One of the most difficult areas to navigate in wound care is the “antimicrobial” claim...
One of the most difficult areas to navigate in wound care is the “antimicrobial” claim. This process starts with the FDA going through titles. First, there was “antibacterial,” followed by “antimicrobial” (an expansion to cover fungus and possible viruses). Then came “bacterial static,” which claimed to kill some bacteria and stop additional growth. A few years later, the FDA added the definition of “bacterial binding products,” which do not kill enough bacteria to be labeled bacteriostatic or bactericidal, though they do have a bacterial destructive effect.
The current FDA guidelines do not account for:
Bacterial resistance
Speed of kill
Impact on biofilm
Effects on healthy tissue
Length of activity
Potential causes of product deactivation
It is clear that the given labels do not account for the list above. So then, where should a clinician go for guidance? We typically turn to the manufacturers of the products in question. However, most manufacturers only want to provide positive data on their product. This information is helpful to a point, but it leaves gaps. The limitations of the products are almost never pointed out or discussed. For example, silver does not kill biofilm and has a negative impact on fibroblast and keratinocytes. hypochlorous acid (HOCl) has a very short active window, and in certain forms has a preservative that is harmful to healthy tissue. Likewise, Hydrofera Blue is deactivated by oxidizers (HOCl and H²O²). This list goes on and on.
Then comes the conflict over when to use active (antimicrobial) dressings. We are instructed to only use these when the wound is infected. However, when patients become infected there are varying levels of reporting (and thus documentation), which can lead to malpractice cases. Additionally, most hospital wound clinics limit products for numerous reasons. If there are lines that offer both an active and nonactive product of the same type, most likely the wound center will choose the active product. This type of product labeling and decision-making can make the caregiver’s decision difficult and confusing.
On a positive note, these types of decisions are driving the development of better antimicrobials, such as a bensal chloride which has both planktonic and biofilm claims, a copper Iodine complex with log 6 planktonic kill and log 4 biofilm kill (harmless to healthy tissues) and an activated carbon technology that is considered bactericidal in Europe and bacterial-binding in the US.
Both the caregiver and clinician need to continue asking better questions, doing their own research and demanding improved outcomes for their patients.
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Article Authors and Lecturers
Barbara J. Aung, DPM (1., Data Trace Publishing Company.)
Daniel Gibson, PhD (n.)
Neil L. Horsley, DPM (n.)
Leland Jaffe, DPM (n.)
Eric J. Lullove, DPM (n.)
James McGuire, DPM, PT (n.)
Marta H. Ostler, PT (n.)
Gregory Schultz, PhD (1.; 2a. Medline; 2b. Medline, Smith & Nephew; 2c. University of Florida; 2d. (paid) Inotec, Molnlycke, Organogenesis; 2e. QuickMed Technologies; 3.)
William H. Tettelbach, MD (n.)
Ashka Trivedi, DPM (n.)
Qeena C. Woodard, DPM (n.)
Brock Liden, DPM
Private Practice, WAFL, Inc., Circleville, OH; Diplomate, American Board of Podiatric Medicine; Certified, Physician in Wound Care; Fellow, American Professional Wound Care Association
CONTRIBUTORS
Barbara J. Aung, DPM
Private Practice, Aung Foot Health Clinics and Advanced Wound Healing Center, Tucson, AZ; Chief of Podiatric Services, Carondelet St. Joseph’s Hospital, Tucson, AZ; American Podiatric Medical Association, Coding Committee Member; American Board of Wound Management, Test Committee Member; Diplomate, American Board of Podiatric Medicine; Certified Wound Specialist
Daniel J. Gibson, PhD
Research Assistant Professor, Institute for Wound Research at the University of Florida, Gainesville, FL
Neil L. Horsley, DPM
Chair, Department of Podiatric Surgery and Applied Biomechanics, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, N. Chicago, IL; Section Chief Podiatric Surgery, Advocate Trinity Hospital, Aurora, IL
