Wound Bed Preparation
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Wound bed preparation (WBP) is a systematic approach to wound management by identifying and removing barriers to healing. The concept was originally developed in plastic surgery. It includes
wound assessment Wound assessment is a component of wound care, wound management. As far as may be practical, the assessment is to be accomplished before prescribing any treatment plan. The objective is to collect information about the patient and about the wound, ...
,
debridement Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), or by maggot therapy. In ...
, moisture balance, bacterial balance, and wound cleaning.


Conceptual frameworks


As applied to chronic wounds

During the year 2000, the concept was applied to systematizing the treatment of
chronic wound A chronic wound is a wound A wound is any disruption of or damage to living tissue, such as skin, mucous membranes, or organs. Wounds can either be the sudden result of direct trauma (mechanical, thermal, chemical), or can develop slowly over t ...
s. The 2000 proposals recommended that wound management address the identifiable impediments to healing in order to achieve more successful outcomes. Three publications appeared that year that focused on the concept of managing the
healing With physical trauma or disease suffered by an organism, healing involves the repairing of damaged tissue(s), organs and the biological system as a whole and resumption of (normal) functioning. Medicine includes the process by which the cells ...
processes of a wound
exudate An exudate is a fluid released by an organism through pores or a wound, a process known as exuding or exudation. ''Exudate'' is derived from ''exude'' 'to ooze' from Latin language, Latin 'to (ooze out) sweat' (' 'out' and ' 'to sweat'). Medi ...
, bioburden and devitalized tissue. Initially, emphasis was placed on
debridement Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), or by maggot therapy. In ...
, moisture balance and bacterial balance as the three guiding principles of good wound care, while at the same time recognizing that the provision of care includes a vast array of patient, clinical and environmental variables.


TIME acronym (Tissue, Inflammation and Infection, Moisture, Epithelial)

Since the year 2000, the wound bed preparation concept has continued to improve. For example, the TIME acronym (Tissue management,
Inflammation Inflammation (from ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...
and
infection An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...
control, Moisture balance, Epithelial (edge) advancement) has supported the transition of basic science to the bedside in order to exploit appropriate wound healing interventions and has not deviated from the important tenets of debridement, moisture balance, and bacterial balance. The TIME framework is not a continuum and as such is applicable to a wide range of
wound A wound is any disruption of or damage to living tissue, such as skin, mucous membranes, or organs. Wounds can either be the sudden result of direct trauma (mechanical, thermal, chemical), or can develop slowly over time due to underlying diseas ...
s. The WBP model can be effectively applied only when a high level of precision is utilized in the assessment of the patient and their wound. The
corollary In mathematics and logic, a corollary ( , ) is a theorem of less importance which can be readily deduced from a previous, more notable statement. A corollary could, for instance, be a proposition which is incidentally proved while proving another ...
of this is that intervention demands an equally high level of precision and this should be preceded by a comprehensive wound assessment.


Aspects of wounds and wound care


Wound assessment

Wound assessment Wound assessment is a component of wound care, wound management. As far as may be practical, the assessment is to be accomplished before prescribing any treatment plan. The objective is to collect information about the patient and about the wound, ...
is a vital first step in the precision management process. The purpose of wound assessment is: To identify: *the origin of the wound, *the effects of the wound on the individual, *the effects of the individual on the wound. To determine: *if healing is taking place, *the most appropriate management of the wound. To gather data: *to permit a comparison of wounds and their management. Unfortunately, universal agreement as regards the precise mechanisms of how this should be accomplished is yet to be agreed.


Debridement

Debridement is an essential element of effective
wound care The history of wound care spans from prehistory to modern medicine. Wounds naturally Wound healing, heal by themselves, but hunter-gatherers would have noticed several factors and certain herbalism, herbal remedies would speed up or assist the pro ...
. Although this view is deeply rooted in practice it is nonetheless based on
empirical observation Empirical evidence is evidence obtained through sense experience or experimental procedure. It is of central importance to the sciences and plays a role in various other fields, like epistemology and law. There is no general agreement on how the ...
. Bradley ''et al.'' have stated that it is "unclear whether wound debridement is a beneficial process that expedites healing". Despite this confusing situation, current recommendation favours regular debridement. It is thought that even in an immune compromised patient debridement can assist in establishing a favourable balance of the wound bioburden.


