Use of antimicrobial dressings in England and the association with published clinical guidance: interrupted time series analysis

A survey of UK nurses about their care of people with malignant fungating wounds

PURPOSE

To gain an understanding of the nursing professionals who treat people with malignant fungating wounds (MFW) in the UK and their current practices, including perceived barriers and facilitators to providing MFW care.

METHOD

An online anonymous questionnaire was created with questions about the role of nursing professionals who reported caring for patients with MFW, the number of people with MFW they regularly cared for, treatment aims, treatments used, and challenges faced. These questions were developed with professional input and piloted. Using a convenience sampling method, we collected responses from UK nurses by distributing the questionnaire via social media and through relevant professional organisations. The questionnaire was constructed in QualtricsXM software and analysed using SPSS.

RESULT

We received 154 questionnaire responses, with three-quarters from tissue viability nurses and the rest from community and other specialist nurses. The most important treatment aim reported was pain management, followed by odour management. Almost all respondents used antimicrobial and standard dressings for these patients, with a range of products reported. Poor access to MFW care training and lack of local and national guidelines were reported as barriers to providing care for people with MFW. Availability of dressings, access to training, and good communication processes were reported as facilitators.

CONCLUSION

This is the first study to explore MFW wound care practices in the UK. A range of nurses are involved in care delivery with variations in the treatments used. Lack of access to MFW care training, resources, and standardised guidelines may impede care delivery.

The Hand and Wrist: AntImicrobials and Infection (HAWAII) trial

BACKGROUND

Hand trauma, comprising injuries to both the hand and wrist, affects over five million people per year in the NHS, resulting in 250 000 operations each year. Surgical site infection (SSI) following hand trauma surgery leads to significant morbidity. Triclosan-coated sutures may reduce SSI in major abdominal surgery but have never been tested in hand trauma. Feasibility needs to be ascertained before a definitive trial can be delivered in hand trauma.

METHODS

A multicentre feasibility RCT of antimicrobial sutures versus standard sutures involving adults undergoing surgery for hand trauma to evaluate feasibility for a definitive trial. Secondary objectives were incidence of SSI in both groups, hand function measured with patient-reported outcome measures, health-related quality of life and change in employment. Randomization was performed on a 1:1 basis, stratified by age of the patient and whether the injury was open or closed, using a secure, centralized, online randomization service. Participants were blinded to allocation.

RESULTS

116 participants were recruited and randomized (60 intervention, 56 control). Of 227 screened, most were eligible (89.5 per cent), and most who were approached agreed to be included in the study (84.7 per cent). Retention was low: 57.5 per cent at 30 days, 52 per cent at 90 days and 45.1 per cent at 6 months. Incidence of SSI was >20 per cent in both groups. Hand function deteriorated after injury but recovered to near pre-injury levels during the study period.

CONCLUSIONS

Risk of SSI after hand trauma is high. A definitive RCT of antimicrobial sutures in hand trauma surgery is feasible, if retention is improved.

TRIAL REGISTRATION

ISRCTN10771059.

Development of curcumin-loaded liposomes in lysine–collagen hydrogel for surgical wound healing

Background

A surgical wound is an incision made by a surgeon. Slow surgical wound healing may lead to chronic wounds which may be a potential health problem. The aim of this study is to formulate curcumin-loaded liposomes in lysine–collagen hydrogel for enhancing surgical wound healing. Curcumin-loaded liposomes were prepared using thin-film hydration method. The liposomal formulation was characterized by analysing its size, morphology, encapsulation efficiency, and in vitro release. The hydrogel base was prepared, and then, curcumin-loaded liposomes were infused to give formulation (F1). Curcumin-loaded liposomes were infused into the hydrogel base after which lysine and collagen were incorporated to give (F2), while (F3) comprised lysine and collagen incorporated in hydrogel base. All formulations were characterized by evaluation of the safety, stability, swelling index, pH, rheological properties, and in vivo wound healing assay. Histology and histomorphometry of tissue samples of wound area treated with formulations F1, F2, and F3 and the control, respectively, were examined.

