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
1. Bendy RH, Nuccio PA, Wolfe E, Collins B, Tamburro C, Class W, Martin CM. Relationship of quantitative wound bacterial counts to healing of decubiti. Effect of topical gentamicin. Antimicrob Agents Chemo Ther. 1964;4:147-155.
2. Robson MC, Lea CE, Dalton JB, Heggers JP. Quantitative bacteriology and delayed wound closure. Surg Forum. 1968;20:501-502.
3. Robson M., Duke W, Krizek T. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res. 1973;14:14:420.
4. Robson M, Heggers J. Surgical infection II: the beta hemolytic streptococcus J Surg Res. 1969;9:289.
5. Sapico F, Canawati H, Witte J, Montgomerie J, et al. Quantitative aerobic and anaerobic bacteriology of infected diabetic feet. J Clin Microbiol. 1980;12:413.
6. Deresinski S. Infections in the diabetic patient strategies for the clinician. Infectious Disease Reports. 1995;January(1):1.
7. Meleney FL. Bacterial synergism in disease process. Ann Surg. 1931;22:961-981.
8. Puhvel S, Reisner R. Anaerobic Bacteria Role in Disease: Dermatologic Anaerobic Infections. Springfield, Ill.: Charles C. Thomas Publisher;1974:442.
9. Bohnen J, Matlow A, Nohr C, et al. Pathogenicity of enterococcus in a rat model of fecal peritonitis. Program abstract 276. The Interscience Conference Antimicrobial Agents. Chemotherapy;1983.
10. Hartley P. Obituaries. Dr. H.D. Dakin. Nature. 1952:169:481-482.
11. Rutaia W, Cole E, Thomann C, Weber D. Stability and bactericidal activity of chlorine solutions, infection control and hospital epidemiology. Infection Control and Epidemiology. 1998;19(5):323-327.
12. Dow G, Browne A, Sibbald G. Infection in chronic wounds: controversies in diagnosis and treatment. Ostomy/Wound Management. 1999;45(8):23-40.
13. Lineweaver WC, Howard R, Soucy D, et al. Topical antimicrobial toxicity. Arch Surg. 1985;120:267-270.
14. Kozol RA, Gillies C, Elgebaly SA. Effects of sodium hypochlorite (Dakin's solution) on cells of the wound module. Arch Surg. 1988;123:420-423.
15. Cuono CB, Barese MS. Correspondence to the editor. Arch Surg. 1989;124:133.
16. Heggers JP, Sazy JA, Stenberg BD, et al. Bacterial and wound-healing properties of sodium hypochlorite solutions. The 1991 Lindenberg Award. J Burn Care Rehab. 1991;12:420-424.
17. Cotter JL, Fader RC, Lilley C, Herndon DN. Chemical parameters, antiseptic actives, and tissue toxicity of 0.1% and 0.5% sodium hypochlorite solutions. Antimicrob Agents Chemother. 1985;28:118-122.
18. Robson MC. Wound infection: a failure of wound healing caused by an imbalance of bacteria. Surg Clin North Am. 1997;77:637-650.
19. Rodeheaver G. Wound cleansing, wound irrigation, wound disinfection. In: Krasner D, Rodeheaver G, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Health Care Professionals, 2nd ed. Wayne, Pa.: Health Management Publications Inc.;1997:97-109.
20. Bowler PG. The 105 bacterial growth guideline: reassessing its clinical relevance in wound healing. Ostomy/Wound Management. 2003;49(1):44-53.
21. Levine N, Lindberg R, Mason A, et al. The quantitative swab culture and smear: a quick, simple method for determining the number of viable aerobic bacteria on open wounds. J Trauma. 1976;16(2):89.
22. United States Pharmacopeia. USP23. 1995 Edition: Microbial Limits Tests (61). Total Aerobic Microbial Count:1684-1685.
23. Lennette EH. Manual of Clinical Microbiology, 4th ed. Washington, DC: American Society of Microbiology;1985:73-98.
24. Sussman C, Bates-Jensen BM. Wound Care: A Collaborative Practice Manual for Physical Therapists and Nurses. Gaithersburg, Md.: Aspen Publishers;1998:88-89.
25. Hoffman PN, Death JE, Coates D. The stability of sodium hypochlorite solutions. In: Collins CH, Allwood MC, Bloomfield SF, Fox A, eds. Disinfectants: Their Use and Evaluation of Their Effectiveness. London: Academic Press;1981:77-83.
26. Dychdala GR. Chlorine and chlorine compounds In: Block SS, Fox A, eds. Disinfection, Sterilization and Preservation, 4th ed. Philadelphia, Pa.: Lea & Febiger;1991:131-151.
27. Edlich RF, Rodeheaver GT, Thacker JG, et al. Management of soft tissue injury. Clin Plast Surg. 1977;4:191-201.