Moisture balance

Establishing a moisture balance beneficial to the wound bed is another prerequisite of care. The natural response to injury is inflammation typified by the local expression of
histamine Histamine is an organic nitrogenous compound involved in local immune responses communication, as well as regulating physiological functions in the gut and acting as a neurotransmitter for the brain, spinal cord, and uterus. Discovered in 19 ...
and
bradykinin Bradykinin (BK) (from Greek ''brady-'' 'slow' + ''-kinin'', ''kīn(eîn)'' 'to move') is a peptide that promotes inflammation. It causes arterioles to dilate (enlarge) via the release of prostacyclin, nitric oxide, and endothelium-derived hyperpo ...
and leading to
vasodilation Vasodilation, also known as vasorelaxation, is the widening of blood vessels. It results from relaxation of smooth muscle cells within the vessel walls, in particular in the large veins, large arteries, and smaller arterioles. Blood vessel wa ...
of the vessels that are in relative close proximity to the site of injury. As
serum Serum may refer to: Biology and pharmacology *Serum (blood), plasma from which the clotting proteins have been removed **Antiserum, blood serum with specific antibodies for passive immunity *Serous fluid, any clear bodily fluid Places *Serum, Ind ...
based fluid moves out of the vessels into the interstitial spaces the resultant soft tissue
oedema Edema (American English), also spelled oedema (British English), and also known as fluid retention, swelling, dropsy and hydropsy, is the build-up of fluid in the body's tissue. Most commonly, the legs or arms are affected. Symptoms may inclu ...
manifests on the wound surface as exudate. In the chronic wound this exudate contains a surfeit of
proteolytic enzyme A protease (also called a peptidase, proteinase, or proteolytic enzyme) is an enzyme that catalyzes proteolysis, breaking down proteins into smaller polypeptides or single amino acids, and spurring the formation of new protein products. They do t ...
s and other components not seen in acute wounds and these compounds have a corrosive effect on the wound bed and surrounding peri-wound skin. The application of dressings, topical negative pressure,
compression garment Compression garments are pieces of clothing that fit tightly around the skin. In medical contexts, compression garments provide support for people who have to stand for long periods or have poor Circulatory system, circulation. These come in va ...
s and leg elevation/exercise have been identified as methods for management of wound exudate.


Bacterial balance

All wounds are considered to harbor
microorganism A microorganism, or microbe, is an organism of microscopic scale, microscopic size, which may exist in its unicellular organism, single-celled form or as a Colony (biology)#Microbial colonies, colony of cells. The possible existence of unseen ...
s. Management of the bacterial balance is of vital importance if delays in healing are to be avoided. The biological removal of micro-organisms, including potential
pathogen In biology, a pathogen (, "suffering", "passion" and , "producer of"), in the oldest and broadest sense, is any organism or agent that can produce disease. A pathogen may also be referred to as an infectious agent, or simply a Germ theory of d ...
s, and tissue debris from the wound of an immune-competent patient is a wound cleansing activity that takes place almost immediately after wounding and which helps to reduce the threat of infection. However, a range of risk factors exist that increase the likelihood of infection intervening, and these include; age, depleted
nutrition Nutrition is the biochemistry, biochemical and physiology, physiological process by which an organism uses food and water to support its life. The intake of these substances provides organisms with nutrients (divided into Macronutrient, macro- ...
, down-regulation of the
immune system The immune system is a network of biological systems that protects an organism from diseases. It detects and responds to a wide variety of pathogens, from viruses to bacteria, as well as Tumor immunology, cancer cells, Parasitic worm, parasitic ...
,
systemic disease A systemic disease is one that affects a number of Organ (anatomy), organs and Tissue (biology), tissues, or affects the Human body, body as a whole. It differs from a localized disease, which is a disease affecting only part of the body (e.g., ...
, and poor tissue perfusion of oxygen. Thus, in the above circumstances or when a wound has become infected, wound cleansing activities beyond the natural biological processes are required so that the wound bioburden is maintained at a level where the host can remain in control.


