Practice development When a wound is assessed as critically


References


16. Thomas S, Andrews, A,Jones M. The use of larval therapy in wound management. J Wound Care 1998; 7(10): 521–24.


17. Mumcoulgy KY, Ingber A, et al. Maggot therapy for the treatment of intractable wounds. Int J Dermatol 1999; 38(8): 623-7.


18. Dissemond J, Assadian O, Gerber V, et al. Classification of wounds at risk and their antimicrobial treatment with Polyhexanide- A practice-


oriented expert recommendation. Skin Pharmacol Physiol 2011; 24: 245–55.


19. Leaper D. Silver dressings: their role in wound management. Int Wound J 2006; 3(4): 282–94.


20. International Consensus:


Appropriate use of silver in wounds. Wounds Int 2012; Available at:


http://www.woundsinternational. com/clinical-guidelines/ international-consensus-


appropriate-use-of-silver-dressings- in-wounds (accessed 12 September, 2012).


21. Cooper R.A. Iodine revisited. Int Wound J 2007; 4:124–37.


22. Biglari B, v.d. Linden PH, Simon A, Aytac S, Gerner HJ, Moghaddam A.


Use of Medihoney as a non surgical therapy for chronic pressure ulcers in patients with spinal injury. Spinal Cord 2011; 1–5.


23. Cooper RA, Molan PC, Harding


KG. Antibacterial activity of honey against strains of Staphylococcus aureus from infectec wounds. J R Soc Med 1999; 92(6): 283–5.


24. Skinner R, Hampton S. The diabetic foot; managing infections using Cutimed Sorbact dressings. Br J Nurs 2010;10-23;19(11): 30, 32–6.


25. Haycocks S, Schofield H, Chadwick P. Single use negative pressure therapy following surgical


debridement of a diabetic foot ulcer. Poster, Wounds UK, 2011.


colonised or locally infected, dressings containing topical antiseptics should be selected. The selection of such a dressing is dependent on the wound condition, exudate level, adaptability of the dressing to suit the wound, patient comfort, associated pain and the treatment goals for the respective wound and the patient. There is little advice to be obtained from systematic reviews regarding choice of topical antimicrobials, and most practice has to be based on the results of research, which has been performed in vitro. The specificity and efficacy of the agent,


its cytotoxicity to human cells, its potential to select resistant strains and its allergenicity must be considered[1]


include polyhexanide (PHMB)[13, 18] 20]


, iodine[21] and honey[22, 23]


. Modern topical antiseptics , silver[19,


. A product range


with hydrophobic technology, the Cutimed Sorbact® (BSN medical) product series, has been developed, where the microorganisms adhere to the dressing by hydrophobic interaction. These dressings do not contain any antiseptic agent[24]


. Table 4 provides a general overview


of some of the common, generic antimicrobial dressings available. These may have different trade names and are not universally available.


NPWT It is beyond the scope for this paper to review negative pressure wound therapy (NPWT) in critically colonised/infected wounds. However, new techniques and devices have been developed which facilitate effective reduction of wound exudate and bacteria in many types of wounds. Some are also applicable for minor wounds, like PICO® (Smith & Nephew)[25]


,


whereas others, such as V.A.C.Ulta™ (KCI) can be used together with an irrigation solution such as Prontosan. NPWT has become a major treatment option for some infected wounds.


CASE STUDY A 55-year-old man with a normal ankle brachial pressure index and a previous ankle fracture presented with a venous stasis ulcer of one year’s duration. A complete medical history demonstrated no co-morbid conditions or medications that would affect healing. The patient had been self-treating the recurrent ulcer. Compression therapy is the cornerstone of treatment for venous ulcers, therefore, no progress could be made with the patient’s ulcer until compression therapy was initiated. However, the patient-centered concerns had to be addressed first. Since the patient


28 Wounds International Vol 3 | Issue 3 | ©Wounds International 2012


had been treating the ulcer by himself for a year, it was evident that he was reluctant to seek treatment from medical professionals. His psychosocial issues had to be addressed, not the least of which was pain. It became necessary to convince him that if the swelling in his leg reduced, the pain would reduce as well. Every part of treatment had to be fully explained in order to convince him of what needed to be done. There was non-viable tissue in the wound bed,


so the ulcer was debrided with a method that did not increase pain. The size and duration of the ulcer, the friable wound bed and the stalled healing were consistent with localised infection. Maceration was visible, indicating that the wound was highly exudating. The wound was cleansed with a irrigation solution, covered with a PHMB-based foam and compression therapy initiated. The wound closed within eight weeks.


CONCLUSION Selection of antimicrobial/antiseptic dressings should always be based on an assessment of the microbial burden in the wound, the host defence of the patient, the type of wound and the location and condition of the wound. Modern antiseptics for wound management


have proven to be safe and efficient, and should not be confused with old, cytotoxic preparations. Wounds in children, major wounds and some patients´ specific sensitivities to components in the antiseptic require consideration when selecting topical antiseptics. Both the overuse and misuse of topical antiseptics might theoretically lead to development of bacterial resistance against the specific substance in the future, although this is unlikely based on the non-specific action of microorganisms. However, in the face of the global threat of increasing antibiotic resistance and environmental hazards associated with antibiotics, the prevention and treatment of critically colonised/locally infected wounds with topical antiseptics, such as PHMB, povidone iodine, silver, honey and similar products is an attractive option.


AUTHOR DETAILS David Keast MSc, MD, FCFP, Centre Director and


Wound Care Theme Leader, Aging, Rehabilitation and Geriatric Care Research Centre, Lawson Health Research Institute, St. Joseph’s Parkwood Hospital, London, Canada


Christina Lindholm RN, PhD, Senior Professor Sophiahemmet University College/Karolinska University hospital, Sweden


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