Super-oxidized solution (Dermacyn Wound Care) as adjuvant treatment in the postoperative management of complicated diabetic foot osteomyelitis: preliminary experience in a specialized department

Comparison of antibiofilm activity of low-concentrated hypochlorites vs polyhexanide-containing antiseptic

Chronic wound infection is highly associated with morbidity and endangers the patient's life. Therefore, wound care products must have a potent antimicrobial and biofilm-eradicating effect. In this work, the antimicrobial/antibiofilm activity of two low-concentrated chlorine-based and releasing solutions was investigated on a total of 78 strains of methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and Candida albicans, using the cohesive spectrum of in vitro settings, including microtiter plate models, biofilm-oriented antiseptic test, cellulose-based biofilm model, biofilm bioreactors and Bioflux model. The antiseptic containing polyhexamethylene biguanide was used in the character of usability control of performed tests. The results obtained by static biofilm models indicate that low-concentrated chlorine-based and releasing solutions display none to moderate antibiofilm activity, while data obtained by means of the Bioflux model, providing flow conditions, indicate the moderate antibiofilm activity of substances compared with the polyhexanide antiseptic. Considering in vitro data presented in this manuscript, the earlier reported favorable clinical results of low-concentrated hypochlorites should be considered rather an effect of their rinsing activity combined with low cytotoxicity but not the antimicrobial effect per se. For the treatment of heavily biofilm-infected wounds, polyhexanide should be considered the agent of choice because of its higher efficacy against pathogenic biofilms.

Is There a Wound Recontamination by Eluates with High Bacterial Load in Negative-Pressure Wound Therapy with Instillation and Dwell Time?

BACKGROUND

This study investigated bacterial colonization of the foam eluate after negative-pressure wound therapy (NPWT) with instillation and dwell time (NPWTi-d) to obtain an indication of possible recontamination of the wound during NPWTi-d. To detect bacterial colonization and the extent of planktonic and nonplanktonic bioburden as comprehensively as possible, routine culture and molecular biology methods were used.

METHODS

Before (time point 1) and after (median 3.0 days; time point 2) NPWT ( n = 15) and NPWTi-d with antiseptic installation ( n = 15), wound bed [22 acute, eight chronic wounds; median age, 51 years (range, 24 to 91); 26 men], foam, and eluate were examined by routine culture methods and fluorescence in situ hybridization (FISH), polymerase chain reaction, and FISH sequencing (FISHseq).

RESULTS

At time point 2, 94.9% (37 of 39) of the pathogens identifiable in the eluate were also detected in the wound bed. Foam and eluate were always bacterially contaminated. NPWTi-d resulted in a significant reduction in the number of pathogen species compared with NPWT (NPWTi-d, time point 1 versus time point 2: P = 0.026; NPWT, time point 1 versus time point 2: not significant). Routine culture of wound bed samples at time point 2 identified only 28 of 52 (53.8%) of the pathogens, whereas examination of wound bed, foam, and eluate and additional FISHseq use detected 50 of 52 (96.2%) of the bacterial species. FISHseq identified biofilm in one and microcolonies in 10 wounds (time point 2).

CONCLUSIONS

The bacterial load of the foam is flushed back into the wound during NPWTi-d. FISHseq should be used in addition to the routine culture method when pathogen identification and detection of nonplanktonic bacterial growth is particularly important for the patient's therapy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

In Vitro Efficacy of Bacterial Cellulose Dressings Chemisorbed with Antiseptics against Biofilm Formed by Pathogens Isolated from Chronic Wounds

Local administration of antiseptics is required to prevent and fight against biofilm-based infections of chronic wounds. One of the methods used for delivering antiseptics to infected wounds is the application of dressings chemisorbed with antimicrobials. Dressings made of bacterial cellulose (BC) display several features, making them suitable for such a purpose. This work aimed to compare the activity of commonly used antiseptic molecules: octenidine, polyhexanide, povidone-iodine, chlorhexidine, ethacridine lactate, and hypochlorous solutions and to evaluate their usefulness as active substances of BC dressings against 48 bacterial strains (8 species) and 6 yeast strains (1 species). A silver dressing was applied as a control material of proven antimicrobial activity. The methodology applied included the assessment of minimal inhibitory concentrations (MIC) and minimal biofilm eradication concentration (MBEC), the modified disc-diffusion method, and the modified antibiofilm dressing activity measurement (A.D.A.M.) method. While in 96-well plate-based methods (MIC and MBEC assessment), the highest antimicrobial activity was recorded for chlorhexidine, in the modified disc-diffusion method and in the modified A.D.A.M test, povidone-iodine performed the best. In an in vitro setting simulating chronic wound conditions, BC dressings chemisorbed with polyhexanide, octenidine, or povidone-iodine displayed a similar or even higher antibiofilm activity than the control dressing containing silver molecules. If translated into clinical conditions, the obtained results suggest high applicability of BC dressings chemisorbed with antiseptics to eradicate biofilm from chronic wounds.

Role of inflammatory markers in the healing time of diabetic foot osteomyelitis treated by surgery or antibiotics

OBJECTIVE

To analyse the predictive role of inflammatory markers in the healing time of diabetic foot osteomyelitis treated by surgery or antibiotics.

