A Comparison of an Antimicrobial Wound Cleanser to Normal Saline in Reduction of Bioburden and its Effect on Wound Healing
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B acteria and other micro-organisms affect wound healing. Almost 40 years ago, Bendy et al1 demonstrated a direct link between bacterial wound bioburden and subsequent healing. Further investigation by Robson et al2 confirmed that a wound bioburden in excess of 1.0 x 105 colony forming units (CFUs) per gram of tissue was a factor in delayed wound healing and closure. Consequently, reduction of wound bioburden became a necessary goal in the wound-healing scheme. Nevertheless, many wounds have been reported to heal despite high bacterial bioburden, suggesting that wound bioburden may be only an interrelated aspect of wound infection.3 Beta-hemolytic Streptococci, even at 102 to 103 CFU/g of tissue, play a significant role in pathogenesis and can result in massive tissue injury.4 Bacterial virulence, rather than bioburden levels, represents the critical factor in infection and delayed wound healing.5 Other factors independent of bioburden levels, such as such as inadequate host resistance and systemic conditions including vascular disease and diabetes, contribute to wound infection risk.6
The bacterial populations of wounds that constitute bioburden are a complex amalgam of aerobic and anaerobic micro-organisms that exhibit many adaptive interactions, such as synergism.7 Bacterial synergy has been recorded for a wide variety of micro-organisms, and investigators have noted that anaerobic bacteria such as Bacteriodies spp., like most other anaerobic commensals, can act as pathogenic opportunists in cases of decreased resistance and particularly in synergism with other micro-organisms, can produce genuine infections and necrosis.8 The pattern of bacterial synergy has been documented for numerous combinations of microbes, even where micro-organisms of low virulence (eg, Enterococcus spp.) may contribute to host injury when present with other pathogens.9
The topical treatment of wounds has a long and well-developed history. The horrific wounds encountered on the battlefields of World War I brought about the development of a wound antiseptic substance through the efforts of Dakin and Carrel.10 This antiseptic is still known as Dakin's solution. Generically, Dakin's solution is referred to as sodium hypochlorite. Sodium hypochlorite is also the active agent in the antimicrobial wound cleanser (AWC) tested, albeit in a less concentrated amount. The concentration of sodium hypochlorite in Dakin's solution is 0.5%; whereas, its concentration in the AWC is 0.057%. The AWC also differs from Dakin's solution in that it contains 0.85% sodium chloride that renders, by nominal concentration, the solution isotonic. Dakin's solution is only stable for 30 days11; the AWC used in this study has a 2-year shelf life.
Topical wound care products in recent use include a variety of anti-infective agents such as antibiotic creams, antiseptics, and silver dressings. All are employed to help control bioburden and prevent wound infection. However, an ongoing controversy exists in the effective topical treatment of heavily colonized or contaminated wounds.12 The use of antiseptics and antimicrobial wound cleansers has been discouraged because the in vitro studies conducted by Lineweaver (1985)13 and Kozol and colleagues (1988)14 indicated that sodium hypochlorite (Dakin's solution) exhibits cytotoxic properties. In response to the Kozol study, in 1989 Cuono published the following (excerpted) statements:
The apparently contradictory results obtained by Kozol et al may, in part, be explained by the
wound module, which bears little similarity to the real wound milieu." And, "Hypochlorites have an
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