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Tricou LP, Al-Hawat ML, Cherifi K, Manrique G, Freedman BR, Matoori S. Wound pH-Modulating Strategies for Diabetic Wound Healing. Adv Wound Care (New Rochelle) 2024; 13:446-462. [PMID: 38149883 DOI: 10.1089/wound.2023.0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
Significance: Chronic diabetic wounds on the lower extremities (diabetic foot ulcers, DFU) are one of the most prevalent and life-threatening complications of diabetes, responsible for significant loss of quality of life and cost to the health care system. Available pharmacologic treatments fail to achieve complete healing in many patients. Recent studies and investigational treatments have highlighted the potential of modulating wound pH in DFU. Recent Advances: Data from in vitro, preclinical, and clinical studies highlight the role of pH in the pathophysiology of DFU, and topical administration of pH-lowering agents have shown promise as a therapeutic strategy for diabetic wounds. In this critical review, we describe the role of pH in DFU pathophysiology and present selected low-molecular-weight and hydrogel-based pH-modulating systems for wound healing and infection control in diabetic wounds. Critical Issues: The molecular mechanisms leading to pH alterations in diabetic wounds are complex and may differ between in vitro models, animal models of diabetes, and the human pathophysiology. Wound pH-lowering bandages for DFU therapy must be tested in established animal models of diabetic wound healing and patients with diabetes to establish a comprehensive benefit-risk profile. Future Directions: As our understanding of the role of pH in the pathophysiology of diabetic wounds is deepening, new treatments for this therapeutic target are being developed and will be tested in preclinical and clinical studies. These therapeutic systems will establish a target product profile for pH-lowering treatments such as an optimal pH profile for each wound healing stage. Thus, controlling wound bed pH could become a powerful tool to accelerate chronic diabetic wound healing.
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Affiliation(s)
- Léo-Paul Tricou
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada
- ISPB Faculté de Pharmacie, Université Claude Bernard Lyon 1, Lyon, France
- Chemical Engineering Department, Polytechnique Montreal, Montréal, Canada
| | | | - Katia Cherifi
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada
| | | | - Benjamin R Freedman
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Simon Matoori
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada
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2
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Jeffcoate W, Boyko EJ, Game F, Cowled P, Senneville E, Fitridge R. Causes, prevention, and management of diabetes-related foot ulcers. Lancet Diabetes Endocrinol 2024; 12:472-482. [PMID: 38824929 DOI: 10.1016/s2213-8587(24)00110-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 06/04/2024]
Abstract
In this Review, we aim to complement the 2023 update of the guidelines of the International Working Group on the Diabetic Foot. We highlight the complexity of the pathological processes that underlie diabetes-related foot ulceration (DFU) and draw attention to the potential implications for clinical management and outcome. Variation observed in the incidence and outcome of DFUs in different communities might result from differences in study populations and the accessibility of care. Comparing differences in incidence, management, and outcome of DFUs in different communities is an essential component of the quality of disease care. Additionally, these comparisons can also highlight the relationship between DFU incidence, management, and outcome and the structure of local clinical services and the availability of staff with the necessary skills. The clinical outcome is, however, also dependent on the availability of multidisciplinary care and the ability of people with DFUs to gain access to that care.
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Affiliation(s)
| | - Edward J Boyko
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Prue Cowled
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Eric Senneville
- Discipline of Infectious Diseases, The University of Lille, Gustave Dron Hospital, Tourcoing, France
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia; Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, SA, Australia.
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3
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Cavallo I, Sivori F, Mastrofrancesco A, Abril E, Pontone M, Di Domenico EG, Pimpinelli F. Bacterial Biofilm in Chronic Wounds and Possible Therapeutic Approaches. BIOLOGY 2024; 13:109. [PMID: 38392327 PMCID: PMC10886835 DOI: 10.3390/biology13020109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/24/2024]
Abstract
Wound repair and skin regeneration is a very complex orchestrated process that is generally composed of four phases: hemostasis, inflammation, proliferation, and remodeling. Each phase involves the activation of different cells and the production of various cytokines, chemokines, and other inflammatory mediators affecting the immune response. The microbial skin composition plays an important role in wound healing. Indeed, skin commensals are essential in the maintenance of the epidermal barrier function, regulation of the host immune response, and protection from invading pathogenic microorganisms. Chronic wounds are common and are considered a major public health problem due to their difficult-to-treat features and their frequent association with challenging chronic infections. These infections can be very tough to manage due to the ability of some bacteria to produce multicellular structures encapsulated into a matrix called biofilms. The bacterial species contained in the biofilm are often different, as is their capability to influence the healing of chronic wounds. Biofilms are, in fact, often tolerant and resistant to antibiotics and antiseptics, leading to the failure of treatment. For these reasons, biofilms impede appropriate treatment and, consequently, prolong the wound healing period. Hence, there is an urgent necessity to deepen the knowledge of the pathophysiology of delayed wound healing and to develop more effective therapeutic approaches able to restore tissue damage. This work covers the wound-healing process and the pathogenesis of chronic wounds infected by biofilm-forming pathogens. An overview of the strategies to counteract biofilm formation or to destroy existing biofilms is also provided.
