Bromelain-based enzymatic debridement of chronic wounds: Results of a multicentre randomized controlled trial

Exploring the Therapeutic Potential of Bromelain: Applications, Benefits, and Mechanisms

Bromelain is a mixture of proteolytic enzymes primarily extracted from the fruit and stem of the pineapple plant (Ananas comosus). It has a long history of traditional medicinal use in various cultures, particularly in Central and South America, where pineapple is native. This systematic review will delve into the history, structure, chemical properties, and medical indications of bromelain. Bromelain was first isolated and described in the late 19th century by researchers in Europe, who identified its proteolytic properties. Since then, bromelain has gained recognition in both traditional and modern medicine for its potential therapeutic effects.

Debridement for surgical wounds

BACKGROUND

Surgical wounds that become infected are often debrided because clinicians believe that removal of this necrotic or infected tissue may expedite wound healing. There are numerous methods of debridement available, but no consensus on which one is most effective for surgical wounds.

OBJECTIVES

To assess the effects of different methods of debridement on the rate of debridement and healing of surgical wounds.

SEARCH METHODS

In October 2021, we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL. To identify additional studies, we searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies, reviews, meta-analyses, and health technology reports. There were no restrictions on language, date of publication, or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled people with a surgical wound that required debridement, and reported time to complete wound debridement or time to wound healing, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment using the RoB 1 tool, data extraction, and GRADE assessment of the certainty of evidence.

MAIN RESULTS

In this fourth update, we identified one additional study for inclusion. The review now includes six studies, with 265 participants, aged three to 91 years. Five studies were published between 1979 and 1990 and one published in 2014. The studies were carried out in hospital settings in China, Denmark, Belgium, and the UK. Six studies provided six comparisons. Due to the heterogeneity of studies, it was not appropriate to conduct meta-analyses. Four studies evaluated the effectiveness of dextranomer beads/paste; however, each study used a different comparator (Eusol-soaked dressings, 10% aqueous polyvinylpyrrolidone, 0.1% chloramine-soaked packs, and silicone foam elastomer dressing). One study compared streptokinase/streptodornase with saline-soaked dressings, and one compared endoscopic surgical debridement with conventional 'open' surgical debridement. Five studies reported time to complete debridement (reported as time to a clean wound bed) and three reported time to complete healing. One study reported effect estimates (surgical debridement via endoscopy versus surgical debridement) for time to a clean wound bed and time to complete wound healing, and it was possible to calculate effect estimates for one other study (dextranomer paste versus silicone foam elastomer) for time to complete wound healing. For the other four studies that did not report effect estimates, it was not possible to calculate time to a clean wound bed or time to complete wound healing due to missing variance and participant exclusions. None of the included studies reported outcomes pertaining to proportion of wounds completely healed, rate of reduction in wound size, rate of infection, or quality of life. All studies had unclear or high risk of bias for at least one key domain. Dextranomer paste/beads (autolytic debridement) compared with four different comparators Four studies compared dextranomer paste or beads with Eusol-soaked gauze (20 participants), 10% aqueous polyvinylpyrrolidone (40 participants), 0.1% chloramine-soaked dressings (28 participants), or silicone foam elastomer (50 participants). There is very low-certainty evidence that there may be no clear difference in time to a clean wound bed between dextranomer beads and Eusol gauze. The study did not report adverse events. There is very low-certainty evidence that there may be no difference in time to a clean wound bed between dextranomer paste and 10% aqueous polyvinylpyrrolidone gauze. There was low-certainty evidence that there may be no difference in deaths and serious adverse events. There may be a difference in time until the wounds were clinically clean and time to complete wound healing between dextranomer paste and 0.1% chloramine favouring 0.1% chloramine, but we are very uncertain. There is low-certainty evidence that there may be no difference in deaths and serious adverse events. There is very low-certainty evidence that there may be no difference in time to complete healing between dextranomer beads and silicone foam elastomer. The study did not report adverse events. Streptokinase/streptodornase solution (enzymatic) compared with saline-soaked dressings One study (21 participants) compared enzymatic debridement with saline-soaked dressings. There is low-certainty evidence that there may be no difference in time to a clean wound bed or secondary suture between streptokinase/streptodornase and saline-soaked dressings. There is very low-certainty evidence that there may be no difference in deaths and serious adverse events. Surgical debridement via endoscopic ('keyhole') surgery compared with surgical debridement by 'open' surgery (the wound is opened using a scalpel) One study (106 participants) reported time to complete wound healing and time to a clean wound bed. There is low-certainty evidence that there may be a reduction in time to complete wound healing and very low-certainty evidence that there may be no difference in time to a clean wound bed with surgical debridement via endoscopy compared to 'open' surgical debridement. The study did not report adverse events. Overall, the evidence was low to very low-certainty for all outcomes. Five included studies were published before 1991 and investigated treatments that are no longer available. Worldwide production of dextranomer products has been discontinued, except for dextranomer paste, which is currently only available in South Africa. Furthermore, Eusol, used in one study as the comparator to dextranomer, is rarely used due to risk of harmful effects on healthy tissue and the enzymatic agent streptokinase/streptodornase is no longer available worldwide.