Biofilms


Biofilm infection

Attaching to a surface is a natural association for bacteria in the wild.
Biofilm A biofilm is a Syntrophy, syntrophic Microbial consortium, community of microorganisms in which cell (biology), cells cell adhesion, stick to each other and often also to a surface. These adherent cells become embedded within a slimy ext ...
phenotype In genetics, the phenotype () is the set of observable characteristics or traits of an organism. The term covers the organism's morphology (physical form and structure), its developmental processes, its biochemical and physiological propert ...
bacteria are microbial communities that are attached to a surface and are embedded in an
extracellular polymeric substance Extracellular polymeric substances (EPS) are biopolymer, natural polymers of molecular mass, high molecular weight secreted by microorganisms into their environment. EPS establish the functional and structural integrity of biofilms, and are consid ...
(EPS) consisting of
protein Proteins are large biomolecules and macromolecules that comprise one or more long chains of amino acid residue (biochemistry), residues. Proteins perform a vast array of functions within organisms, including Enzyme catalysis, catalysing metab ...
s,
glycoprotein Glycoproteins are proteins which contain oligosaccharide (sugar) chains covalently attached to amino acid side-chains. The carbohydrate is attached to the protein in a cotranslational or posttranslational modification. This process is known a ...
s,
nucleic acid Nucleic acids are large biomolecules that are crucial in all cells and viruses. They are composed of nucleotides, which are the monomer components: a pentose, 5-carbon sugar, a phosphate group and a nitrogenous base. The two main classes of nuclei ...
s (
RNA Ribonucleic acid (RNA) is a polymeric molecule that is essential for most biological functions, either by performing the function itself (non-coding RNA) or by forming a template for the production of proteins (messenger RNA). RNA and deoxyrib ...
,
DNA Deoxyribonucleic acid (; DNA) is a polymer composed of two polynucleotide chains that coil around each other to form a double helix. The polymer carries genetic instructions for the development, functioning, growth and reproduction of al ...
) and
polysaccharide Polysaccharides (), or polycarbohydrates, are the most abundant carbohydrates found in food. They are long-chain polymeric carbohydrates composed of monosaccharide units bound together by glycosidic linkages. This carbohydrate can react with wat ...
s (slime). This mantle affords protection from antimicrobial and cellular attack. In contrast, planktonic phenotype bacteria are free-floating in nature and do not possess the defence structures afforded by the creation of the EPS slime. Within the biofilm, a rich biological diversity may be found. The attached (sessile) bacteria release proteases which help to perpetuate a chronic inflammatory state. Therefore, the potential exists for these exogenous proteases to work in tandem with endogenously produced
protease A protease (also called a peptidase, proteinase, or proteolytic enzyme) is an enzyme that catalysis, catalyzes proteolysis, breaking down proteins into smaller polypeptides or single amino acids, and spurring the formation of new protein products ...
s and degrade
growth factor A growth factor is a naturally occurring substance capable of stimulating cell proliferation, wound healing, and occasionally cellular differentiation. Usually it is a secreted protein or a steroid hormone. Growth factors are important for ...
s and tissue proteins that are necessary for the healing process.


Biofilm management

We are developing greater insight into the association between delayed healing and the presence of biofilm. The relationship between delayed healing and the need for debridement is also being acknowledged. It has been suggested that the presence of wound slough provides an indication of biofilm presence, therefore, indicating the need to reduce the wound bioburden. Methods of effectively managing wound biofilms have been reported and include the use of topical agents, systemic antibiotics and regular episodes of debridement. Despite these advances it has been recognised that indiscriminate and widespread use of
antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...
s both inside and outside of medicine is playing a substantial role in the emergence of
bacterial resistance Antimicrobial resistance (AMR or AR) occurs when microbes evolve mechanisms that protect them from antimicrobials, which are drugs used to treat infections. This resistance affects all classes of microbes, including bacteria (antibiotic resista ...
. On a more positive note, antiseptics have been reported to possess a clear cut role in the control of wound bioburden where there are indications or risk of infection.


