Christian Willy

Recommendations on negative pressure wound therapy with instillation and antimicrobial solutions – when, where and how to use: what does the evidence show?

Infections of contaminated or colonised acute or chronic wounds remain a grave risk for patients even today. Despite modern surgical debridement concepts and antibiotics, a great need exists for new therapies in wound management. Since the late 1990s, advantageous effects of negative pressure wound therapy (NPWT) have been combined with local antiseptic wound cleansing in the development of NPWT with instillation (NPWTi). This article summarises the current scientific knowledge on this topic. MEDLINE literature searches were performed on the subject of negative pressure wound and instillation therapy covering publications from the years 1990 to 2013 (36 peer‐reviewed citations) and regarding randomised controlled trials (RCTs) covering wound care with bone involvement (27 publications) or soft‐tissue wounds without bone participation (11 publications) from 2005 to 2012. The use of NPWTi in the therapy of infected wounds appears to be not yet widespread, and literature is poor and inhomogeneous. However, some reports indicate an outstanding benefit of NPWTi for patients, using antiseptics such as polyhexanide (concentration 0·005–0·04%) and acetic acid (concentration 0·25–1%) in acute and chronic infected wounds and povidone‐iodine (10% solution) as prophylaxis in contaminated wounds with potential viral infection. Soaking times are recommended to be 20u2009minutes each, using cycle frequencies of four to eight cycles per day. Additionally, the prophylactic use of NPWTi with these substances can be recommended in contaminated wounds that cannot be closed primarily with surgical means. Although first recommendations may be given currently, there is a great need for RCTs and multicentre studies to define evidence‐based guidelines for an easier approach to reach the decision on how to use NPWTi.

Negative-pressure wound therapy with instillation: international consensus guidelines.

Background: Negative-pressure wound therapy with instillation is increasingly utilized as an adjunct therapy for a wide variety of wounds. Despite its growing popularity, there is a paucity of evidence and lack of guidance to provide effective use of this therapy. Methods: A panel of experts was convened to provide guidance regarding the appropriate use of negative-pressure wound therapy with instillation. A face-to-face meeting was held where the available evidence was discussed and individual clinical experience with this therapy was shared. Follow-up communication among the panelists continued until consensus was achieved. The final consensus recommendations were derived through more than 80 percent agreement among the panelists. Results: Nine consensus statements were generated that address the appropriate use of negative-pressure wound therapy with instillation. The question of clinical effectiveness of this therapy was not directly addressed by the consensus panel. Conclusion: This document serves as preliminary guidelines until more robust evidence emerges that will support or modify these consensus recommendations.

Closed incision negative pressure therapy: international multidisciplinary consensus recommendations

Surgical site occurrences (SSOs) affect up to or over 25% of patients undergoing operative procedures, with the subset of surgical site infections (SSIs) being the most common. Commercially available closed incision negative pressure therapy (ciNPT) may offer surgeons an additional option to manage clean, closed surgical incisions. We conducted an extensive literature search for studies describing ciNPT use and assembled a diverse panel of experts to create consensus recommendations for when using ciNPT may be appropriate. A literature search of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials using key words ‘prevention’, ‘negative pressure wound therapy (NPWT)’, ‘active incisional management’, ‘incisional vacuum therapy’, ‘incisional NPWT’, ‘incisional wound VAC’, ‘closed incisional NPWT’, ‘wound infection’, and ‘SSIs’ identified peer‐reviewed studies published from 2000 to 2015. During a multidisciplinary consensus meeting, the 12 experts reviewed the literature, presented their own ciNPT experiences, identified risk factors for SSOs and developed comprehensive consensus recommendations. A total of 100 publications satisfied the search requirements for ciNPT use. A majority presented data supporting ciNPT use. Numerous publications reported SSI risk factors, with the most common including obesity (body mass index ≥30 kg/m2); diabetes mellitus; tobacco use; or prolonged surgical time. We recommend that the surgeon assess the individual patients risk factors and surgical risks. Surgeons should consider using ciNPT for patients at high risk for developing SSOs or who are undergoing a high‐risk procedure or a procedure that would have highly morbid consequences if an SSI occurred.

