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Challenging Cases: Achieving Optimal Outcomes With Hydrophobic Dressings While Avoiding Harm

Children With Wounds: Asking the Right Questions

Challenging Cases: Achieving Optimal Outcomes With Hydrophobic Dressings While Avoiding Harm

CASE 1

A 16-year-old female patient receiving palliative care due to terminal malignancy was admitted to the Hematology Oncology Department for an infected central port in the upper left arm. Initial treatment of the infection was attempted without removing the port, but progressive cellulitis developed around the port area with progressive swelling, edema, and erythema. There were concerns about spreading systemic infection. The port was taken out, and the pocket was packed with tape, only to persistently drain serosanguinous exudate. The affected area remained tender, warm, and erythematous. Culture results were positive for methicillin-sensitive Staphylococcus aureus. 

The author was consulted about wound management. Physical examination revealed the periwound area to be warm, erythematous, swollen, and very painful when touched. The patient wanted to go home because it was the pre-Christmas season and likely to be her last. Unfortunately, the wound was infected and resistant to granulation tissue growth (most likely due to overlying biofilm and suppressed proliferative stage secondary to various medications). In the past, the patient had experienced resistance to various antibiotics, which is a common occurrence in patients with frequent hospitalizations. 

It was decided to use Cutimed Sorbact (BSN Medical, Charlotte, NC) hydrophobic antimicrobial dressing in 2 ways. The hydrophobic ribbon was used as packing material (Figure 1A), and Cutimed Siltec (BSN Medical) was used as an atraumatic, antimicrobial secondary dressing (Figure 1B). Dressings, including the packing, were changed on days 2 and 5. By day 5 the pain had subsided; swelling, erythema, and exudate diminished greatly; and granulation was visible (Figure 1C). The wound was packed again, and the patient was sent home. She was seen in an outpatient clinic 5 days later, at which point the pocket was smaller and partially filled in with granulation tissue; in addition, the patient no longer complained of pain.

CASE 2

A 1-day-old neonate was born with congenital ichthyosis, a group of monogenetic disorders of cornification sometimes associated with systemic symptoms. Ichthyosis leads to an abnormal quality or quantity of scaly skin, abnormal thickness of stratum corneum, or abnormal keratinocyte kinetics often associated with skin inflammation. The patient presented with a collodion (a shiny, waxy-appearing outer layer of the skin) membrane, ectropion, eclabium, and visibly tight skin on the upper and lower extremities. Collodion membrane normally sheds 10 to 14 days after birth, causing cracks and deep fissures (Figure 2A) and revealing (once shed) the main symptom of ichthyosis—extensive scaling caused by hyperkeratosis. The goals of care are temperature and humidity control in an isolette until the collodion membrane is shed, gentle skin handling, prevention of infection, prevention of deep skin fissures during membrane desquamation, and adequate nutrition. Emollients (petrolatum) and later keratolytic (retinoid) agents are applied. 

During the first week, the patient’s collodion membrane started desquamating, producing erythematous, fragile skin under the fissures, especially at the joint areas. In hopes to donate moisture, protect from outside friction, and provide antimicrobial protection, hydrogel-impregnated dressing was used to wrap all involved areas (Figure 2B). Given the fragility of the skin, general propensity of ichthyotic skin to bacterial and fungal colonization, young age of the patient, and desire to use a non-toxic dressing with no systemic absorption while providing antimicrobial protection, a hydrophobic nonmedicated antimicrobial dressing capable of binding microorganisms without systemic absorption was chosen. The skin continued to desquamate as the humidity of the isolette was slowly weaned. None of the fissured areas developed infections or progressed to deeper wounds; eventually, all outer scales desquamated (Figure 2C).

CASE 3

A full-term neonate was delivered with congenital amniotic band syndrome resulting in an injury to his right ankle and foot. Amniotic band syndrome can occur when the inner layer of the placenta, called the amnion, is damaged during pregnancy. If this happens, thin strands of tissue (amniotic bands) form inside the amnion. These fiber-like bands tangle around the developing fetus, restrict blood flow, and affect the growth of certain body parts. This can cause congenital deformities of limbs and at times lead to in utero amputation. Due to severe compression by the amniotic bands, the patient sustained circumferential skin, muscle, and bone (tibia and fibula) breaks as well as edematous and abnormally developed foot tissue (Figure 3A). 

The goal was to avoid foot amputation and eventually reconstruct the foot, but this could be done only if the bones healed and distal tissues of the leg and foot remained viable. Hydrophobic antimicrobial dressing was placed as an outer dressing to protect the area and prevent colonization and infection (Figure 3B). The dressing was changed every 3 to 4 days. By the end of 2 weeks, the circumferential injury was filling in, granulation tissue started growing over the muscle, and calluses were forming over the fractured bones. The patient was discharged after 3 weeks with parental instructions to continue the same simple care. After 4 weeks, the wound was healing nicely; after 6 weeks, the foot was reconstructed.

WHAT DO THESE CASES HAVE IN COMMON?

These cases all share a need for an effective yet nontoxic topical antimicrobial dressing. As one of the few choices available for fragile pediatric (and adult) populations, hydrophobic dialkyl carbamoyl chloride (DACC)-coated dressings represent an excellent choice to consider. As 2020 comes to an end and another COVID-19 surge is happening, it benefits practitioners to become more critical as we evaluate evidence, challenge the ways we have always done things, and recognize the importance of nonmaleficence and avoidance of toxic side effects.

