31-1 Wound Care Dressings: Antimicrobials Past, Present and Future

Description

Editorial

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:

1. Bacterial resistance
2. Speed of kill
3. Impact on biofilm
4. Effects on healthy tissue
5. Length of activity
6. 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 H^²O^²). 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.

Brock Liden, DPM