Negative-pressure wound therapy with instillation

Background: Negative-pressure wound therapy with instillation is increasingly utilized as an adjunct therapy for a wide variety of wounds. Despite its growing popularity, there is a paucity of evidence and lack of guidance to provide effective use of this therapy. Methods: A panel of experts was convened to provide guidance regarding the appropriate use of negative-pressure wound therapy with instillation. A face-to-face meeting was held where the available evidence was discussed and individual clinical experience with this therapy was shared. Follow-up communication among the panelists continued until consensus was achieved. The final consensus recommendations were derived through more than 80 percent agreement among the panelists. Results: Nine consensus statements were generated that address the appropriate use of negative-pressure wound therapy with instillation. The question of clinical effectiveness of this therapy was not directly addressed by the consensus panel. Conclusion: This document serves as preliminary guidelines until more robust evidence emerges that will support or modify these consensus recommendations.

Breakthrough ideas leading to new futures: prologue.

Since commercialisation almost 20u2009years ago, negative pressure wound therapy (NPWT; V.A.C.® Therapy; KCI USA, Inc., San Antonio, TX) has been used to treat a wide variety of wound types and continues to evolve as research expands understanding of the mechanisms of action that enable this adjunct therapy to facilitate wound closure. In 2010, the educational International Surgical Wound Forum (ISWF) was created to facilitate discussion among experts from all over the world regarding modern wound treatment challenges and techniques. This is the first of two supplements, which are based on the 2012 and 2013 ISWF presentations and demonstrate the evolution of the role of NPWT in wound care. This first supplement provides an overview of current health care challenges and clinical practice and reviews evidence and experience using NPWT with instillation, which combines NPWT with computer‐controlled delivery and removal of topical solutions and suspensions to cleanse and/or treat wounds.

The impact of surgical site occurrences and the role of closed incision negative pressure therapy

Surgical site occurrences are observed in up to 60% of inpatient surgical procedures in industrialised countries. The most relevant postoperative complication is surgical site infection (SSI) because of its impact on patient outcomes and enormous treatment costs. Literature reviews (‘SSI’, ‘deep sternal wound infections’ (DSWI), ‘closed incision negative pressure wound therapy’ (ciNPT) were performed by electronically searching MEDLINE (PubMed) and subsequently using a ‘snowball’ method of continued searches of the references in the identified publications. Search criteria included publications in all languages, various study types and publication in a peer‐reviewed journal. The SSI literature search identified 1325, the DSWI search 590 and the ciNPT search 103 publications that fulfilled the search criteria. Patient‐related SSI risk factors (diabetes mellitus, obesity, smoking, hypertension, female gender) and operation‐related SSI risk factors (re‐exploration, emergency operations, prolonged ventilation, prolonged operation duration) exist. We found that patient‐ and operation‐related SSI risk factors were often different for each speciality and/or operative procedure. Based on the evidence, we found that high‐risk incisions (sternotomy and incisions in extremities after high‐energy open trauma) are principally recommended for ciNPT use. In ‘lower’‐risk incisions, the addition of patient‐related or operation‐related risk factors justifies the application of ciNPT.