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Affiliation(s)
- Ilaria Cavallo
- Microbiology and Virology Unit, San Gallicano Dermatological Institute IRCSS, 00144 Rome, Italy
| | - Francesca Sivori
- Microbiology and Virology Unit, San Gallicano Dermatological Institute IRCSS, 00144 Rome, Italy
| | - Arianna Mastrofrancesco
- Microbiology and Virology Unit, San Gallicano Dermatological Institute IRCSS, 00144 Rome, Italy
| | - Elva Abril
- Microbiology and Virology Unit, San Gallicano Dermatological Institute IRCSS, 00144 Rome, Italy
| | - Martina Pontone
- Microbiology and Virology Unit, San Gallicano Dermatological Institute IRCSS, 00144 Rome, Italy
| | - Enea Gino Di Domenico
- Department of Biology and Biotechnology "C. Darwin", Sapienza University of Rome, 00185 Rome, Italy
| | - Fulvia Pimpinelli
- Microbiology and Virology Unit, San Gallicano Dermatological Institute IRCSS, 00144 Rome, Italy
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4
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Malone M, Nygren E, Hamberg T, Radzieta M, Jensen SO. In vitro and in vivo evaluation of the antimicrobial effectiveness of non-medicated hydrophobic wound dressings. Int Wound J 2024; 21:e14416. [PMID: 37770025 PMCID: PMC10824701 DOI: 10.1111/iwj.14416] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 10/03/2023] Open
Abstract
There is an increasing use of non-medicated wound dressing with claims of irreversible bacterial binding. Most of the data are from in vitro models which lack clinical relevance. This study employed a range of in vitro experiments to address this gap and we complemented our experimental designs with in vivo observations using dressings obtained from patients with diabetes-related foot ulcers. A hydrophobic wound dressing was compared with a control silicone dressing in vitro. Test dressings were placed on top of a Pseudomonas aeruginosa challenge suspension with increasing concentrations of suspension inoculum in addition to supplementation with phosphate buffered saline (PBS) or increased protein content (IPC). Next, we used the challenge suspensions obtained at the end of the first experiment, where bacterial loads from the suspensions were enumerated following test dressing exposure. Further, the time-dependent bacterial attachment was investigated over 1 and 24 h. Lastly, test dressings were exposed to a challenge suspension with IPC, with or without the addition of the bacteriostatic agent Deferiprone to assess the impacts of limiting bacterial growth in the experimental design. Lastly, two different wound dressings with claims of bacterial binding were obtained from patients with chronic diabetes-related foot ulcers after 72 h of application and observed using scanning electron microscope (SEM). Bacteria were enumerated from each dressing after a 1-h exposure time. There was no statistical difference in bacterial attachment between both test dressings when using different suspension inoculum concentrations or test mediums. Bacterial attachment to the two test dressings was significantly lower (p < 0.0001) when IPC was used instead of PBS. In the challenge suspension with PBS, only the hydrophobic dressing achieved a statistically significant reduction in bacterial loads (0.5 ± 0.05 log colony forming units; p = 0.001). In the presence of IPC, there was no significant reduction in bacterial loads for either test dressing. When bacterial growth was arrested, attachment to the test dressings did not increase over time, suggesting that the number of bacteria on the test dressings increases over time due to bacterial growth. SEM identified widespread adsorption of host fouling across the test dressings which occurred prior to microbial binding. Therein, microbial attachment occurred predominantly to host fouling and not directly to the dressings. Bacterial binding is not unique to dialkylcarbamoyl chloride (DACC) dressings and under clinically relevant in vitro conditions and in vivo observations, we demonstrate (in addition to previously published work) that the bacterial binding capabilities are not effective at reducing the number of bacteria in laboratory models or human wounds.