Results

Curcumin-loaded liposomes were 5–10 µm in size, and the values for encapsulation efficiency and flux of the loaded liposomes are 99.934% and 51.229 µg/cm2/h, respectively. Formulations F1, F2, and F3 had a pH of 5.8. F1 had the highest viscosity, while F2 had the highest swelling index indications for efficient sustained release of drug from the formulation. The in vivo wound healing evaluation showed that curcumin-loaded liposomes in lysine–collagen hydrogel had the highest percentage wound contraction at 79.25% by day three post-surgical operation. Histological evaluation reflected a normal physiological structure of the layers of the epidermis and dermis after surgical wound healing in tissue samples from wound areas treated with formulations F1 and F2. The histomorphometrical values show highest percentage of collagen, lowest inflammatory rates, highest presence of microvessels, and re-epithelization rates at wound site in wounds treated with formulation F2 (curcumin-loaded liposomes in lysine–collagen hydrogel).

Conclusion

Curcumin-loaded liposomes in lysine–collagen hydrogel was found to be the most effective of the three formulations in promoting wound healing. Hence, this formulation can serve as a prototype for further development and has great potential as a smart wound dressing for the treatment of surgical wounds.

Working in partnership to implement change in wound dressings use

BACKGROUND

Wound care provision relies on safety, effectiveness, patient acceptance and accessibility of selected wound management products, supported by a sound education programme. Challenges with changing patient needs and service provision before and during the COVID-19 pandemic have resulted in new training and service delivery programmes to manage increased prevalence of wounds with dwindling resources.

METHOD

South Warwickshire University NHS Foundation Trust incorporated a wound care audit identifying local challenges, available resources and areas for improvement, which led to changes in practice around training and the supply of dressings. This article sets out the rationale for change and steps taken to implement new practice, keeping the patient at the heart of care while following clinical governance.

RESULTS

The new practice resulted in a rigorous training programme to cover total wound management from assessment to standardised treatment that could encourage self-care where possible and improve patient outcomes. Wise use of all resources to manage stock levels released more qualified staff to focus on complex cases. Non-prescription ordering of dressings reduced stock wastage and the Trust recorded cost savings of more than 25% on the previous year.

CONCLUSION

Sound wound care practice aligned to the National Wound Care Strategy, training in partnership with industry and the use of an efficient dressings delivery system achieved positive patient outcomes and significant financial savings for the Trust.

Health service costs of treating venous leg ulcers in the UK: evidence from a cross-sectional survey based in the north west of England

OBJECTIVES

To estimate and examine the direct healthcare costs of treating people with open venous leg ulcers in the UK.

DESIGN

Cost-of-illness study.

SETTING

A cross-sectional survey of nine National Health Service community locales over 2-week periods in 2015/2016.

METHODS

We examined the resource use and prevalence of venous leg ulcer treatment in the community. Examination of variation in these obtained costs was performed by ordinary least squares regression. We used additional resource use information from a randomised control trial and extrapolated costs to the UK for an annual period.

RESULTS

The average 2-week per person cost of treating patients where a venous leg ulceration was the primary (most severe) wound was estimated at £166.39 (95% CI £157.78 to £175.00) with community staff time making up over half of this amount. Costs were higher where antimicrobial dressings were used and where wound care was delivered in the home. Among those with any recorded venous leg ulcer (primary and non-primary), we derived a point prevalence of 3.2 per 10 000 population and estimated that the annual prevalence could be no greater than 82.4 per 10 000 population. We estimated that the national cost of treating a venous leg ulcer was £102 million with a per person annual cost at £4787.70.

