A cleansing solution

With so many wound care products available it’s important for health professionals to keep informed. Here, Gary Bain evaluates Prontosan on problematic leg ulcers.

The Sydney Adventist Hospital’s Wound Clinic treats over 500 outpatients each year. The majority of these individuals present with chronic wounds, of which the largest group are those with leg ulcers.

Wound repair for many patients is compromised by persistent inflammation due to biofilm build-up on the wound surface. Having previously seen literature on Prontosan, the clinic approached B. Braun Australia for the purpose of evaluating the product on problematic leg ulcer wounds.

Leg ulcer wounds can struggle to heal. Many factors can be responsible for this including those that are derived from the host, the environment, the availability of resources and the clinicians providing care.

One of the impediments to repair is persistent bacterial invasion. Delayed healing and increasing pain are indicative of infection, as are other signs such as cellulitis, exudation, purulence and malodour.

However, chronic wounds will not always display these characteristics, yet they remain constrained by an inflammatory state. Cutting proposes that biofilm formation is a potential cause of chronic wound infection.

Biofilm has been defined as “communities of microbial cells, attached to surfaces and encased in slime.” Current treatment strategies are directed at suppressing biofilms, while host cells repair the chronic wound. Key elements in this process include (the combination of) frequent debridement, the application of topical antiseptics and administration of antibiotics. Another potential tool in the minimisation of biofilm build-up is the addition of a tissue-tolerant detergent.

Prontosan is a wound cleansing solution containing the active ingredients of undecylenamidopropyl betaine and polyhexanide. Product documentation proposes that Prontosan will break down biofilm coatings in preparation for removal by irrigation, wound cleansing and/or debridement.

The following case reports provide some measure of Prontosan’s clinical effect on patients with biofilm coated, difficult-to-heal, leg ulcers.

Patient 1
History: Morbidly obese, 62 year old male. A non-insulin dependent diabetic. He experienced a recent CVA. He has poorly controlled hypertension and fluid retention subsequent to renal failure. He presented with spontaneously occurring, extensive bilateral lower leg ulcers of greater than seven year duration, demonstrating heavy exudate and maceration. Swab pathology indicated that the wounds were colonised with MRSA and multi-resistant Pseudomonas. Upon initial consultation he was receiving pulsed treatments of IVI Meropenem – which was dosage dependent based on renal function.

Intervention: The patient was having the ulcers treated every two days with silver based dressings and calibrated multi-layered compression bandaging. Despite some weeks of this treatment (including IVI antibiotics), the wounds demonstrated ongoing heavy exudate volumes, friability, pain and malodour. Wound cleansing with Prontosan prior to the dressing procedure was instigated. Gauze dressings were soaked with Prontosan solution, then applied directly to the ulcers and held in-situ with under-cast padding for up to 15 minutes. After this time the gauze dressing was removed (any residual Prontosan was not washed off) and the routine dressing was applied. Dressing frequency remained unchanged.

Outcome: The patient was re-evaluated after two weeks, upon which time the wounds were observed to be clean and vascular, with no malodour, demonstrating reduced depth and wound surface contraction. It was also noted that local inflammation (erythema) had decreased but that epithelial replication had not yet commenced at the ulcer margins.

Patient 2
History: Overweight, 57 year old female. She had a 15 year history of Multiple Sclerosis. She sustained a right lower leg injury resulting in an ulcer of five months duration, which was determined to have both arterial and venous flow complications. The wound demonstrated a heavy exudate volume, local erythema and malodour. Swab pathology identified MRSA and mixed coliform colonisation. She was taking Augmentin Duo oral antibiotics at the time of consultation.

Intervention: The patient was having the wound treated twice per week with alginate dressings, absorbent padding and low sub-bandage pressure compression bandaging. Re-vascularisation via stenting of the anterior tibial artery was performed after a few weeks of treatment. This procedure significantly reduced wound pain and allowed for an increased compression profile. While the ulcer was now more comfortable, slough along with a moderate exudate volume, local inflammation and malodour continued to persist. Application of Prontosan-soaked gauze dressings were commenced after wound cleansing and prior to the dressing application. A 15 minute dwell time was maintained, after which the dressing procedure was attended.

Outcome: During the next two weeks the local erythema progressively subsided and the malodour was eliminated Granulation tissue deposition became evident whilst epithelial replication took a number of more weeks to become well established.

Patient 3
History: An immobile elderly woman – age unknown (late 70’s probably). She presented with a trauma induced left lower leg ulcer of 11 month duration. The wound was diagnosed as a complex venous ulcer (due to extensive areas of thrombosis in superficial and deep veins in both calf and thigh). Her medical history included an auto-immune collagen deficiency and multiple skin allergies. She also reported being allergic to all antibiotic preparations. Wound swab pathology revealed MRSA and mixed skin organisms. The ulcer surface possessed a very thick and tenacious biofilm which was resistant to autolytic debridement.

Intervention: Twice per week dressings utilising cadexomer iodine and a bi-layered cohesive bandaging system were commenced. Despite eight weeks of therapy the dense biofilm was slow to lyse. The Prontosan soak process was added to the procedure in an attempt to expedite cleansing or removal of the biofilm.

Outcome: Within the first week of instigating the Prontosan it was observed that pain control had improved. Wound exudate volume and the intensity of local erythema were reduced. By the third week of this same treatment, the rate of biofilm decay and the generation of granulation tissue appeared to gain pace.

Findings
In the case studies, the only alteration to wound management was the addition of Prontosan to each regime. Our clinical observations suggest that when Prontosan is added to recognised strategies to reduce biofilm formation, that down-regulation of chronic inflammation appears to accelerate. This has led us to conclude that Prontosan’s chemical interaction provides a synergic benefit to the actions of wound debridement, local biocide application and antibiotic therapy, suffice to bolster biofilm removal and prevent its reformation.

Gary Bain is the manager of the Sydney Adventist Hospital’s Wound Clinic. Referenced version of article available by emailing [email protected]

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