Warren S Joseph, DPM, FIDSA identifies the process in distinguishing infected from non infected wounds. Dr Joseph discusses the different treatments available for wound healing and explains the need to critically examine the literature available regarding these treatments.
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Release Date: 03/16/2018 Expiration Date: 12/31/2018
Warren Joseph, DPM
Roxborough Memorial Hospital
Editor - Journal of the APMA
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Warren Joseph Warren S Joseph, DPM, FIDSA has disclosed that he receives Honorarium/Expenses, is a Consultant to and serves on the Speaker's Bureau for Pfizer and Merck.
Male Speaker: On wounds. Alright, time to change gears a little bit. Differentiating infected from noninfected wounds, how do you diagnose infection? If I had a lot of time, we were sitting around at a dinner meeting or something, I would ask you that question and ask you to give me the wrong answer. Because invariably, one of you is going to give me the wrong answer and say, “You take a culture.” No, you don’t take a culture, that’s not how you diagnose wound infection. Wound infection is a clinical diagnosis. You diagnose infection with your eyes, with your ears, with your hands, with your nose. You don’t need your mouth, that would be a little gross, okay? But everything else up to that point. We said this in our IDSA guidelines in 2004. We said it again in 2012. The evidence shows this and our opinion has not changed. Some people will say that delayed wound healing may be a sign of wound infection. These are the so-called secondary signs of infection. The primary signs are those signs of Celsus, erythema, warmth, tenderness, induration, that sort of thing, rubor, tumor, dolor, calor, functio laesa, loss of function. The wound healing people will tell you there are secondary signs, things such as delayed wound healing, changes in the granulation tissue, if you have pale, friable granulation tissue that’s edematous looking. It’s not your good, healthy, red granulation tissue. They say that might be a sign of infection. I think it may suggest that there’s something going on, but to me, I’m still almost always going to go with those principle signs, the redness, heat, swelling pain and loss of function. A lot of people in the wound care will talk about this so-called wound infection continuum. Some of you, if you’ve worked in wound care centers, you’re familiar with that. You talk about contamination, colonization, critical colonization and then infection. I don’t know how many of you are familiar with these. This is all over the wound care literature. They talk about this. The problem is, there’s not a lot of basis in science for any of it. And notice, almost everything I say here does have references to it but it doesn’t mean it’s good high level evidence. And this is just a cartoon that shows the difference, contamination, the organisms are just sitting there, colonization, you’ve got a couple of more organisms that are now replicating. Alright. Critical colonization, you not only got replication but you’ve got some local damage, and then infection where not only do you have the replication but you have more significant damage. What’s the key phase here? It’s critical colonization. By the way, that whole 10 to the fifth bacteria thing, don’t get it, don’t buy into it. How many of your hospitals want you to do quantitative bacteriology? How many of you have ever done punch biopsies to find 10 to the fifth organisms? No. Sorry. You see, although that’s the gold standard, no one uses it, don’t worry about it. Alright. Critical colonization is the pivotal phase in the wound healing continuum. Now, its definition, bacteria is replicating and possibly causing some damage but without an over host response. But once the patient is in a critically colonized state, it can go one of three ways. It can deteriorate to a clinical infection, it can remain in a critically colonized state, or can improve following appropriate intervention and go back to colonization or contamination. Well, the problem with this is the recommendations for the treatment of critical colonization are all low level. There’s no good evidence to support colonization or critical colonization and how to do it. It may not always be associated with overt signs of infection. The diagnosis, again, is usually should be based on a clinical science. But this is a direct quote from this paper in 2005, more research into assessment and treatment of skin ulcer infection is needed, because there’s not a lot of good evidence. Nobody seems to know what we’re doing with wound infections. Health is not a germ-free state. You can’t sterilize a wound. The only way you sterilize a wound, anybody know how to do that? Healing. Alright. It’s the only way you’re going to get a wound sterile. It doesn’t mean because bacteria are there that they’re necessarily a bad thing. But you hear nowadays, the big buzzword nowadays and wounds never really stable, organisms tend to change overtime. The big buzzword nowadays is biofilms. You’re all familiar with the term biofilms. And in fact, if you read the wound healing literature, they talk about the concept of biofilm-based therapies. Biofilm-based therapies. The whole idea is that these organisms -- and don’t get me wrong, it’s really cool. I posted on my blog a couple of things about quorum sensing and biofilms.