AUTHORS' CONCLUSIONS

Evidence for the effects of different methods of debridement on complete wound debridement and healing of surgical wounds remains unclear. Adequately powered, methodologically robust RCTs evaluating contemporary debridement interventions for surgical wounds are needed to guide clinical decision-making.

An Appraisal of Pharmacotherapy-Pertinent Literature Published in 2021 and 2022 for Clinicians Caring for Patients With Thermal or Inhalation Injury

Studies focusing on pharmacotherapy interventions to aid patients after thermal injury are a minor focus in burn injury-centered studies and published across a wide array of journals, which challenges those with limited resources to keep their knowledge current. This review is a renewal of previous years' work to facilitate extraction and review of the most recent pharmacotherapy-centric studies in patients with thermal and inhalation injury. Twenty-three geographically dispersed, board-certified pharmacists participated in the review. A Medical Subject Heading-based, filtered search returned 2336 manuscripts over the previous 2-year period. After manual review, 98 (4%) manuscripts were determined to have a potential impact on current pharmacotherapy practice. The top 10 scored manuscripts are discussed. Only 17% of those reviewed were assessed to likely have little effect on current practice. The overall impact of the current cohort was higher than previous editions of this review, which is encouraging. There remains a need for investment in well-designed, high-impact, pharmacotherapy-pertinent research for patients sustaining thermal or inhalation injuries.

Bromelain-based enzymatic burn debridement: A systematic review of clinical studies on patient safety, efficacy and long-term outcomes

In 2012 the European Medicines Agency approved a pineapple stem-derived Bromelain-based debridement concentrate of proteolytic enzymes (NexoBrid®, MediWound Ltd, Yavne, Israel) for adult deep burns. Over 10 000 patients have been successfully treated with NexoBrid® globally, including in the US. The aim of our study is to perform a systematic review of the current literature on Nexobrid® outcomes. We conducted a literature search in PubMed, Google Scholar, Embase, and other search engines (2013-2023). The online screening process was performed by two independent reviewers with the Covidence tool. The protocol was reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses, and it was registered at the International Prospective Register of Systematic Reviews of the National Institute for Health Research. We identified 103 relevant studies of which 34 were found eligible. The included studies report the positive effects of Nexobrid® on burn debridement, functional and cosmetic outcomes, scarring, and quality of life. Also, they validate the high patient satisfaction thanks to enhanced protocols of analgosedation and/or locoregional anaesthesia during Bromelain-based debridement. Two studies investigate potential risks (coagulopathy, burn wound infection) which concluded there is no strong evidence of these adverse events. NexoBrid® is a safe, selective, non-surgical eschar removal treatment modality. The benefits of Bromelain-based debridement are faster debridement and healing times, reduced operations, length of stay, cases of sepsis, blood transfusions, and prevention of compartment syndrome. Existing evidence suggests that the indications and the role of Bromelain-based debridement are expanding to cover "off-label" cases with significant benefits to the global healthcare economy.

Efficacy and safety of bromelain: A systematic review and meta-analysis

Background: Pineapple has an important role in ethnopharmacology and its enzyme, bromelain, has been extensively investigated for its medicinal properties. Aim: This systematic review and meta-analysis aimed to assess clinical evidence concerning the efficacy and safety of bromelain. Methods: A systematic search was conducted from conception to August 2022 using CINAHL Complete, MEDLINE, ScienceDirect, Scopus, and Thai Journal Online (TJO). The risk of bias was assessed using Risk of Bias 2 or ROBIN-I. A random-effect model with inverse variance weighting and DerSimonian and Laird method was used for meta-analysis. The heterogeneity was evaluated by I2 statistics. Results: We included 54 articles for qualitative summary and 39 articles for meta-analysis. The systematic review found that bromelain presented in serum with retained proteolytic activity after oral absorption. Bromelain may be effective against sinusitis but was not effective for cardiovascular diseases. Pain reduction from oral bromelain was slightly but significantly better than controls (mean difference in pain score = -0.27; 95% CI: -0.45, -0.08; n = 9; I2 = 29%). Adverse events included flatulence, nausea, and headache. Topical bromelain significantly reduced the time to complete debridement (mean difference in time = -6.89 days; 95% CI: -7.94, -5.83; n = 4; I2 = 2%). Adverse events may be irrelevant and include burning sensation, pain, fever, and sepsis. Conclusions: Moderate-quality studies demonstrated the potential of oral bromelain in pain control and topical bromelain in wound care. Major health risks were not reported during the treatment with bromelain.