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Affiliation(s)
- Matthew Malone
- Research and DevelopmentMolnlycke Healthcare ABGothenburgSweden
- South West Sydney Limb Preservation and Wound ResearchSouth West Sydney Local Health DistrictSydneyNew South WalesAustralia
- Infectious Diseases and Microbiology, School of MedicineWestern Sydney UniversitySydneyNew South WalesAustralia
| | - Erik Nygren
- Research and DevelopmentMolnlycke Healthcare ABGothenburgSweden
| | - Tina Hamberg
- Research and DevelopmentMolnlycke Healthcare ABGothenburgSweden
| | - Michael Radzieta
- South West Sydney Limb Preservation and Wound ResearchSouth West Sydney Local Health DistrictSydneyNew South WalesAustralia
- Infectious Diseases and Microbiology, School of MedicineWestern Sydney UniversitySydneyNew South WalesAustralia
| | - Slade O. Jensen
- South West Sydney Limb Preservation and Wound ResearchSouth West Sydney Local Health DistrictSydneyNew South WalesAustralia
- Infectious Diseases and Microbiology, School of MedicineWestern Sydney UniversitySydneyNew South WalesAustralia
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5
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Astrada A, Pamungkas RA, Abidin KR. Advancements in Managing Wound Biofilm: A Systematic Review and Meta-analysis of Randomized Controlled Trials on Topical Modalities. Foot Ankle Spec 2024:19386400231225708. [PMID: 38282327 DOI: 10.1177/19386400231225708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Despite numerous available agents claiming anti-biofilm properties on wounds, the substantiating evidence remains inconclusive. This study aimed to assess the immediate impact of topical wound treatments on wound biofilm and healing outcomes in acute and chronic ulcers. We comprehensively searched PubMed, ClinicalTrials.gov, and Google Scholar. In addition, eligible gray literature was incorporated. English-language randomized controlled trials (RCTs), observational, cohort, and case-control studies targeting biofilm prevention, inhibition, or elimination across diverse wound types were included. Primary outcomes included biofilm presence and elimination, supplemented by secondary outcomes encompassing reduced wound size, complete closure, and diminished infection indicators. Bacterial load reduction and biofilm presence were also assessed. Twenty-eight articles met the inclusion criteria. Various modalities were identified, including biofilm-visualization techniques, such as wound blotting and handheld autofluorescence imaging. Pooled analysis for the primary outcomes was infeasible due to limited eligible studies and data-reporting challenges. As for the secondary outcomes, the pooled analysis for complete surgical wound closure (2 RCTs, yielding n=284) and presence of surgical site infections/inflammation (2 RCTs, yielding n=284) showed no significant difference, with a log odds ratio (LOD) of 0.58 (95% confidence interval [CI]: -.33, 1.50) and LOD -0.95 (95% CI: -3.54, 1.64; τ2 = 2.32, Q = 2.71, P = .10), respectively. Our findings suggest insufficient evidence to support anti-biofilm claims of topical modalities. Clinicians' skill appears to play a pivotal role in biofilm elimination and wound healing enhancement, with potential optimization through visual-guided techniques, such as wound blotting and autofluorescence imaging. More rigorous clinical trials are warranted to ascertain the efficacy of these techniques.Level of Evidence: Therapeutic, 1A.
