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Antiseptic Stewardship for Wound and Mucosal Antiseptics
Abstract
Wound and mucosal antiseptics can be based on chlorhexidine digluconate, polyhexanide, hydrogen peroxide, sodium hypochlorite, povidone iodine or octenidine dihydrochloride. Silver can also be used as an antimicrobial agent in wound treatment, for example, in wound dressings. A health benefit can be expected at least in patients with infected or critically colonised wounds. Povidone iodine has been shown to have a low adaptive response, an inconsistent effect on biofilm formation and a moderate or strong removal of existing biofilm. Sodium hypochlorite and hydrogen peroxide also showed a low adaptive response, but may enhance biofilm formation and have mostly a moderate ability to remove biofilm. Limited data with octenidine dihydrochloride shows an inconsistent picture. Polyhexanide can show a strong adaptive response, mainly in Gram-positive species. Its ability to remove biofilm is mostly moderate. Chlorhexidine digluconate and silver can both often show a strong adaptive response, mainly in Gram-negative species. Silver can moderately inhibit biofilm formation, whereas the effect of chlorhexidine digluconate is lower. For biofilm removal, silver usually has a moderate effect, whereas the effect of chlorhexidine digluconate is usually poor or moderate. Overall, povidone iodine seems to have the lowest selection pressure and chlorhexidine digluconate the highest.
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Wound antisepsis has undergone a renaissance due to the introduction of highly effective wound-compatible antimicrobial agents and the spread of multidrug-resistant organisms (MDROs). However, a strict indication must be set for the application of these agents. An infected or critically colonized wound must be treated antiseptically. In addition, systemic antibiotic therapy is required in case the infection spreads. If applied preventively, the Wounds-at-Risk Score allows an assessment of the risk for infection and thus appropriateness of the indication. The content of this updated consensus recommendation still largely consists of discussing properties of octenidine dihydrochloride (OCT), polihexanide, and iodophores. The evaluations of hypochlorite, taurolidine, and silver ions have been updated. For critically colonized and infected chronic wounds as well as for burns, polihexanide is classified as the active agent of choice. The combination 0.1% OCT/phenoxyethanol (PE) solution is suitable for acute, contaminated, and traumatic wounds, including MRSA-colonized wounds due to its deep action. For chronic wounds, preparations with 0.05% OCT are preferable. For bite, stab/puncture, and gunshot wounds, polyvinylpyrrolidone (PVP)-iodine is the first choice, while polihexanide and hypochlorite are superior to PVP-iodine for the treatment of contaminated acute and chronic wounds. For the decolonization of wounds colonized or infected with MDROs, the combination of OCT/PE is preferred. For peritoneal rinsing or rinsing of other cavities with a lack of drainage potential as well as the risk of central nervous system exposure, hypochlorite is the superior active agent. Silver-sulfadiazine is classified as dispensable, while dyes, organic mercury compounds, and hydrogen peroxide alone are classified as obsolete. As promising prospects, acetic acid, the combination of negative pressure wound therapy with the instillation of antiseptics (NPWTi), and cold atmospheric plasma are also subjects of this assessment.
The global push to combat the problem of antimicrobial resistance has led to the development of antimicrobial stewardship programs (ASPs), which were recently mandated by The Joint Commission and the Centers for Medicare and Medicaid Services. However, the use of topical antibiotics in the open surgical wound is often not monitored by these programs nor is it subject to any evidence-based standardization of care. Survey results indicate that the practice of using topical antibiotics intraoperatively, in both irrigation fluids and powders, is widespread. Given the risks inherent in their use and the lack of evidence supporting it, the practice should be monitored as a core part of ASPs, and alternative agents, such as antiseptics, should be considered.
Objectives
In this review and meta-analysis, we analyse the evidence to compare the efficacy of honey and povidone iodine-based dressings on the outcome of wound healing.
Method
A systematic literature search was performed using PRISMA guidelines in academic databases including MEDLINE, Scopus, Embase and CENTRAL. A meta-analysis was carried out to assess the effect of honey and povidone iodine-based dressings on mean healing duration, mean hospital stay duration and visual analogue scale (VAS) score of pain.
Results
From the search, 12 manuscripts with a total of 1236 participants (mean age: 40.7±11.7 years) were included. The honey-based dressings demonstrated a medium-to-large effect in reduction of mean healing duration (Hedge's g: –0.81), length of hospital stay (–3.1) and VAS score (–1.2) as compared with the povidone iodine-based dressings. We present evidence (level 1b) in favour of using honey for improvement of wound recovery as compared with povidone iodine.
Conclusion
This review and meta-analysis demonstrate beneficial effects of honey-based dressings over povidone iodine-based dressings for wound recovery.
The empiric use of antibiotics is being restricted due to the spread of antimicrobial resistance. However, topical antiseptics are less likely to induce resistance, owing to their unspecific mode of action and the high concentrations in which they can be used. One such antiseptic, octenidine dihydrochloride (OCT), can be used either prophylactically or therapeutically on the skin, mucosa and wounds. Evidence to support its use comes from in-vitro, animal and clinical studies on its safety, tolerability and efficacy. This article summarises the physical, chemical and antimicrobial properties of OCT in the context of wound care.
Honey has been widely accepted as food and medicine by all generations, traditions, and civilizations, both ancient and modern. For at least 2700 years, honey has been used by humans to treat a variety of ailments through topical application, but only recently have the antiseptic and antimicrobial properties of honey been discovered. Honey has been reported to be effective in a number of human pathologies. Clinical studies have demonstrated that application of honey to severely infected cutaneous wounds rapidly clears infection from the wound and improves tissue healing. A large number of in vitro and limited clinical studies have confirmed the broad-spectrum antimicrobial (antibacterial, antifungal, antiviral, and antimycobacterial) properties of honey, which may be attributed to the acidity (low pH), osmotic effect, high sugar concentration, presence of bacteriostatic and bactericidal factors (hydrogen peroxide, antioxidants, lysozyme, polyphenols, phenolic acids, flavonoids, methylglyoxal, and bee peptides), and increase in cytokine release, and to immune modulating and anti-inflammatory properties of honey; the antimicrobial action involves several mechanisms. Despite a large amount of data confirming the antimicrobial activity of honey, there are no studies that support the systemic use of honey as an antibacterial agent.
Colonization and infection of wounds represent a major reason for the impairment of tissue repair. Recently, it has been reported that tissue-tolerable plasma (TTP) is highly efficient in the reduction of the bacterial load of the skin. In the present study, the antiseptic efficacy of TTP was compared to that of octenidine hydrochloride with 2-phenoxyethanol. Both antiseptic methods proved to be highly efficient. Cutaneous treatment of the skin with octenidine hydrochloride and 2-phenoxyethanol leads to a 99% elimination of the bacteria, and 74% elimination is achieved by TTP treatment. Technical challenges with an early prototype TTP device could be held responsible for the slightly reduced antiseptic properties of TTP, compared to a standard antiseptic solution, since the manual treatment of the skin surface with a small beam of the TTP device might have led to an incomplete coverage of the treated area.
Should antimicrobial dressings be classified according to their activity and be subject to stewardship like antibiotics?
- E Nichols
- J Tickle
- P Spruce
- S Westgate
Prävention postoperativer Wundinfektionen