METHODS

An observational study of patients with diabetic foot ulcers (DFU) and clinically suspected osteomyelitis. The patients underwent surgical or antibiotic treatment for bone infection in a specialised diabetic foot unit. Blood samples were taken from each patient to analyse biomarkers. The main outcome was the number of weeks until healing occurred.

RESULTS

A total of 116 patients took part in the study. The number of weeks until healing was similar for both groups (surgical n=96 and antiobiotic n=20, treatments). No association was observed among biomarkers as predictors of time-to-healing.

CONCLUSION

There is not enough evidence to define the prognostic role of inflammatory markers in the healing time of DFUs complicated with diabetic foot osteomyelitis, regardless of the treatment administered.

Correlation between Empirical Antibiotic Therapy and Bone Culture Results in Patients with Osteomyelitis

OBJECTIVE

To analyze the correlation between empirical antibiotic therapies prescribed in primary care centers by general practitioners and the microbiology results of bone culture in patients with diabetic foot-related osteomyelitis.

METHODS

This observational study involved 80 patients with diabetic foot ulcers and clinically suspected osteomyelitis. The patients were taking antibiotics prescribed by general practitioners to treat diabetic foot infections. Bone samples were taken from every patient for microbiology analysis in a specialized diabetic foot unit.

MAIN OUTCOME MEASURE

The sensitivity of the bone cultures to antibiotics was compared with the patient's previous antibiotic therapy, and antibiotic and bacterial resistance were analyzed.

MAIN RESULTS

The bone cultures from only 16 patients (22.3%) showed sensitivity to the antibiotics that the patient had been prescribed. Fifty-six patients (77.8%) displayed bacterial resistance to the antibiotic that they were taking.

CONCLUSIONS

Awareness and implementation of international antibiotic stewardship guidelines are poor in primary care centers. It is important to establish strategies that foster a better understanding of treatment management standards and ensure the proper implementation of guidelines.

Postoperative effects on lower third molars of using mouthwashes with super-oxidized solution versus 0.2% chlorhexidine gel: A randomized double-blind trial

BACKGROUND

The main objective of the present study is to evaluate the effects and possible benefits with regard to the postoperative period of lower third molar extractions, comparing the intraalveolar application of a bioadhesive gel of 0.2% chlorhexidine (CHX) to the use of a mouthwash with a super-oxidized solution, (SOS) Dermacyn® Wound Care (Oculus Innovative Sciences lnc., California, USA).

MATERIAL AND METHODS

A randomized double-blind study was carried out in 20 patients with a split-mouth design, with a total of 40 extractions of symmetrically impacted bilateral lower third molars. Patients were divided into two groups, a control group (C = 20) and an experimental group (D = 20). Any infectious complications, wound healing, plaque accumulation in the stitches, and presence of trismus and inflammation were evaluated using the distance between different facial points, at three, eight, and fifteen days after extraction. Pain, swelling, and amount of analgesics taken were evaluated using the VAS scale throughout the 15 days following extraction. Tolerance to treatment was evaluated using a verbal scale. Results were statistically compared using the Student's t- and chi-squared tests.

RESULTS

No statistically significant differences were found between the two groups with regard to infectious complications, swelling, or wound healing. Use of analgesics and self-reported pain levels were slightly lower in the experimental group than in the control group during days 6 and 7 of the study (p < 0.05). The global treatment tolerance was satisfactory and similar in both groups.

CONCLUSIONS

Both CHX and SOS are effective at improving the postoperative period after extraction of lower third molars.

Consensus on Wound Antisepsis: Update 2018

Wound antisepsis has undergone a renaissance due to the introduction of highly effective wound-compatible antimicrobial agents and the spread of multidrug-resistant organisms (MDROs). However, a strict indication must be set for the application of these agents. An infected or critically colonized wound must be treated antiseptically. In addition, systemic antibiotic therapy is required in case the infection spreads. If applied preventively, the Wounds-at-Risk Score allows an assessment of the risk for infection and thus appropriateness of the indication. The content of this updated consensus recommendation still largely consists of discussing properties of octenidine dihydrochloride (OCT), polihexanide, and iodophores. The evaluations of hypochlorite, taurolidine, and silver ions have been updated. For critically colonized and infected chronic wounds as well as for burns, polihexanide is classified as the active agent of choice. The combination 0.1% OCT/phenoxyethanol (PE) solution is suitable for acute, contaminated, and traumatic wounds, including MRSA-colonized wounds due to its deep action. For chronic wounds, preparations with 0.05% OCT are preferable. For bite, stab/puncture, and gunshot wounds, polyvinylpyrrolidone (PVP)-iodine is the first choice, while polihexanide and hypochlorite are superior to PVP-iodine for the treatment of contaminated acute and chronic wounds. For the decolonization of wounds colonized or infected with MDROs, the combination of OCT/PE is preferred. For peritoneal rinsing or rinsing of other cavities with a lack of drainage potential as well as the risk of central nervous system exposure, hypochlorite is the superior active agent. Silver-sulfadiazine is classified as dispensable, while dyes, organic mercury compounds, and hydrogen peroxide alone are classified as obsolete. As promising prospects, acetic acid, the combination of negative pressure wound therapy with the instillation of antiseptics (NPWTi), and cold atmospheric plasma are also subjects of this assessment.