CONCLUSION

Our point prevalence figures are in line with the literature. However, our annual prevalence estimations and costs are far lower than those reported in recent literature which suggests that the costs of treating venous leg ulcers are lower than previously thought. Movement towards routinely collected and useable community care activity would help provide a transparent and deeper understanding of the scale and cost of wound care in the UK.

Testing the efficacy of topical antimicrobial treatments using a two- and five-species chronic wound biofilm model

AIMS

The effectiveness of commercially available wound dressings and a HOCl gel formulation was tested against two- and five-species biofilms in a dynamic in vitro chronic wound infection model.

METHOD

Two-species biofilms (Pseudomonas aeruginosa and Staphylococcus aureus) were cultured using a biofilm flow device and treated with wound dressings containing silver, iodine, polyhexamethylene biguanide, crystal violet or HOCl gel at 5 h. Five-species biofilms (P. aeruginosa, S. aureus, Enterococcus faecalis, Streptococcus pyogenes and Escherichia coli) were similarly cultured and treated with HOCl gel at 5 and 24 h. Multidose experiments used two- and five-species biofilms with HOCl applied at 24, 48 and 72 h.

RESULTS

None of the treatments completely disrupted the biofilms and, with the exception of silver, bacteria recovered in number post-treatment. HOCl was most effective when applied to 24 h established biofilms with most activity against P. aeruginosa. Recovery post-treatment was negligible with HOCl applied at 24 h and multiple doses indicated that bacteria were not becoming tolerant to treatment.

CONCLUSIONS

Realistic models are necessary to test the effectiveness of antimicrobial wound treatments to ensure findings are clinically translatable. HOCl gel shows promise as a new topical antimicrobial for wounds, especially due to its ability to inhibit P. aeruginosa.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study highlights a need for robust in vitro data to support development and use of wound treatments that can only be obtained from the refinement of realistic infection models. Furthermore, it indicates the potential use of HOCl gel for chronic wound management.

Routine Fluorescence Imaging to Detect Wound Bacteria Reduces Antibiotic Use and Antimicrobial Dressing Expenditure While Improving Healing Rates: Retrospective Analysis of 229 Foot Ulcers

Foot ulcers and their bacterial burden produce a significant strain on the National Healthcare System (NHS). Subjectivity of wound infection assessment makes appropriate dressing selection challenging. To aid point-of-care detection of bacterial burden, a fluorescence imaging device (MolecuLight i:X) was introduced to the Whipps Cross Hospital Podiatry clinic. This retrospective pre/post-analysis evaluated how implementation of fluorescence imaging impacted (1) antimicrobial dressings and antibiotics use and (2) wound healing rates. Over a 2-year period 229 lower extremity wounds were treated. Wound-related outcomes and antimicrobial dressing costs were quantified over 1-year before (2018/2019) and after (2019/2020) incorporating fluorescence imaging into routine practice. The period of fluorescence imaging saw a 27% increase in the number of wounds seen, yet annual antimicrobial dressing expenditure decreased by 33%. Implementation of fluorescence imaging was also associated with a 49% decrease in prescription of antimicrobial dressings, a 33% decrease in antibiotic prescriptions, and a 23% increase in wound healing rates within 12-weeks (48% vs. 39%), likely due to earlier bacterial detection and improved wound hygiene. This increased healing rate is projected to decrease annual wound costs by 10% (£762 per patient). Routine bacterial imaging appears to diminish clinical and economic burden to patients and the NHS.

Skin infections in older adults

Skin infections are extremely common throughout the community in older people. Cellulitis and infected ulcers are the most common cutaneous skin infections in older adults, but various other aetiologies can be identified by community nurses and healthcare staff throughout their area's patient population. Staphylococcus aureus is common and increases morbidity so prompt identification is required. Assessment of the skin and appropriate swabbing is necessary and crucial in order to be proficient when looking after people with skin conditions and infections in the community. This article will cover the basic principles of assessment, investigation and treatment, as well as encouraging an awareness of risk, touching on the common predictors of skin infections in older people.