Bedeutung von Wundspüllösungen und Flüssigkeiten mit antiseptischer Wirkung in Therapie und Prophylaxe

INTRODUCTIONnDespite the use of modern antibiotics as well as complex perioperative, intraoperative and postoperative prophylactic measures, the rate of surgical site infections (SSI) could not be significantly reduced. The introduction of biocompatible antiseptic drugs with axa0high microbiocidal effect provided axa0successful alternative for infection prevention and therapy, particularly in axa0time of increasing occurrence of multi-drug resistant pathogens. Hence, questions about the risk-benefit ratio of antiseptic wound irrigation solutions, the prophylactic use of wound irrigation solutions for the reduction of SSI and the effect of negative pressure wound therapy combined with instillation (NPWTi) need to be answered.nnnMETHODnAgainst the background of our own experiences with the use of antiseptic wound irrigation solutions, axa0literature analysis (e.g. computer-supported MEDLINE, EMBASE and Cochrane database research as of April 2017) was performed.nnnRESULTSnAntiseptic fluids can be used both prophylactically and therapeutically, in acute and chronic, clean, contaminated and infected wounds to reduce the posttraumatic and postoperative wound infection rates. The antiseptic solutions that are commonly used in orthopedic and trauma surgery (e.g. PVP-iodine, octenidine, polyhexanide, sodium hypochlorite/hypochlorous acid and acetic acid), have in common that no development of resistance has so far been shown and that when the contraindications are taken into account, the antiseptic effect can develop without any clinically significant local and systemic side effects. As a rule the biocompatibility index is higher than 1 for the substances mentioned. In addition, they show an antiseptic effect against biofilms and multi-drug resistant pathogens. These antiseptic solutions can also be used for NPWTi with some limitations for octenidine.nnnCONCLUSIONnAs the basic equipment in trauma surgery, axa0selection of three different antiseptic wound irrigation solutions for the reduction of the rates of posttraumatic and SSI can be recommended. The use of antiseptics should be reviewed on an ongoing basis in the daily clinical routine and particular attention should be paid to unwanted effects in the course of the healing process. After application of 7-14xa0days, the indications for continuing the use of the antiseptic solutions must be carefully re-evaluated.ZusammenfassungEinleitungTrotz moderner Antibiotika sowie aufwendiger prä-, peri-, intra- und postoperativer Maßnahmen zur Prophylaxe postoperativer Infektionen („surgical site infections“, SSI) konnte deren Rate nicht entscheidend reduziert werden. Die Einführung biokompatibler antiseptischer Wirkstoffe mit hohem mikrobioziden Effekt bietet in einer Zeit des zunehmenden Auftretens multiresistenter Erreger (MRE) die Option erfolgreicher Infektionsprävention und -therapie. Daher sollen Fragen zur Nutzen-Risiko-Abwägung antiseptischer Wundspüllösungen, zum prophylaktischen Einsatz zur Reduktion von SSI und zum Effekt der Instillationsanwendung bei der Vakuumversiegelungsmethode („negative pressure wound therapy combined with instillation“, NPWTi) beantwortet werden.MethodeVor dem Hintergrund der eigenen Erfahrung mit dem Einsatz antiseptischer Wundspüllösungen wurde eine Literaturanalyse (computergestützte MEDLINE-, EMBASE- und Cochrane-Recherche, Stand April 2017) durchgeführt.ErgebnisseDen für die Orthopädie und Unfallchirurgie geeigneten