Leland Jaffe, DPM
Assistant Professor, Department of Medicine and Radiology, Scholl College of Podiatric Medicine at Rosalind Franklin University, N. Chicago, IL; Fellow, American College of Foot and Ankle Surgeons; Diplomate, American Board of Foot and Ankle Surgery; Certified Wound Specialist Physician
Eric J. Lullove, DPM
Medical Director, West Boca Center for Wound Healing, Boca Raton, FL; AAWC Liaison, Alliance for Woundcare Stakeholders; Fellow, American College of Clinical Wound Specialists
James McGuire, DPM, PT
Director, Leonard Abrams Center for Advanced Wound Healing of the Foot and Ankle Institute; Clinical Professor, Departments of Podiatric Medicine and Biomechanics, Temple University School of Podiatric Medicine, Philadelphia, PA; Licensed Pedorthist; Fellow Certified, Academy of Physicians in Wound Healing
Marta H. Ostler, PT
Lead Physical Therapist, St. Vincent’s Healthcare, Billings, MO; Certified Wound Specialist; Certified Lymphatic Therapist; Diplomate, American Professional Wound Care Association
Gregory Schultz, PhD
Professor, Established the Institute for Wound Research, University of Florida, Gainesville, FL
William H. Tettelbach, MD
Medical Director of Wound Care, Infection Prevention and Antibiotic Stewardship, Landmark Hospital, Salt Lake City, UT; Adjunct Assistant Professor, Duke University School of Medicine, Durham, NC; Associate Chief Medical Officer at MiMedx Group, Inc., Marietta, GA; Fellow, American College of Physicians, Fellow, Infectious Diseases Society of America, Fellow, Undersea and Hyperbaric Medicine, Certified Wound Specialist
Ashka Trivedi, DPM
Podiatrist, Scholl Foot and Ankle Clinic-North Chicago, IL; Clinical Instructor in the Department of Podiatric Biomechanics and Surgery, Scholl College, Rosalind Franklin University of Medicine and Science, North Chicago, IL
Qeena C. Woodard, DPM
Associate Professor, Podiatric Surgery and Applied Biomechanics, Rosalind Franklin University of Medicine and Science, Dr. William M. Scholl College of Podiatric Medicine; Coordinator of Diabetic Foot and Wound Care/Associate, Smith Centers for Foot and Ankle Care, Chicago, IL; Fellow, American College of Foot and Ankle Surgeons; Certified Wound Specialist
Antimicrobial Peptides as Potential Tool to Fight Bacterial Biofilm
Commentary by Qeena C. Woodard, DPM
Super-Oxidized Solution (Dermacyn® Wound Care) as Adjuvant Treatment in the Postoperative Management of Complicated Diabetic Foot Osteomyelitis: Preliminary Experience in a Specialized Department
Commentary by Neil L. Horsley, DPM
Smart Dressings Based on Nanostructured Fibers Containing Natural Origin Antimicrobial, Anti-Inflammatory and Regenerative Compounds
Commentary by Neil L. Horsley, DPM
In Vitro Activity of an Engineered Honey, Medical-Grade Honeys and Antimicrobial Wound Dressings Against Biofilm-Producing Clinical Bacterial Isolates
Commentary by Daniel J. Gibson, PhD
Surfactants and their Role in Wound Cleansing and Biofilm Management
Commentary by Marta H. Ostler, PT
Update: Topical Antimicrobial Agents for Chronic Wounds
Commentary by William H. Tettelbach, MD
Pterostilbene, a Methoxylated Resveratrol Derivative, Efficiently Eradicates Planktonic, Biofilm and Intracellular MRSA by Topical Application
Commentary by James McGuire, DPM, PT
Consensus on Wound Antisepsis: Update 2018
Commentary by James McGuire, DPM, PT
Antimicrobial Drugs Encapsulated in Fibrin Nanoparticles for Treating Microbial-Infested Wounds
Commentary by Eric J. Lullove, DPM
Update on the Role of Infection and Biofilms in Wound Healing: Pathophysiology and Treatment
Commentary by Ashka Trivedi, DPM
Biofilms: Prevention and Treatment
Commentary by Ashka Trivedi, DPM
Potential Application of Antimicrobial Peptides in the Treatment of Bacterial Biofilm Infections
Commentary by Qeena C. Woodard, DPM
Dynamic Reciprocity in the Wound Micro-Environment
Commentary by Le land Jaffe, DPM
AUDIO LECTURE 1:Battling Biofilms: Winning the War in Wounds
Gregory Schultz, PhD
AUDIO LECTURE 2: Identifying Antimicrobial Wound Dressings
Barbara J. Aung, DPM