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Affiliation(s)
- Adam Astrada
- School of Nursing, Faculty of Health Sciences, Esa Unggul University, Jakarta Barat, Indonesia
| | - Rian Adi Pamungkas
- School of Nursing, Faculty of Health Sciences, Esa Unggul University, Jakarta Barat, Indonesia
- School of Nursing, University of Michigan, Ann Arbor, Michigan
| | - Khoirul Rista Abidin
- Department of Medical Laboratory Technology, Politeknik 'Aisyiyah Pontianak, Pontianak City, Indonesia
- Department of Biotechnology, Postgraduate School, Padjadjaran University, Indonesia
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Labens R, Raidal S, Borgen-Nielsen C, Pyecroft S, Pant SD, De Ridder T. Wound healing of experimental equine skin wounds and concurrent microbiota in wound dressings following topical propylene glycol gel treatment. Front Vet Sci 2023; 10:1294021. [PMID: 38155761 PMCID: PMC10752953 DOI: 10.3389/fvets.2023.1294021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/23/2023] [Indexed: 12/30/2023] Open
Abstract
Introduction Topical wound treatments rely on carrier formulations with little to no biological impact. The potential for a common vehicle, a propylene glycol (PG) gel, to affect wound healing measures including microbiota is not known. Microbiome characterization, based on next generation sequencing methods is typically performed on tissue or directly obtained wound fluid samples. The utility for primary wound dressings to characterize equine wound microbiota in the context of topical treatments is currently unknown. This investigation reports the topical effect of an 80% PG based gel on wound healing and microbiota in wound dressings. Methods Experiments were performed in six mature horses utilizing a surgical, distal limb wound model, histology of sequential wound biopsies, photographic wound measurements and microbiota profiling via 16s rRNA sequencing of wound dressing samples. Experimental wounds were surveyed for 42 days and either treated (Day 7, 14, 21 and 28; at 0.03 ml/cm2) or unexposed to the PG gel. Wound surface area, relative and absolute microbial abundances, diversity indices and histologic parameters were analyzed in the context of the experimental group (treatment; control) using qualitative or quantitative methods depending on data characteristics. Results Compared to controls, treatment slowed the wound healing rate (17.17 ± 4.27 vs. 18.56 ± 6.3 mm2/day), delayed the temporal decline of polymorphonucleated cells in wound beds and operational taxonomic units (OTU) in wound dressings and lowered alpha-diversity indices for microbiota in primary wound dressing. Relative abundances of OTUs were in line with those previously reported for equine wounds. Clinical outcomes 42 days post wounding were considered similar irrespective of PG gel exposure. Discussion Results highlight the potential for vehicle exposure to alter relevant wound outcome measures, imposing the need for stringent experimental control measures. Primary wound dressings may represent an alternate sample source for characterization of the wound microbiome alleviating the need for additional interventions. Further studies are warranted to contrast the microbiome in wound dressings against that present on wound surfaces to conclude on the validity of this approach.
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Affiliation(s)
- Raphael Labens
- School of Agricultural, Environmental and Veterinary Sciences, Faculty of Science, Charles Sturt University, Wagga Wagga, NSW, Australia
- QBiotics Group Ltd., Yungaburra, QLD, Australia
| | - Sharanne Raidal
- School of Agricultural, Environmental and Veterinary Sciences, Faculty of Science, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Cathrine Borgen-Nielsen
- School of Agricultural, Environmental and Veterinary Sciences, Faculty of Science, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Stephen Pyecroft
- School of Animal and Veterinary Sciences, Faculty of Sciences, Engineering and Technology, University of Adelaide, Roseworthy, SA, Australia
| | - Sameer D. Pant
- School of Agricultural, Environmental and Veterinary Sciences, Faculty of Science, Charles Sturt University, Wagga Wagga, NSW, Australia
- Gulbali Institute, Charles Sturt University, Wagga Wagga, NSW, Australia
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7
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Malone M, Radzieta M, Schwarzer S, Walker A, Bradley J, Jensen SO. In vivo observations of biofilm adhering to a dialkylcarbamoyl chloride-coated mesh dressing when applied to diabetes-related foot ulcers: A proof of concept study. Int Wound J 2022. [PMID: 36567138 DOI: 10.1111/iwj.14054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/27/2022] [Accepted: 12/04/2022] [Indexed: 12/27/2022] Open
Abstract
In this proof-of-concept study of twenty participants, we sought to determine if a DACC (Dialkylcarbamoyl chloride)-coated mesh dressing demonstrates an ability to adhere biofilm when placed on Diabetes Related Foot Ulcers (DRFUs) with chronic infection. The study also sought to determine if removal of the DACC-coated mesh dressings contributes to reducing the total number of bacteria in DRFUs, by exploring the total microbial loads, microbial community composition, and diversity. Standard of care was provided in addition to the application of DACC or DACC hydrogel every three days for a total of two weeks. Wound swabs, tissue curettage, and soiled dressings were collected pre and post-treatment. Tissue specimens obtained pre-treatment were analysed with scanning electron microscopy (SEM) and peptide nucleic acid fluorescent in situ hybridisation (PNA-FISH) with confocal laser scanning microscopy and confirmed the presence of biofilm in all DRFUs. SEM confirmed the presence of biofilms readily adhered to soiled DACC-coated mesh dressings pre- and post-treatment in all participants. Real-time quantitative polymerase chain reaction (qPCR) demonstrated the mean total microbial load of DRFUs in 20 participants did not change after two weeks of therapy (pre-treatment = 4.31 Log10 16 S copies (±0.8) versus end of treatment = 4.32 Log10 16 S copies (±0.9), P = .96, 95% CI -0.56 to 0.5). 16 S sequencing has shown the microbial composition of DACC dressings and wound swabs pre- and post-treatment remained similar (DACC; R = -.047, P = .98, Swab; R = -.04, P = .86), indicating the microbial communities originate from the ulcer. Biofilms adhere to DACC-coated mesh dressings; however, this may not reduce the total microbial load present within DRFU tissue. Wound dressings for use in hard-to-heal wounds should be used as an adjunct to a good standard of care which includes debridement and wound bed preparation.