Wound cleansing and excision

Wound cleansing is a fundamental component of wound care. It consists of the removal of foreign matter, dead (devitalized) tissue and other physical impedimenta to healing, such as ragged edges. Despite the move in the 21st century toward
evidence-based practice Evidence-based practice is the idea that occupational practices ought to be based on scientific evidence. The movement towards evidence-based practices attempts to encourage and, in some instances, require professionals and other decision-makers ...
, the only general consensus that exists here is that cleansing and excision reduce infection rates. The recommendation has been made that cleansing is required when: * excess exudate is delaying healing, * infected exudate is present, * there is contamination by a
foreign body A foreign body (FB) is any object originating outside the body of an organism. In machinery, it can mean any unwanted intruding object. Most references to foreign bodies involve propulsion through natural orifices into hollow organs. Foreign b ...
including dirt and bacteria * revitalised tissue (
slough Slough () is a town in Berkshire, England, in the Thames Valley, west of central London and north-east of Reading, at the intersection of the M4, M40 and M25 motorways. It is part of the historic county of Buckinghamshire. In 2021, the ...
and
necrosis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. The term "necrosis" came about in the mid-19th century and is commonly attributed to German pathologist Rudolf Virchow, who i ...
) is present. Wound cleansing is often undertaken as a ritual exercise rather than as an evidence-based activity. However, it has a role to play in all four domains of the WBP model. Wounds that are 'clean' and progressing do not require extraneous cleansing.


Criteria for a cleansing agent

Wound cleansing forms an integral part of wound management and generally suggests the application of a
fluid In physics, a fluid is a liquid, gas, or other material that may continuously motion, move and Deformation (physics), deform (''flow'') under an applied shear stress, or external force. They have zero shear modulus, or, in simpler terms, are M ...
to aid the removal of surface
contaminant Contamination is the presence of a constituent, impurity, or some other undesirable element that renders something unsuitable, unfit or harmful for the physical body, natural environment, wiktionary:Workplace, workplace, etc. Types of contamina ...
s, bacteria, and debris from the wound surface and surrounding skin. Water as a cleansing agent, especially in chronic wounds has been proposed and is widely used especially in the management of infected wounds. Despite the plethora of work focussing on the value of
water Water is an inorganic compound with the chemical formula . It is a transparent, tasteless, odorless, and Color of water, nearly colorless chemical substance. It is the main constituent of Earth's hydrosphere and the fluids of all known liv ...
/
saline Saline may refer to: Salt-related * Saline (medicine), a liquid with salt content to match the human body * Saline water, non-medicinal salt water * Saline, a historical term (especially American) for a salt works or saltern Places United States ...
in wound cleansing there is no current consensus as to whether water has an active role to play in the promotion of healing. With this unclear position in mind, alternative cleansing agents such as
antiseptic An antiseptic ( and ) is an antimicrobial substance or compound that is applied to living tissue to reduce the possibility of sepsis, infection, or putrefaction. Antiseptics are generally distinguished from ''antibiotics'' by the latter's abil ...
s that possess the potential to improve clinical outcomes should be considered. The use of antiseptics on open wounds is justified in terms of prevention/treatment of infection and improved healing outcomes. Criteria by which a wound cleansing agent could be deemed suitable for use on wounds include: * non-toxic to mammalian cells * broad spectrum in action * reduction of wound bioburden * maintaining optimal moist wound environment * easy to apply * manages wound
pain Pain is a distressing feeling often caused by intense or damaging Stimulus (physiology), stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sense, sensory and emotional experience associated with, or res ...
and malodor * does not cause pain on application * compatible with a variety of available wound dressings There is a scant evidential provision in respect of guidance as to the optimal wound cleanser. In general, recommendations for practice are based on consensus opinion often derived from clinical experience and
in vitro ''In vitro'' (meaning ''in glass'', or ''in the glass'') Research, studies are performed with Cell (biology), cells or biological molecules outside their normal biological context. Colloquially called "test-tube experiments", these studies in ...
and/or
in vivo Studies that are ''in vivo'' (Latin for "within the living"; often not italicized in English) are those in which the effects of various biological entities are tested on whole, living organisms or cells, usually animals, including humans, an ...
studies.


Specific agents


Polyhexamethylene biguanide (polyhexanide, PHMB)