Anacaulase-bcdb for the treatment of severe thermal burns

INTRODUCTION

Accurate burn depth assessment and early excision of burn eschar with maximal dermal preservation are key concepts in the optimal care of burn injury. Although excision with knife has long since been standard of care, a newer technique for wound bed preparation utilizing a bromelain-based enzyme has gained popularity worldwide and may offer several advantages.

AREAS COVERED

Here we report the pharmacologic properties, evidence for clinical efficacy, safety, and tolerability of anacaulase-bcdb for the treatment of deep partial thickness and full thickness burns.

EXPERT OPINION

Anacaulase-bcdb is a safe, non-surgical, selective eschar removal agent. It offers advantages over surgical excision of burn with knife and fulfills two unmet needs: burn depth assessment and dermal preservation during excision. Evidence supports a faster time to complete eschar removal; reduced number of operations; reduction in the amount of autografting, length of stay, and blood loss; prevention of burn induced compartment syndrome; and improved cosmetic outcome.

Multifunctional and Smart Wound Dressings—A Review on Recent Research Advancements in Skin Regenerative Medicine

The healing of wounds is a dynamic function that necessitates coordination among multiple cell types and an optimal extracellular milieu. Much of the research focused on finding new techniques to improve and manage dermal injuries, chronic injuries, burn injuries, and sepsis, which are frequent medical concerns. A new research strategy involves developing multifunctional dressings to aid innate healing and combat numerous issues that trouble incompletely healed injuries, such as extreme inflammation, ischemic damage, scarring, and wound infection. Natural origin-based compounds offer distinct characteristics, such as excellent biocompatibility, cost-effectiveness, and low toxicity. Researchers have developed biopolymer-based wound dressings with drugs, biomacromolecules, and cells that are cytocompatible, hemostatic, initiate skin rejuvenation and rapid healing, and possess anti-inflammatory and antimicrobial activity. The main goal would be to mimic characteristics of fetal tissue regeneration in the adult healing phase, including complete hair and glandular restoration without delay or scarring. Emerging treatments based on biomaterials, nanoparticles, and biomimetic proteases have the keys to improving wound care and will be a vital addition to the therapeutic toolkit for slow-healing wounds. This study focuses on recent discoveries of several dressings that have undergone extensive pre-clinical development or are now undergoing fundamental research.

Positionspapier der Initiative Chronische Wunde (ICW) e. V. zur Nomenklatur des Débridements chronischer Wunden

Die heute in der Wundbehandlung verwendete Nomenklatur ist interdisziplinär und interprofessionell sehr unterschiedlich. Daher ist es ein Anliegen der Fachgesellschaft Initiative Chronische Wunde (ICW) e. V. bislang unklare Begriffe eindeutig und nachvollziehbar zu beschreiben. Von den Experten der ICW wurde daher in einem Konsensusverfahren als Débridement chronischer Wunden die Entfernung von anhaftendem, abgestorbenem Gewebe, Krusten oder Fremdkörpern aus Wunden bezeichnet. Hierfür gibt es verschiedene Therapieoptionen, die als autolytisches, biochirurgisches, mechanisches, osmotisches, proteolytisches/enzymatisches und technisches Débridement unterschieden werden können. Bei dem chirurgischen Débridement wird zudem zwischen meist ambulant durchführbaren scharfen Débridements wie beispielsweise kleineren chirurgischen Eingriffen und chirurgischen Débridements mit adäquater Anästhesie in einem Operationssaal differenziert. Als Wundspülung wird von der ICW die Entfernung von nicht haftenden Bestandteilen auf Wunden mit sterilen Lösungen bezeichnet.

Débridement und/oder Wundspülung sind oft der erste Schritt einer phasengerechten modernen Wundbehandlung. Mehrere Methoden eignen sich für die Anwendung einer kombinierten oder sukzessiven Therapie. Bei der Entscheidung, welche therapeutische Option hierbei zum Einsatz kommt, sollte eine Vielzahl individuell unterschiedlicher Faktoren in Abhängigkeit von den zu behandelnden Patienten, aber auch von den Therapeuten berücksichtigt werden. Die letztendliche individuelle Entscheidung für eine Methode sollte jeweils gemeinsam mit den Patienten getroffen und anschließend adäquat dokumentiert werden.

Bromelain and Nisin: The Natural Antimicrobials with High Potential in Biomedicine

Infectious diseases along with various cancer types are among the most significant public health problems and the leading cause of death worldwide. The situation has become even more complex with the rapid development of multidrug-resistant microorganisms. New drugs are urgently needed to curb the increasing spread of diseases in humans and livestock. Promising candidates are natural antimicrobial peptides produced by bacteria, and therapeutic enzymes, extracted from medicinal plants. This review highlights the structure and properties of plant origin bromelain and antimicrobial peptide nisin, along with their mechanism of action, the immobilization strategies, and recent applications in the field of biomedicine. Future perspectives towards the commercialization of new biomedical products, including these important bioactive compounds, have been highlighted.