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Affiliation(s)
- Matthew Malone
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, New South Wales, Australia.,High Risk Foot Service, Liverpool Hospital, South West Sydney LHD, Sydney, New South Wales, Australia.,Infectious Diseases and Microbiology, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Michael Radzieta
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, New South Wales, Australia.,Infectious Diseases and Microbiology, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Saskia Schwarzer
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, New South Wales, Australia.,High Risk Foot Service, Liverpool Hospital, South West Sydney LHD, Sydney, New South Wales, Australia
| | - Amy Walker
- High Risk Foot Service, Monash Health, Clayton, Victoria, Australia
| | - Justin Bradley
- High Risk Foot Service, Monash Health, Clayton, Victoria, Australia
| | - Slade O Jensen
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, New South Wales, Australia.,Infectious Diseases and Microbiology, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
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8
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Hampton J, Sharpe A, McCluskey P, Styche T, Hughes J, Woodmansey E. Diagnosis and treatment of infected wounds: A multi-centre audit of current clinical practice across the UK, Ireland and Scandinavia. J Clin Nurs 2022. [PMID: 36097436 DOI: 10.1111/jocn.16527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/13/2022] [Accepted: 08/22/2022] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES Surveillance of wound infection including signs of infection alongside antimicrobial usage (types, duration, frequency) can highlight knowledge gaps and inconsistencies. This manuscript aims to highlight these, identify and inform opportunities for practice improvement and to show impact of infection management practice may be having on the issue of antimicrobial resistance. BACKGROUND Infected wounds pose challenges to healthcare professionals. Balancing risk of wound deterioration and progression to systemic infection with appropriate use of antimicrobials is necessary to minimise development of resistance. METHODS Analysis consisted of a practice survey of 9661 wounds across 70 community sites over a period of one week. Data were collected from projects between 2017 and 2020. The form was available to providers within the UK, Ireland, Norway, Denmark, Sweden and Finland. EQUATOR research guidelines were followed; STROBE checklist for observational research reporting was completed. RESULTS Infection rates of 8.9% were reported from wounds assessed. These data indicate inconsistencies with diagnosis across practice with non-specialists more likely to be unsure of wound infection. Greater confidence in infection identification was observed as number of signs increased. Inconsistencies were also observed in appropriate treatment; antimicrobials were used in 35% of wounds considered not infected and not used in 41% of wounds that were identified as infected. CONCLUSIONS This investigation of infection management practice of over 9000 wounds provides an insight into diagnosis and treatment of infection. Inconsistencies in diagnosis and treatment of wound infections reported highlight the need for increased education, awareness of diagnosis and treatment of infection. RELEVANCE TO CLINICAL PRACTICE Variability in management of infected wounds highlights opportunities to aid more effective diagnosis and treatment of infected wounds. Incorporation of support tools or evidence-based pathways into practice may enhance confidence in management of local infection, balanced with appropriate use, potentially minimising resistance and improving outcomes.
