on negative pressure wound therapy with instillation and antimicrobial solutions - when, where and how to use: what does the evidence show?

Infections of contaminated or colonised acute or chronic wounds remain a grave risk for patients even today. Despite modern surgical debridement concepts and antibiotics, a great need exists for new therapies in wound management. Since the late 1990s, advantageous effects of negative pressure wound therapy (NPWT) have been combined with local antiseptic wound cleansing in the development of NPWT with instillation (NPWTi). This article summarises the current scientific knowledge on this topic. MEDLINE literature searches were performed on the subject of negative pressure wound and instillation therapy covering publications from the years 1990 to 2013 (36 peer-reviewed citations) and regarding randomised controlled trials (RCTs) covering wound care with bone involvement (27 publications) or soft-tissue wounds without bone participation (11 publications) from 2005 to 2012. The use of NPWTi in the therapy of infected wounds appears to be not yet widespread, and literature is poor and inhomogeneous. However, some reports indicate an outstanding benefit of NPWTi for patients, using antiseptics such as polyhexanide (concentration 0·005-0·04%) and acetic acid (concentration 0·25-1%) in acute and chronic infected wounds and povidone-iodine (10% solution) as prophylaxis in contaminated wounds with potential viral infection. Soaking times are recommended to be 20 minutes each, using cycle frequencies of four to eight cycles per day. Additionally, the prophylactic use of NPWTi with these substances can be recommended in contaminated wounds that cannot be closed primarily with surgical means. Although first recommendations may be given currently, there is a great need for RCTs and multicentre studies to define evidence-based guidelines for an easier approach to reach the decision on how to use NPWTi.