Polyhexamethylene biguanide hydrochloride is a fast-acting, broad-spectrum synthetic compound that binds to the
cell envelope The cell envelope comprises the inner cell membrane and the cell wall of a bacterium. In Gram-negative bacteria an bacterial outer membrane, outer membrane is also included. This envelope is not present in the Mollicutes where the cell wall is abse ...
of both
Gram-positive In bacteriology, gram-positive bacteria are bacteria that give a positive result in the Gram stain test, which is traditionally used to quickly classify bacteria into two broad categories according to their type of cell wall. The Gram stain is ...
and
Gram-negative bacteria Gram-negative bacteria are bacteria that, unlike gram-positive bacteria, do not retain the Crystal violet, crystal violet stain used in the Gram staining method of bacterial differentiation. Their defining characteristic is that their cell envelo ...
, disrupting the bacterial
cell membrane The cell membrane (also known as the plasma membrane or cytoplasmic membrane, and historically referred to as the plasmalemma) is a biological membrane that separates and protects the interior of a cell from the outside environment (the extr ...
and enabling seepage of ions. PHMB has a long history of use as a
contact lens Contact lenses, or simply contacts, are thin lenses placed directly on the surface of the eyes. Contact lenses are ocular prosthetic devices used by over 150 million people worldwide, and they can be worn to correct vision or for cosmetic ...
cleanser,
mouthwash Mouthwash, mouth rinse, oral rinse, or mouth bath is a liquid which is held in the mouth passively or swirled around the mouth by contraction of the perioral muscles and/or movement of the head, and may be gargled, where the head is tilted back ...
and more recently in wound care. It is regarded as being quite safe to use as it has been incorporated as a
preservative A preservative is a substance or a chemical that is added to products such as food products, beverages, pharmaceutical drugs, paints, biological samples, cosmetics, wood, and many other products to prevent decomposition by microbial growth or ...
in
cosmetics Cosmetics are substances that are intended for application to the body for cleansing, beautifying, promoting attractiveness, or altering appearance. They are mixtures of chemical compounds derived from either Natural product, natural source ...
. A retrospective analysis of wound cleanser clinical efficacy and cost-effectiveness focused on polyhexamethylene biguanide solution,
Ringer's solution Ringer's solution is a solution of several salts dissolved in water for the purpose of creating an isotonic solutions, isotonic solution relative to the body fluids of an animal. Ringer's solution typically contains sodium chloride, potassium chlo ...
or saline in 112
venous leg ulcer Venous ulcer is defined by the American Venous Forum as "a full-thickness defect of skin, most frequently in the ankle region, that fails to heal spontaneously and is sustained by chronic venous disease, based on venous duplex ultrasound testing. ...
patients. The study group received the polyhexamethylene biguanide solution (n=59) and the control group received either
Ringer's solution Ringer's solution is a solution of several salts dissolved in water for the purpose of creating an isotonic solutions, isotonic solution relative to the body fluids of an animal. Ringer's solution typically contains sodium chloride, potassium chlo ...
or saline (n=53). In both arms,
ulcer An ulcer is a discontinuity or break in a bodily membrane that impedes normal function of the affected organ. According to Robbins's pathology, "ulcer is the breach of the continuity of skin, epithelium or mucous membrane caused by sloughin ...
healing patterns were evaluated. Within the first 3 months of treatment, a shorter
time Time is the continuous progression of existence that occurs in an apparently irreversible process, irreversible succession from the past, through the present, and into the future. It is a component quantity of various measurements used to sequ ...
to healing was recorded in the study group when compared with the
control group In the design of experiments, hypotheses are applied to experimental units in a treatment group. In comparative experiments, members of a control group receive a standard treatment, a placebo, or no treatment at all. There may be more than one tr ...
- 60% v. 28% with corresponding
mean A mean is a quantity representing the "center" of a collection of numbers and is intermediate to the extreme values of the set of numbers. There are several kinds of means (or "measures of central tendency") in mathematics, especially in statist ...
time Time is the continuous progression of existence that occurs in an apparently irreversible process, irreversible succession from the past, through the present, and into the future. It is a component quantity of various measurements used to sequ ...
to healing being 3.31 months (study group) compared to 4.42 months (control group) p= <0.0001. More patients in the polyhexamethylene biguanide group healed in the 6-month period when compared with the controls - 97% v. 89%. The authors concluded that optimization of the local wound environment was significantly influenced through cleansing with polyhexanide solution. In an in vitro model developed to compare the efficiency of wound-rinsing solutions, Kaehn ''et al.'' compared four sterile wound-cleansing solutions (saline,