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Affiliation(s)
- Jane Hampton
- Wound Care Specialist Nurse in Primary Care, Aarhus Municipality, Aarhus, Denmark
| | - Andrew Sharpe
- Salford Care Organisation, the Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Pat McCluskey
- Advanced Nurse Practitioner and Wound Care Consultant, Cork, Ireland
| | - Tim Styche
- Smith+Nephew Advanced Wound Management, Hull, UK
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9
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Malone M, Schultz G. Challenges in the diagnosis and management of wound infection. Br J Dermatol 2022; 187:159-166. [PMID: 35587707 DOI: 10.1111/bjd.21612] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2022] [Indexed: 12/16/2022]
Abstract
Human epithelia are constantly exposed to microorganisms present in the environment or residing as part of commensal flora. Despite this exposure, infections involving the skin and subcutaneous tissue in healthy individuals are, fortunately, quite rare. Many of the wounds that afflict the human body occur in individuals of ill health and/or where the mechanism of wounding is impeded by host immunological, physiological or regenerative dysfunction. The interplay between microorganisms and host immunity is complex and remains ill defined; however, the interpretation of downstream manifestations of the host response to invading microorganisms is still based largely on the clinical signs and symptoms of an active infectious process. In this review article we will provide a brief overview of the current challenges clinicians face in diagnosing wound infections, how chronic infections caused by biofilms are a major challenge, and how there have been minimal advancements in developing new diagnostics or therapeutics in the identification and management of wound infections.
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Affiliation(s)
- Matthew Malone
- South West Sydney Limb Preservation and Wound Research, South Western Sydney LHD, Sydney, NSW, Australia.,Infectious Diseases and Microbiology, School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Gregory Schultz
- Institute for Wound Research, University of Florida, Gainesville, FL, USA
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10
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Bellomo TR, Lee S, McCarthy M, Tong KPS, Ferreira SS, Cheung TP, Rose-Sauld S. Management of the Diabetic Foot. Semin Vasc Surg 2022; 35:219-227. [DOI: 10.1053/j.semvascsurg.2022.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/02/2022] [Accepted: 04/07/2022] [Indexed: 11/11/2022]
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11
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Aswathanarayan JB, Rao P, HM S, GS S, Rai RV. Biofilm-Associated Infections in Chronic Wounds and Their Management. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022. [DOI: 10.1007/5584_2022_738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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12
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Kunimitsu M, Kataoka Y, Nakagami G, Weller CD, Sanada H. Factors related to the composition and diversity of wound microbiota investigated using culture-independent molecular methods: a scoping review. Drug Discov Ther 2021; 15:78-86. [PMID: 33952764 DOI: 10.5582/ddt.2021.01036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
All open wounds are often colonized by commensal microbes as a loss of skin can provide a ready portal of entry for microorganisms. Although the wound microbiota is known to be associated with wound infection and with delayed healing, the factors related to the formations of wound microbiota contributing to such poor clinical outcomes are not clear and have not led to effective infection prevention interventions. This review aimed to scope the factors related to the composition and diversity of wound microbiota that have been investigated using culture-independent molecular methods. Original articles on wound microbiota published from January 1986 to February 2020 were included in this review. Thirty-one articles met the inclusion criteria and were grouped according to wound types: chronic, acute, and animal model wounds. The factors identified were categorized according to patient characteristics, wound characteristics, treatment, and sampling. Although some studies reported the effect size of the factors, the values were small. No studies elucidated the mechanism of wound microbiota formation. The results of this scoping review highlight that the factors associated with the diversity of wound microbiota are poorly understood and that further studies are needed.
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Affiliation(s)
- Mao Kunimitsu
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Japan Society for the Promotion of Science, Tokyo, Japan
| | - Yukie Kataoka
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Gojiro Nakagami
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Carolina D Weller
- School of Nursing and Midwifery, Monash University, Melbourne, Australia
| | - Hiromi Sanada
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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13
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Maillard JY, Kampf G, Cooper R. Antimicrobial stewardship of antiseptics that are pertinent to wounds: the need for a united approach. JAC Antimicrob Resist 2021; 3:dlab027. [PMID: 34223101 PMCID: PMC8209993 DOI: 10.1093/jacamr/dlab027] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Long before the nature of infection was recognized, or the significance of biofilms in delayed healing was understood, antimicrobial agents were being used in wound care. In the last 70 years, antibiotics have provided an effective means to control wound infection, but the continued emergence of antibiotic-resistant strains and the documented antibiotic tolerance of biofilms has reduced their effectiveness. A range of wound dressings containing an antimicrobial (antibiotic or non-antibiotic compound) has been developed. Whereas standardized methods for determining the efficacy of non-antibiotic antimicrobials in bacterial suspension tests were developed in the early twentieth century, standardized ways of evaluating the efficacy of antimicrobial dressings against microbial suspensions and biofilms are not available. Resistance to non-antibiotic antimicrobials and cross-resistance with antibiotics has been reported, but consensus on breakpoints is absent and surveillance is impossible. Antimicrobial stewardship is therefore in jeopardy. This review highlights these difficulties and in particular the efficacy of current non-antibiotic antimicrobials used in dressings, their efficacy, and the challenges of translating in vitro efficacy data to the efficacy of dressings in patients. This review calls for a unified approach to developing standardized methods of evaluating antimicrobial dressings that will provide an improved basis for practitioners to make informed choices in wound care.