Hypochlorous acid gel technology-Its impact on postprocedure treatment and scar prevention

BACKGROUND

A pre-and postprocedure regime aimed at prevention of infection, reduction of inflammation and risk of scarring, is to enable optimal outcomes.

OBJECTIVES

The role of a hypochlorous acid containing spray and translucent scar gel formulation that combines modified silicon oil with hypochlorous acid, was explored for pre- and postprocedure treatment and scar management.

METHODS

For this purpose a literature review was conducted to explore the value of the technology used in pre-and postprocedural regimes. A panel of dermatologists and plastic surgeons who practice in the United States discussed the summarized search results, taking into account their current clinical practice. A nominal group process for consensus was used, followed by online reviews of the manuscript.

RESULTS

Based on panel discussions, consensus was reached regarding clinical recommendations given for postprocedure treatment and scar management. The hypochlorous acid products are produced with electrolysis and are classified among biocidal substances. The technology has demonstrated efficacy and safety for pre-and postprocedure use. The safety of hypochlorous solution use demonstrated to be comparable to that of standard local antiseptics. Small studies demonstrated better results with the scar gel compared to silicone gel regarding the appearance of hypertrophic and keloid scars, relief of associated pruritus and pain.

CONCLUSIONS

A postprocedure regime using this technology, aimed at preventing infection, reducing inflammation, and promoting healing is proposed to have benefits over current regimes as it appears to be effective, safe, and well tolerated.

Diagnostic and therapeutic update on diabetic foot osteomyelitis

Diabetic foot osteomyelitis (DFO) is the most common infection associated to diabetic foot ulcers (DFU). This review is designed to provide an update on the diagnosis and treatment of DFO based on an analysis of MEDLINE through PubMed using as search criterion "Diabetic Foot Osteomyelitis". Authors have included in this review the most relevant manuscripts regarding diagnosis and treatment of DFO. After review and critical analysis of publications, it may be concluded that diagnosis of DFO is not simple because of its heterogeneous presentation. Clinical inflammatory signs, probe-to-bone test, and plain X-rays are postulated as the basic tests for clinical diagnosis when DFO is suspected. Diagnosis should be supported by laboratory tests, of which ESR (>70mm/h) has been shown to be most precise. MRI is the most accurate imaging test, especially for differential diagnosis with Charcot foot. Pathogen isolation by bone culture is essential when the patient is treated with ATB only. Medical or surgical treatment should be based on the clinical characteristics of the patient and the lesion. Surgery should always be an option if medical treatment fails.

Novel negative pressure wound therapy with instillation and the management of diabetic foot infections

PURPOSE OF REVIEW

The use of negative pressure wound therapy with instillation (NPWTi) in complex or difficult-to-treat acute and chronic wounds has expanded rapidly since the introduction of commercially available NPWTi systems. We summarize the evidence related to NPWTi and particularly focus on the application of this technology in diabetic foot ulcers, diabetic foot infections and postoperative diabetic wounds.

RECENT FINDINGS

The benefits of negative pressure wound therapy (NPWT) are well documented in the treatment of complex acute and chronic wounds, including noninfected postoperative diabetic wounds and diabetic foot ulcers. Combining intermittent wound irrigation with NPWT may offer additional benefits compared to NPWT alone, including further reduction of wound bed bioburden, increased granulation tissue formation and provision of wound irrigation in a sealed environment, thus preventing potential cross-contamination events. Recently, available evidence suggests that adjunctive NPWTi may be superior to standard NPWT in the management of diabetic infections following surgical debridement and may promote granulation tissue formation in slow-to-heal wounds.

SUMMARY

Available evidence relating to the utilization of NPWTi in diabetic foot infections is promising but limited in quality, being derived mostly from case series or small retrospective or prospective studies. In order to confirm or refute the potential benefits of NPWTi in this patient cohort, well designed randomized controlled studies are required that compare NPWTi to NPWT or standard wound care methodologies.

Diabetic foot infections: state-of-the-art

Foot infections are frequent and potentially devastating complications of diabetes. Unchecked, infection can progress contiguously to involve the deeper soft tissues and ultimately the bone. Foot ulcers in people with diabetes are most often the consequence of one or more of the following: peripheral sensory neuropathy, motor neuropathy and gait disorders, peripheral arterial insufficiency or immunological impairments. Infection develops in over half of foot ulcers and is the factor that most often leads to lower extremity amputation. These amputations are associated with substantial morbidity, reduced quality of life and major financial costs. Most infections can be successfully treated with optimal wound care, antibiotic therapy and surgical procedures. Employing evidence-based guidelines, multidisciplinary teams and institution-specific clinical pathways provides the best approach to guide clinicians through this multifaceted problem. All clinicians regularly seeing people with diabetes should have an understanding of how to prevent, diagnose and treat foot infections, which requires familiarity with the pathophysiology of the problem and the literature supporting currently recommended care.