antiseptischen Lösungen PVP-Iod, Octenidin, Polihexanid (PHMB), Natriumhypochlorit/hypochlorige Säure sowie Essigsäure ist gemeinsam, dass bisher keine Resistenzentwicklung nachgewiesen wurde und sich bei Beachtung der Kontraindikationen die antiseptische Wirkung ohne klinisch bedeutende lokale und systemische Nebenwirkungen entwickeln kann. Für die vorgestellten Substanzen gilt in der Regel, dass ein Biokompatibilitätsindexxa0>1 vorliegt. Sie sind gegen Biofilme und multiresistente Erreger wirksam. Die aufgeführten antiseptischen Substanzen können, mit Vorbehalt für Octenidin, auch für die Vakuuminstillationstherapie (NPWTi) eingesetzt werden.SchlussfolgerungFür die Unfallchirurgie ist als Grundausstattung eine Auswahl von 3 verschiedenen antiseptischen Wundspüllösungen zur Reduktion der Rate posttraumatischer und -operativer Wundinfektionen zu empfehlen. Die Anwendung der Antiseptika sollte im klinischen Alltag fortlaufend überprüft und insbesondere das Augenmerk auf unerwünschte Auffälligkeiten im Heilungsverlauf gerichtet werden. Nach 7‑ bis 14-tägiger Anwendung muss die Indikation zum Einsatz der Antiseptika erneut kritisch überprüft werden.AbstractIntroductionDespite the use of modern antibiotics as well as complex perioperative, intraoperative and postoperative prophylactic measures, the rate of surgical site infections (SSI) could not be significantly reduced. The introduction of biocompatible antiseptic drugs with axa0high microbiocidal effect provided axa0successful alternative for infection prevention and therapy, particularly in axa0time of increasing occurrence of multi-drug resistant pathogens. Hence, questions about the risk-benefit ratio of antiseptic wound irrigation solutions, the prophylactic use of wound irrigation solutions for the reduction of SSI and the effect of negative pressure wound therapy combined with instillation (NPWTi) need to be answered.MethodAgainst the background of our own experiences with the use of antiseptic wound irrigation solutions, axa0literature analysis (e.g. computer-supported MEDLINE, EMBASE and Cochrane database research as of April 2017) was performed.ResultsAntiseptic fluids can be used both prophylactically and therapeutically, in acute and chronic, clean, contaminated and infected wounds to reduce the posttraumatic and postoperative wound infection rates. The antiseptic solutions that are commonly used in orthopedic and trauma surgery (e.g. PVP-iodine, octenidine, polyhexanide, sodium hypochlorite/hypochlorous acid and acetic acid), have in common that no development of resistance has so far been shown and that when the contraindications are taken into account, the antiseptic effect can develop without any clinically significant local and systemic side effects. As a rule the biocompatibility index is higher than 1 for the substances mentioned. In addition, they show an antiseptic effect against biofilms and multi-drug resistant pathogens. These antiseptic solutions can also be used for NPWTi with some limitations for octenidine.ConclusionAs the basic equipment in trauma surgery, axa0selection of three different antiseptic wound irrigation solutions for the reduction of the rates of posttraumatic and SSI can be recommended. The use of antiseptics should be reviewed on an ongoing basis in the daily clinical routine and particular attention should be paid to unwanted effects in the course of the healing process. After application of 7–14xa0days, the indications for continuing the use of the antiseptic solutions must be carefully re-evaluated.