The whole concept of quorum sensing is really neat. What it is, is the bacteria getting cased into this polyglycolic slime which then sits on top of a wound. Well, once in these colonies sitting on top of the wound encased in the slime level, the bacteria are actually able to communicate. They can actually talk to each other. And this ability to communicate is what we call quorum sensing. It’s really close. It’s a relatively new concept. It’s only been out there for about four or five years. And they have found through sending chemical signals, the bacteria could say, “It’s time to get quiet, it’s time to go to sleep”, or, “It’s time to wake up and it’s time to be infectious.” Everybody wants to treat biofilms. But we don’t even have any evidence that biofilms make a difference. Just because bacteria are on a wound isn’t necessarily bad. The first VAC study that was ever done by KCI, what they actually found is that when they look at the VAC versus just plain gauze, fine gauze, mesh dressings, okay, they found that the VAC patients healed more rapidly than the gauze dressings. But they also found that the bacterial load was higher under the VAC foam than under the plain dressings. So it did with a higher bioburden, wounds still heal. They did a followup study to that, it was published relatively recently in the last two years in wounds where did they it in animal trial, I think it was on pigs and they used the VAC, they used the silver foam VAC so silver impregnated, and they used fine mesh gauze. And sure enough, they found fine mesh gauze didn’t heal and had a very low bioburden. There was no difference in healing rates between the silver foam and the regular VAC foam but the bioburden was less under the silver but it made no difference. Despite increased numbers of bacteria, wounds still can heal. And you see the references here. I’m not making this up. So often in lectures, you see people go, “This is my opinion, this is what I do. This is how you should do it.” No, everything I’m going to tell you, we back up, I try to back up with evidence. That’s this art of medicine nowadays. If you see a lecture and they don’t have a single reference, start questioning the lecture, alright? You need to have references. So, what may be more important is which organisms are there? Biofilms, we talked about it. I’m not sold that they play that much of a role. There are people out there in the wound world who just go on and on about biofilms. A lot of them have commercial interests in biofilm breaking up companies so you have to read the literature. I mean, there’s one person in particular, an MD who’s very big in the biofilm world. He’s the nicest guy in the world. I’ve lectured with him countless times. And what happens is when you read his literature, always talking about biofilm, biofilm, biofilm, then you realize, he has an interest in different laboratories in different companies that detect and treat biofilms so be very cautious when you read it. He discloses it. It’s cool. But when you’re reading the literature that I want you to read, not just listen to some pod God preaching to you, what I want you to do is read it critically. So not just look at the literature, look at the literature critically. It doesn’t mean because somebody has a conflict of interest, something is bad. This is, by the way, preaching. This isn’t talking science to you, but I have a bully pulpit now so I’m going to. You’re young, you’re impressionable, what the heck. Get to them while they’re young, you know, start doing it now. How many of you have bookmarked on your computer, PubMed? That’s pretty pathetic. You’re all familiar with PubMed.gov, it’s MEDLINE. It’s how you do MEDLINE searches. How many of you have bookmarked on your computer, the Cochrane Collaborative, the cochrane.org. They do systematic reviews of the literature on every topic in medicine to say whether or not there’s evidence to back it up. These are organizations. These are websites you need to be familiar with, to critically review the literature. Do we need to remove biofilm? Who knows? How are you going to do it? You can use cold steel. You can use ultrasound either contact or non-contact. And there are various chemicals you can use, surfactants, enzymes, and some of the chlorinated water solutions. What about antimicrobial use in wounds? The routine use of systemic antibiotics is not necessary in clinically noninfected wounds and is not supported by the evidence. What about topicals? The next time a company comes to you and says, “Doc, we’ve got the best silver dressing or a foam dressing or antimicrobial solution.”