Ringer's solution Ringer's solution is a solution of several salts dissolved in water for the purpose of creating an isotonic solutions, isotonic solution relative to the body fluids of an animal. Ringer's solution typically contains sodium chloride, potassium chlo ...
, Prontosan® and Octenisept®) using a wound coating model consisting of slides containing dried
blood plasma Blood plasma is a light Amber (color), amber-colored liquid component of blood in which blood cells are absent, but which contains Blood protein, proteins and other constituents of whole blood in Suspension (chemistry), suspension. It makes up ...
or
fibrin Fibrin (also called Factor Ia) is a fibrous protein, fibrous, non-globular protein involved in the Coagulation, clotting of blood. It is formed by the action of the protease thrombin on fibrinogen, which causes it to polymerization, polymerize. ...
. The concentration of dissolved proteins was measured and the findings indicate that a surfactant containing solution (polyhexamethylene biguanide with
betaine A betaine () in chemistry is any neutral chemical compound with a positively charged cationic functional group that bears no hydrogen atom, such as a Quaternary ammonium cation, quaternary ammonium or phosphonium cation (generally: Onium compou ...
) (Prontosan®) was more effective than
saline Saline may refer to: Salt-related * Saline (medicine), a liquid with salt content to match the human body * Saline water, non-medicinal salt water * Saline, a historical term (especially American) for a salt works or saltern Places United States ...
in removing the
protein Proteins are large biomolecules and macromolecules that comprise one or more long chains of amino acid residue (biochemistry), residues. Proteins perform a vast array of functions within organisms, including Enzyme catalysis, catalysing metab ...
(adhered dried plasma or fibrin). The proteins in the
antiseptic An antiseptic ( and ) is an antimicrobial substance or compound that is applied to living tissue to reduce the possibility of sepsis, infection, or putrefaction. Antiseptics are generally distinguished from ''antibiotics'' by the latter's abil ...
solution (Octenisept®) were denatured and became insoluble. The authors suggest this implies that the antiseptic solution is unsuitable as a 'general' wound cleanser and that its use should be restricted to infected wounds. In a double-blind, randomised, stratified, controlled, parallel-group study the influence of two antiseptics (
octenidine Octenidine dihydrochloride is a cationic surfactant, with a gemini-surfactant structure, derived from 4-aminopyridine. It is active against Gram-positive and Gram-negative bacteria. Since 1987, it has been used primarily in Europe as an antisept ...
, polyhexanide) versus a
placebo A placebo ( ) can be roughly defined as a sham medical treatment. Common placebos include inert tablets (like sugar pills), inert injections (like saline), sham surgery, and other procedures. Placebos are used in randomized clinical trials ...
of Ringer's solution on wound healing in a porcine model was conducted. Assessment of healing was recorded using
planimetry Euclidean geometry is a mathematical system attributed to ancient Greek mathematics, Greek mathematician Euclid, which he described in his textbook on geometry, ''Euclid's Elements, Elements''. Euclid's approach consists in assuming a small set ...
and
histopathology Histopathology (compound of three Greek words: 'tissue', 'suffering', and '' -logia'' 'study of') is the microscopic examination of tissue in order to study the manifestations of disease. Specifically, in clinical medicine, histopatholog ...
. At nine days post wounding, the octenidine-treated wounds demonstrated retarded contraction at significantly greater extent than
placebo A placebo ( ) can be roughly defined as a sham medical treatment. Common placebos include inert tablets (like sugar pills), inert injections (like saline), sham surgery, and other procedures. Placebos are used in randomized clinical trials ...
and polyhexanide. At days 18 and 28 the polyhexanide treated wounds supported contraction significantly more than
placebo A placebo ( ) can be roughly defined as a sham medical treatment. Common placebos include inert tablets (like sugar pills), inert injections (like saline), sham surgery, and other procedures. Placebos are used in randomized clinical trials ...
and
octenidine Octenidine dihydrochloride is a cationic surfactant, with a gemini-surfactant structure, derived from 4-aminopyridine. It is active against Gram-positive and Gram-negative bacteria. Since 1987, it has been used primarily in Europe as an antisept ...
. The polyhexanide treated wounds led to complete wound closure after 22.9 days, in comparison to the placebo octenidine treated wounds respectively, 24.1 days (p < 0.05) and 28.3 days (no statistical difference to
placebo A placebo ( ) can be roughly defined as a sham medical treatment. Common placebos include inert tablets (like sugar pills), inert injections (like saline), sham surgery, and other procedures. Placebos are used in randomized clinical trials ...
).