Nonmaleficence is defined as non-harming or inflicting the least amount of harm as possible to reach a beneficial outcome.1 Harm and its lingering effects are major components of the ethical decision-making processes in the neonatal intensive care unit. Short-term and long-term harm, although unintentional, often accompany life-saving treatment. When thinking about the most common medications used in clinics and hospitals every day, antibiotics immediately come to mind. Despite life-saving effects, short-term harm is common and includes  side effects such as diarrhea, rashes, and kidney injury among many others. Long-term side effects represent a more elusive concept, but many recognize it clearly as the development of antimicrobial resistance (AMR). In 2019, the World Health Organization reported that 700 000 people died of AMR around the world, with 50 000 in the United States alone.2 If the use of systemic antibiotics continues at its current utilization rate, 10 million people will die of AMR every year by 2050.3,4

AMR is not a stranger in wound care. Many practitioners use systemic antibiotics to treat wounds, contributing significantly to global AMR.5,6 A path to good antimicrobial stewardship is to 1) recognize that many wounds do not require systemic antibiotics, 2) develop better diagnostic tests to differentiate between colonization and infection, 3) understand the advantages of topical antimicrobial care, 4) understand that biofilm is an important determinant of how practitioners treat wounds and that systemic antibiotics are not very effective in biofilm-encapsulated bacteria, and 5) understand the differences and the nuances of the various topical antimicrobial agents. 

All wounds require a systematic approach to healing: debridement, infection prevention or treatment, inflammation suppression, moisture balance, and epithelial edge viability.6 It is the author’s opinion that biofilm-based wound care applies to both chronic and acute wounds. It is known that 90% of chronic wounds have biofilm at the wound surface, but so do 6% to 10% of acute wounds (the naked eye is not a sensitive diagnostician of biofilm); in addition, most wounds are contaminated or colonized by some bacteria.7 Biofilms are complex communities of bacteria that have evolved ways to communicate with each other through water channels and have a protective extracellular polysaccharide matrix covering.8 Through these communication channels, the bacterial colonies are able to upregulate or downregulate transcription of genes and protein products that are beneficial to them and detrimental to the host by a phenomenon called quorum sensing. Biofilm bacteria change from planktonic to biofilm phenotypes, become quiescent or metabolically inactive, and resist antibiotic killing by these mechanisms.9 When bacteria surround their community with extrapolymeric matrix, then inflammation, edema, and erythema occur because the matrix components are pro-inflammatory. Systemic antibiotics do not kill biofilm bacteria successfully because they require metabolically active organisms, many of which are not in the biofilm community.8,9 Many common topical antimicrobials struggle with the biofilm bacteria as they need to be in  contact with the organisms to kill them or need to penetrate the matrix, which can be challenging without proper debridement as well.10 

DO NO HARM

The Hippocratic Oath states, Primum non nocere, which is the Latin translation from the original Greek, “First, do no harm.” This principle is key to the discussion of AMR. 

Most topical antimicrobials kill bacteria. The traditional interpretation of “antimicrobial” is to assume biocidal action; that is, the ability of a chemical to kill bacteria. But what negative effect might the death of bacteria within the wound have on the wound healing cascade? Bacterial death results in the release of endotoxins from within each cell and the dumping of cell debris leading to further inflammatory events, mediated by neutrophils and macrophages.11 While the breakdown of growth factors, production of oxygen radicals, and presence of hypoxemia promote a further inflammatory state, the decrease in fibroblast and epithelial cell proliferation may produce further systemic inflammatory injury, especially in sensitive populations such as neonatal, immunocompromised, acutely ill, and elderly patients. Hydrophobic antimicrobial dressings utilize principles of hydrophobicity to bypass this bacterial killing and work by removing live bacteria without harmful debris release.12

All bacterial microorganisms use principles of hydrophobic interactions to communicate with each other, obtain food, and adhere to surfaces. Once bound to hydrophobic surfaces, bacteria are inactivated and prevented from proliferating or releasing harmful toxins. DACC is a natural fatty acid derivative that possesses hydrophobicity. Bound to a variety of dressing materials, it becomes a scaffold for bacterial attachment.12 Almost immediate attachment to DACC-coated surfaces by fungi, gram-positive organisms, and gram-negative organisms as well as continuous attachment for many days have been reported.12 Even superbugs such as methicillin-resistant S aureus, Pseudomonas, and Klebsiella are inactivated,13–15 while fibroblasts growth is enhanced.16 Pediatric17,18 and adult populations can be treated,19 including wounds of venous or arterial insufficiency, pressure injuries, dehisced surgical wounds, pediatric congenital wounds such as ichthyosis or epidermolysis bullosa, fungal infections, and post-radiation skin breakdown.

Bacterial resistance to various topical antimicrobials (eg, silver, mupirocin, iodine) has developed, but no resistance exists toward hydrophobic dressings.11 This dressing eradiates infection, prevents biofilm formation, and increases the speed of wound closure compared with silver-based dressings, which may slow healing due to their cytotoxicity. Because DACC-coated dressings have no cytoxicity, the author uses them as preventive measures. High-risk incisions can be covered by a hydrophobic outer dressing, or a piece of the hydrophobic ribbon or contact layer can be left on the incision under a secondary dressing. Prevention of skin colonization is ensured, allowing successful incision healing.

CONCLUSION

The author uses hydrophobic antimicrobial dressings in challenging and sensitive populations. By utilizing hydrophobic technology, topical antimicrobial treatment and prevention are provided, antimicrobial resistance potential is minimized, and principles of antimicrobial stewardship are upheld–all while causing no harm. 

All photos provided are with the consent of the patients’ parents. This article was not subject to the Wound Management & Prevention peer-review process.

Affiliation

Dr. Boyar is director of Neonatal Wound Services, Cohen Children’s Medical Center of New York, New Hyde Park, and assistant professor of Pediatrics, Zucker School of Medicine, Hofstra/Northwell, Hempstead, NY.