Ask three questions. Question number one, does your antimicrobial topical solution/dressing decrease bioburden? You’d be amazed how few even have that answer. Question number two, by reducing the bioburden, can you heal the wound more quickly? You think you should be able to, right, but I showed you evidence, that’s not true. But you would think a company selling you a dressing that decreases bioburden should heal the wound more quickly. Otherwise, why use it? Well, maybe you should use it for the third question, will reduction in the biofilm prevent a noninfected wound from becoming clinically infected? Larry Lavery showed 50% of all diabetic foot wounds during their lifecycle will become clinically infected requiring systemic antibiotics. By using a topical antimicrobial, can we reduce that 50% to 40%, or 30%, or even 20%? You’d be amazed how few of these questions have been answered and that is because these products are not drugs. They have device or 5109(k) clearances, they don’t have the same requirements through the FDA to prove they work. Silver, everybody and their mother uses silver, alright? Let’s just go to silver dressings. How many people in this room use silver dressings? Yeah, okay, all of you. Alright. We know silvers are potent broad spectrum antimicrobial. You know why silver was originally put in wounds? Not to decrease bioburden in the wound, but to make it so the nurses didn’t have to change the dressings as often. Because the schmutz would get up in the wound and the wound would start -- the dressing, excuse me, from the wound up to the dressing, the dressing would start smelling. By putting silver into dressing, you decrease the smell because you killed the bacteria in the dressing. Had nothing to do with decreasing the bacteria on the wound. Now, everybody and their mother has silver dressings, alright. And it’s considered to be the gold standard dressing based on, what? Well, the Cochrane organization did a review of silver dressings. They found there are only three randomized controlled trials in the entire world literature on the use of silver dressings. And what they found is just the schematic from the Cochrane review done in 2009. What they found is that silver do not increase complete healing. There was a greater reduction in size not only with silver, leakage occurred less frequently in silver but there was no difference in the use of antibiotics, pain, patient satisfaction or length of stay. One of my favorite web post of all times, go back on my blog, was called the VULCAN study, it’s only logical. VULCAN, logic, that’s pop culture reference, Star Trek. Anyway, what happened in that study? It was a large venous ulcer leg study done out of the UK and they used standard venous therapy versus silver therapy. And you know what they found? The only difference between the silver and the standard therapy was it cost 10 times more to use the silver than standard therapy. Otherwise there was no difference in healing rates. So, Cochrane came out and said there’s insufficient evidence to recommend the use of silver containing dressings yet everybody here uses them. Be very cautious when people try to sell you things. Now, the chlorine-based solutions are kind of interesting. These are electrolytically based from saline, basically they put saline and they put an anode and a cathode in. And they get a chlorine-based solution, sodium hypochlorite and hypochlorous acid. Sodium hypochlorite is basically what people used to know as Dakin solution. Since I’m out of time, let me just tell you, and this lecture is sponsored by Alcavis and ExSept Plus out there. This is actually an interesting product. This is 0.114 sodium hypochlorite solution. Alright. I looked at the literature on this when they came to talk to me. And it’s got a broad spectrum antimicrobial agent, it’s effective against bacteria including MSSA, MRSA, vancomycin-resistant enterococcus and pseudomonas. It’s active against fungus, including T. rubrum. It’s got better bacterial clearance and better tolerability than Silvadene when given in wounds. And this was a study published by Colombo and I couldn’t read the journal or the date on it. But it’s out of Italy and they compared this solution in Italy to Silvadene and found better bacterial clearance and better tolerability than Silvadene which is used all the time in wounds. This is interesting. This is a well-known journal. It was more effective than povidone iodine in reducing bacterial counts in preoperative preps. My wife just had bunion surgery last week. They used Betadine to prep it. Alright. This stuff actually works as well at least as Betadine. And it’s well tolerated and does not harm tissues.
Let me end with this. A lot of you working in hospitals or work in wound care clinics are maybe familiar with the wound. Let me say it this way, this is being videoed so I don’t want to piss anyone off. There are a lot of people out there who make statements about wound and topical wound care that don’t know what they’re talking about. How many of you have heard Betadine as tissue toxic? Everybody in this room, right? Betadine as tissue toxic. Do you know there’s not a single study in the world literature to show that Betadine inhibits wound healing? All they do is they quote studies done by Rod Haver [Phonetic] who’s PhD like 30 years ago that showed that Betadine inhibits fibroblast proliferation. How many of you have heard like Dakin solution is tissue toxic? Basically, this is a dilute version of that. And you know what, they just quote some literature by Aleena Weaver [Phonetic], another PhD, who didn’t even talk about whether to use buffered Dakin’s or regular Dakin’s, didn’t talk about as protocol. The point I’m trying to say is there are these people out there who spout stuff about wound care, about topical antimicrobials and wounds, about how they’re dangerous to use, they heal, they damage good tissue. Ask to see the science. I’ve lectured at wound nursing meetings a lot and a lot of the wound nurses are the ones who perpetuate this stuff. And I’ll get up in front of a group of 100 nurses and say, “Betadine does not inhibit wound healing, I use Betadine on wounds.” Sodium hypochlorite solutions don’t inhibit wound healing. Alright. And it’s like I get jumped on by a 100 nurses, which isn’t necessarily a bad thing, okay. But, the point I’m trying to make is, there are a lot of people out there that are promoting a lot of nonsense or science that’s really not good science and making you change your practice. Be alert to this, be aware of what’s out there, question what I’m telling you. If you agree or disagree with what I’m saying, question it. Lord knows my residents well. I shouldn’t have said that, I’ve got a couple of them here. The point is don’t be afraid, question authority, question your attendings. That’s the only way you’re going to learn. Don’t take some proclamation as gospel, do your own research. You’re new generation of podiatrists, you got to take over from us. We were taught the old way. You’re being taught the new way. I expect a lot from you. Thank you very much.