Prontosan

Prontosan (B Braun) Wound Irrigation Solution and Prontosan Wound Gel are proprietary preparations of PHMB with
betaine A betaine () in chemistry is any neutral chemical compound with a positively charged cationic functional group that bears no hydrogen atom, such as a Quaternary ammonium cation, quaternary ammonium or phosphonium cation (generally: Onium compou ...
, an
alkaloid Alkaloids are a broad class of natural product, naturally occurring organic compounds that contain at least one nitrogen atom. Some synthetic compounds of similar structure may also be termed alkaloids. Alkaloids are produced by a large varie ...
surfactant Surfactants are chemical compounds that decrease the surface tension or interfacial tension between two liquids, a liquid and a gas, or a liquid and a solid. The word ''surfactant'' is a Blend word, blend of "surface-active agent", coined in ...
. Surfactants lower the surface tension of the fluid medium making it easier to infiltrate wound coatings, debris and bacteria. Both the wound irrigation solution and the wound gel are colorless cleansing agents that are indicated for use in acute and chronic wounds. They also have the potential to be used in conjunction with a range of dressing materials which include occlusive dressings. In vitro studies on clinical isolates of
E. coli ''Escherichia coli'' ( )Wells, J. C. (2000) Longman Pronunciation Dictionary. Harlow ngland Pearson Education Ltd. is a gram-negative, facultative anaerobic, rod-shaped, coliform bacterium of the genus ''Escherichia'' that is commonly foun ...
and S. epidermidis have demonstrated the anti-biofilm efficacy of PHMB. The activity of five
biocide A biocide is defined in the European legislation as a chemical substance or microorganism intended to destroy, deter, render harmless, or exert a controlling effect on any harmful organism. The US Environmental Protection Agency (EPA) uses a sli ...
s at various concentrations was recorded following exposure to the isolates. The biocides found to be most active towards planktonic (free floating) cells were PHMB and
peracetic acid Peracetic acid (also known as peroxyacetic acid, or Percidine) is an organic compound with the formula CH3CO3H. This peroxy acid is a colorless liquid with a characteristic acrid odor reminiscent of acetic acid. It can be highly corrosive. Perac ...
. A corresponding level of activity towards biofilm phenotype bacteria was also found with the two agents. Prontosan's activity on
MRSA Methicillin-resistant ''Staphylococcus aureus'' (MRSA) is a group of gram-positive bacteria that are genetically distinct from other strains of ''Staphylococcus aureus''. MRSA is responsible for several difficult-to-treat infections in humans. ...
biofilms has been investigated using an in vivo porcine wound model. Prontosan activity was compared with Ringer's solution, saline, and untreated control. A comparative reduction in MRSA at 48 and 72 hours in the Prontosan-treated group was found to be statistically significant compared to the other groups (p-value <0.05). The study results indicated that extended
irrigation Irrigation (also referred to as watering of plants) is the practice of applying controlled amounts of water to land to help grow crops, landscape plants, and lawns. Irrigation has been a key aspect of agriculture for over 5,000 years and has bee ...
with Prontosan may provide additional reduction in wound bioburden as the largest reduction of MRSA was found from 48 to 72 hours. A clinical evaluation of Prontosan wound cleanser was undertaken with ten community care patients where saline had been used for at least one month previously on wounds that had a mean duration of 2.6 years. The findings include; an overall reduction in wound size, a reduction in malodour, reduction or elimination of wound pain. These results correlate well with the patients' reports of improvement in
quality of life Quality of life (QOL) is defined by the World Health Organization as "an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards ...
and a reduction in the number of nursing visits. In addition, the wound cleansing effects of Prontosan with achieving a visible wound bed was reported by the author and linked to the removal of wound biofilm. Although this association is speculative it does appear to correspond with the other reported improvements found in these wounds.


Conclusions

Wound bed preparation is an accepted strategy that facilitates wound management interventions. Management of wound exudate, bioburden and debridement are all associated with effective wound cleansing and are thus integral components of effectual wound bed preparation. Choice of cleansing solution should consider not only the piecemeal wound requirements but also the patient and be reinforced by a sound knowledge/experience base. This knowledge should include insight into bacterial phenotype 'behavior' and the most appropriate methods of management. Current findings indicate that PHMB in conjunction with a surfactant (betaine) is superior to Ringer's solution and saline when used as wound cleansers and also appears to demonstrate efficacy when used in wounds where biofilms are suspected or present.


References

{{Reflist Medical treatments