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Affiliation(s)
- Jean-Yves Maillard
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, Wales, UK
| | - Günter Kampf
- Institute of Hygiene and Environmental Medicine, University of Greifswald, Germany
| | - Rose Cooper
- School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, Wales, UK
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Malone M, Radzieta M, Schwarzer S, Jensen SO, Lavery LA. Efficacy of a topical concentrated surfactant gel on microbial communities in non-healing diabetic foot ulcers with chronic biofilm infections: A proof-of-concept study. Int Wound J 2021; 18:457-466. [PMID: 33476485 PMCID: PMC8273583 DOI: 10.1111/iwj.13546] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/18/2020] [Accepted: 12/28/2020] [Indexed: 12/15/2022] Open
Abstract
This proof‐of‐concept study sought to determine the effects of standard of care (SOC) and a topically applied concentrated surfactant gel (SG) on the total microbial load, community composition, and community diversity in non‐healing diabetic foot ulcers (DFUs) with chronic biofilm infections. SOC was provided in addition to a topical concentrated SG, applied every 2 days for 6 weeks. Wound swabs were obtained from the base of ulcers at baseline (week 0), week 1, mid‐point (week 3), and end of treatment (week 6). DNA sequencing and real‐time quantitative polymerase chain reaction (qPCR) were employed to determine the total microbial load, community composition, and diversity of patient samples. Tissue specimens were obtained at baseline and scanning electron microscopy and peptide nucleic acid fluorescent in situ hybridisation with confocal laser scanning microscopy were used to confirm the presence of biofilm in all 10 DFUs with suspected chronic biofilm infections. The application of SG resulted in 7 of 10 samples achieving a reduction in mean log10 total microbial load from baseline to end of treatment (0.8 Log10 16S copies, ±0.6), and 3 of 10 samples demonstrated an increase in mean Log10 total microbial load (0.6 log10 16S copies, ±0.8) from baseline to end of treatment. Composition changes in microbial communities were driven by changes to the most dominant bacteria. Corynebacterium sp. and Streptococcus sp. frequently reduced in relative abundance in patient samples from week 0 to week 6 but did not disappear. In contrast, Staphylococcus sp., Finegoldia sp., and Fusobacterium sp., relative abundances frequently increased in patient samples from week 0 to week 6. The application of a concentrated SG resulted in varying shifts to diversity (increase or decrease) between week 0 and week 6 samples at the individual patient level. Any shifts in community diversity were independent to changes in the total microbial loads. SOC and a topical concentrated SG directly affect the microbial loads and community composition of DFUs with chronic biofilm infections.
