Time to Abandon Antimicrobial Approaches in Wound Healing

A Paradigm Shift

Jeanette Sams-Dodd, BSc, BScVet; Frank Sams-Dodd, PhD, Dr.med

Disclosures

Wounds. 2018;30(11):345-352. 

In This Article

MPPT and Nonhealing Wounds

Guest et al[58] reported that 48% of the wounds falling within the responsibility of a Clinical Commissioning Group in the United Kingdom (a group responsible for primary care in a certain geographic region) are chronic wounds. This is a very high proportion and raises the question of whether this can be attributed to the treatment approaches used in wound care, which predominantly would be antimicrobial approaches.[59] If this is the case, it is possible that the use of a nonantimicrobial approach could improve the outcome for these wounds.

Micropore particle technology has been used on a number of infected wounds and ulcers that had not responded to a wide range of antimicrobial approaches and a few of these previously unpublished cases are briefly summarized below; MPPT was able to rapidly advance the healing of these wounds in these cases.

Case 1: Chronic Pressure Ulcer

A 74-year-old paraplegic man had developed a category 3 or 4 pressure ulcer on the buttock. Hydrogel, Manuka honey, and Flaminal Forte (Flen Health, Senningerberg, Luxembourg), all in combination with DURAFIBER (Smith & Nephew, London, UK) packing, were used daily over a 9-week period, but no signs of healing were noted. The wound remained nonhealing and slowly deteriorating (ie, expanding). After having developed the ulcer, the patient at one point developed septicemia, which most likely originated from the ulcer. At 9 weeks, the ulcer had an external opening of 2 cm x 1.5 cm, but was deep with 2 sinuses (3 cm and 2.5 cm deep) and undermining (1 cm along the left half of the opening). Micropore particle technology was applied once daily for 3 consecutive days into the ulcer (ie, into the sinuses and covering all surfaces of the undermining). It immediately initiated healing, and from day 0 to day 6, there was > 90% reduction in the volume of the wound; the wound continued towards closure.

Case 2: Chronic Diabetic Foot Ulcer

An 80-year-old woman with type 2 diabetes had a 3-year-old diabetic foot ulcer covering the entire plantar heel with a surface area of about 30 cm2. A wide range of approaches had been attempted to facilitate healing without success. The ulcer was associated with considerable pain in the leg but not in the wound itself, which was without sensation due to diabetic neuropathy. The wound was washed with water and dried, MPPT was applied, and the foot was enclosed in a full cast to offload the heel. The following day, the wound had changed from a dark-red, very dull, lifeless appearance to a red color, normal of healing tissue; clear signs of granulation and epithelialization were present, and the pain level had reduced. This rapid reduction in pain level continued the following 2 days, and on the third day after first application, the pain was gone. This alone led to a huge increase in the patient's state of mind. Four weeks after first application, the ulcer had decreased 55% in surface area, and at 16 weeks after first application, the wound had closed by 85%. Due to the necessity of the full cast, daily application was only achieved the first 3 days, thereafter it was applied twice weekly throughout the treatment period.

Case 3: Venous Stasis Ulcer

A 51-year-old man had developed a venous stasis ulcer of about 7 cm x 4 cm on the foot in the malleolus area. For the first 4 weeks, the ulcer had been managed with plain absorbent dressings without antimicrobials, and the severe pain had been just manageable with co-codamol (30 mg codeine/500 mg paracetamol) every 6 hours; this necessitated the daily use of laxatives. However, an infection developed. The ulcer was dressed with Manuka honey underneath full compression. The pain was reported to be excruciating and not controllable with the permitted maximum daily dose of co-codamol. As the ulcer had not improved after 2 weeks, treatment was changed to an iodine dressing under full compression. The pain level would increase even further, and this forced the removal of the dressing after 3 days (4 days prior to the planned dressing change). The ulcer was left for 6 days dressed with plain absorbent occlusive dressings. The pain reduced to the level of excruciating. As the infection and the pain were still uncontrolled, PHMB dressings under light compression were applied for 10 days, during which time the pain remained unchanged. After 10 days with PHMB, the infection and the pain were still not under control and MPPT was tried. The MPPT was applied on days 0 and 1. Twenty-four hours after first application, the infection had cleared and the pain reduced by half, this measure was based on the need of pain killers being halved. Within the subsequent 24 hours, the pain reduced again to the level that only 1 dose of pain relief was needed in the morning instead of 4 daily doses. Over the next days, the pain continued to reduce steadily, and 3 weeks after the first MPPT application, the patient did not need pain killers. As the infection was gone after the second application, the wound started healing with no further need of treatment. The wound was left with a permeable contact layer dressing, kept in place by stockinette. It was checked, and the described dressing changed after 3 days, then 5, then 7. After that, dressing changes were performed every other week, which then was extended to every 3 weeks. On day 90, the patient was discharged by his physician because they did not consider their supervision necessary. The wound was 2 mm x 3 mm, noninfected, and causing no pain. The ulcer closed fully.

Cases 4 and 5: Biofilm in a Pressure Ulcer and in a Venous Stasis Ulcer

eFigures 5 and 6 show 2 wounds – the first in a horse and latter in a person with venous stasis. Both wounds had a pale, lifeless appearance and had been stagnant for several months despite a number of attempts to promote healing. Twenty-four hours after MPPT application, the surface appearance changed completely, and the wounds started to progress towards healing (additional applications were required to reach closure).

eFigure 5.

Pressure ulcer in a horse. (A) The wound had completely stopped healing for several months and did not respond to a range of topical and systemic antibiotics. Diagnosis by the responsible veterinarian concluded that healing was hindered by biofilm based on the pale, lifeless appearance of the wound surface; and (B) same wound 24 hours later after 1 application of micropore particle technology. The wound surface is much healthier, and the wound healing process has been reinitiated.
Reprinted with permission from Willingsford Ltd, Southampton, United Kingdom.

eFigure 6.

eFigure 6. Venous leg ulcer in a man. (A) Chronic leg ulcer that had stopped healing despite significant efforts and different approaches by the responsible tissue viability nurse. The wound had a lifeless appearance with a surface area of 12.6 cm2; and (B) same wound 24 hours later after application of micropore particle technology (MPPT). The wound surface clearly shows strong granulation tissue together with new epithelium along the wound edges and in the center. The presence of new epithelialization tissue as islets in the wound bed is frequently seen with MPPT. Surface area is 8.1cm2 (a reduction of 36% over 24 hours).
Reprinted with permission from Willingsford Ltd, Southampton, United Kingdom.

While these effects need to be formally evaluated, they are consistent with the notion that MPPT enables the immune system to rapidly regain control of the wound environment.

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