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Affiliation(s)
- Matthew Malone
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, Australia.,High Risk Foot Service, Liverpool Hospital, South West Sydney LHD, Sydney, Australia.,Infectious Diseases and Microbiology, School of Medicine, Western Sydney University, Sydney, Australia
| | - Michael Radzieta
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, Australia.,Infectious Diseases and Microbiology, School of Medicine, Western Sydney University, Sydney, Australia
| | - Saskia Schwarzer
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, Australia.,High Risk Foot Service, Liverpool Hospital, South West Sydney LHD, Sydney, Australia
| | - Slade O Jensen
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, Australia.,Infectious Diseases and Microbiology, School of Medicine, Western Sydney University, Sydney, Australia.,Antimicrobial Resistance and Mobile Elements Group, Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Lavery LA, Killeen AL, Farrar D, Akgul Y, Crisologo PA, Malone M, Davis KE. The effect of continuous diffusion of oxygen treatment on cytokines, perfusion, bacterial load, and healing in patients with diabetic foot ulcers. Int Wound J 2020; 17:1986-1995. [PMID: 32840063 PMCID: PMC7754349 DOI: 10.1111/iwj.13490] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 02/03/2023] Open
Abstract
To evaluate continuous diffusion of oxygen therapy (CDO) on cytokines, perfusion, and bacterial load in diabetic foot ulcers we evaluated 23 patients for 3 weeks. Tissues biopsies were obtained at each visit to evaluate cytokines and quantitative bacterial cultures. Perfusion was measured with hyperspectral imaging and transcutaneous oxygen. We used paired T tests to compare continuous variables and independent T tests to compare healers and nonhealers. There was an increase from baseline to week 1 in TGF-β (P = .008), TNF-α (P = .014), VEGF (P = .008), PDGF (P = .087), and IGF-1 (P = .058); baseline to week 2 in TGF-β (P = .010), VEGF (P = .051), and IL-6 (P = .031); and baseline to week 3 with TGF-β (P = .055) and IL-6 (P = .054). There was a significant increase in transcutaneous oxygen after 1 week of treatment on both medial and lateral foot (P = .086 and .025). Fifty-three percent of the patients had at least a 50% wound area reduction (healers). At baseline, there were no differences in cytokines between healers and nonhealers. However, there was an increase in CXCL8 after 1 week of treatment (P = .080) and IL-6 after 3 weeks of treatment in nonhealers (P = .099). There were no differences in quantitative cultures in healers and nonhealers.
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Affiliation(s)
- Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Amanda L Killeen
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - David Farrar
- Department of Immunology and Molecular Biology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yucel Akgul
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Peter A Crisologo
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew Malone
- South West Sydney Limb Preservation and Wound Research Academic Unit, Sydney, New South Wales, Australia
| | - Kathryn E Davis
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Malone M, Schwarzer S, Radzieta M, Jeffries T, Walsh A, Dickson HG, Micali G, Jensen SO. Effect on total microbial load and community composition with two vs six-week topical Cadexomer Iodine for treating chronic biofilm infections in diabetic foot ulcers. Int Wound J 2019; 16:1477-1486. [PMID: 31487117 DOI: 10.1111/iwj.13219] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/18/2019] [Accepted: 08/21/2019] [Indexed: 12/13/2022] Open
Abstract
This study compares two vs six weeks of topical antimicrobial therapy with Cadexomer Iodine in patients with diabetic foot ulcers (DFUs) complicated by chronic biofilm infections. Patients with non-healing DFUs with suspected chronic biofilm infections were eligible for enrolment. Patients were randomised to receive either two or six weeks of treatment with topical Cadexomer Iodine. Tissue biopsies from the ulcers were obtained pre-and-post treatment and underwent DNA sequencing and real-time quantitative polymerase chain reaction (PCR) to determine the total microbial load, community composition, and diversity of bacteria. Scanning electron microscopy confirmed biofilm in all 18 ulcers with suspected chronic biofilm infections. Cadexomer Iodine resulted in 14 of 18 (78%) samples achieving a mean 0.5 log10 reduction in microbial load. Regardless of treatment duration, there was no statistical difference in the reduction of total microbial loads. No difference in the rate of wound healing in the two groups was seen at 6 weeks. Cadexomer Iodine reduces the total microbial load in DFUs with chronic biofilm infections and affects microbial community composition and diversity. All ulcers in both groups showed an initial reduction in wound size with application of Cadexomer Iodine, which might reflect its effect on biofilms.
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Affiliation(s)
- Matthew Malone
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, New South Wales, Australia.,High Risk Foot Service, Liverpool Hospital, South West Sydney LHD, Sydney, New South Wales, Australia.,Infectious Diseases and Microbiology, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Saskia Schwarzer
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, New South Wales, Australia.,High Risk Foot Service, Liverpool Hospital, South West Sydney LHD, Sydney, New South Wales, Australia
| | - Michael Radzieta
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, New South Wales, Australia.,Infectious Diseases and Microbiology, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Thomas Jeffries
- Infectious Diseases and Microbiology, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Annie Walsh
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, New South Wales, Australia.,High Risk Foot Service, Liverpool Hospital, South West Sydney LHD, Sydney, New South Wales, Australia
| | - Hugh G Dickson
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, New South Wales, Australia
| | - Grace Micali
- Antimicrobial Resistance and Mobile Elements Group, Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Slade O Jensen
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, New South Wales, Australia.,Infectious Diseases and Microbiology, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia.,Antimicrobial Resistance and Mobile Elements Group, Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
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