Akute Maßnahmen beim „limb salvage“-Prozedere Teil 2

ZusammenfassungDie Qualität der Primärversorgung von Gustilo-Anderson(GA)-IIIB- und -IIIC-Extremitätenverletzungen ist entscheidend für den Erfolg des „limb salvage“-Vorgehens. Vor dem Hintergrund eigener Erfahrungen und der aktuellen Literatur stellt dieser Beitrag die teilweise einheitlich, jedoch auch sehr kontrovers diskutierten Aspekte des initialen Debridements, der modernen Lavage- und Wundverschlusstechniken sowie aktuelle Aspekte der Antibiotika- und Antiseptikagabe zusammen. Herauszustellen ist: Bei schweren Extremitätenverletzungen mit ausgeprägter Kontamination (GA-IIIA, -IIIB und -IIIC) muss nach wie vor mit einer Infektionsrate von bis zu 60u2009% gerechnet werden. Das initiale Debridement sollte zum frühestmöglichen Zeitpunkt erfolgen, an dem ein erfahrener Traumachirurg verfügbar ist. Sicher avitales Gewebe wird entfernt; traumatisiertes, aber möglicherweise überlebendes Gewebe muss bei einem „second look“ nach 36–48xa0Stunden reevaluiert werden. Die Biofilmentwicklung setzt bei ausreichendem Kontaminationsausmaß bereits nach etwaxa06xa0Stunden ein. Die perioperative Antibiotikaprophylaxe muss frühzeitig begonnen und sollte für 24xa0Stunden (GA-I und -II) bis zu 5xa0Tagen (GA-III) fortgesetzt werden. Bei bakterieller Kontamination sind Wundspüllösungen mit Zusätzen wie Polyhexanid, Octenidin oder superoxidiertem Wasser sinnvoll. Die Spülung der Wunde sollte nur mit leichtem manuellem Druck (keine Jet-Lavage) in einer Menge von 3–9xa0Litern erfolgen. Der definitive primäre Wundverschluss ist bei sicherer Dekontamination und Vitalität des Wundgrunds möglichst initial anzustreben (GA-I und -II). Bei höchstgradigen Verletzungen kann die temporäre Vakuumversiegelungstechnik die Zeit bis zum frühestmöglich anzustrebenden definitiven plastischen Wundverschluss überbrücken.AbstractThe quality of the primary care of Gustilo–Anderson (GA) type IIIB and IIIC extremity injuries is crucial to the success of the limb salvage procedure. This article provides a compilation of consistent, but often controversially discussed aspects of initial debridement, modern techniques of lavage and wound closure, in addition to current issues on the application of antibiotics and antiseptics, based on our own experiences and the latest literature. The following points should be stressed. Severe extremity injuries with gross contamination (GA IIIA, B, and C) will still be associated with an infection rate of up to 60u2009%. The initial debridement should be performed as soon as an experienced trauma surgeon is available. Tissue that is definitely avital will have to be removed, whereas traumatized but potentially surviving tissue will have to be re-evaluated during a second-look operation after 36–48xa0h. Given a high enough level of contamination, biofilms will form after as few as 6xa0h. The perioperative antibiotic prophylaxis has to be initiated early and should be continued for at least 24xa0h (GA I/II) or up to 5xa0days (GA III). In cases of bacterial contamination, wound irrigation will be useful with additives such as polyhexanide, octenidine or superoxidized water. Rinsing of the wound should be performed with 3–9xa0L and only slight manual pressure (no jet lavage). The definitive primary closure of a wound should be achieved in the initial operation, but only in the case of certain “decontamination” and overall vitality of the wound (GA I and II). In the presence of high-grade injuries, a temporary vacuum sealing technique can be used until the earliest possible definitive plastic surgical wound closure.

Negative Pressure Wound Therapy with Instillation: Consensus Guidelines

Background: Negative-pressure wound therapy with instillation is increasingly utilized as an adjunct therapy for a wide variety of wounds. Despite its growing popularity, there is a paucity of evidence and lack of guidance to provide effective use of this therapy. Methods: A panel of experts was convened to provide guidance regarding the appropriate use of negative-pressure wound therapy with instillation. A face-to-face meeting was held where the available evidence was discussed and individual clinical experience with this therapy was shared. Follow-up communication among the panelists continued until consensus was achieved. The final consensus recommendations were derived through more than 80 percent agreement among the panelists. Results: Nine consensus statements were generated that address the appropriate use of negative-pressure wound therapy with instillation. The question of clinical effectiveness of this therapy was not directly addressed by the consensus panel. Conclusion: This document serves as preliminary guidelines until more robust evidence emerges that will support or modify these consensus recommendations.

„Antibiotic Stewardship“@@@Antibiotic stewardship: Programmatischer Ansatz zum optimierten Antibiotikamanagement@@@A programmatic approach to improved antimicrobial management

ZusammenfassungVor dem Hintergrund der zunehmenden Selektion und Verbreitung multiresistenter Mikroorganismen (v.u2009a. gramnegativer Bakterien) und der unzureichenden Entwicklung neuer antimikrobieller Substanzen kommt dem verantwortungsvollen und klugen Gebrauch der vorhandenen Antibiotika besondere Bedeutung zu. In Deutschland lässt sich die Verpflichtung zum rationalen Antiinfektivaeinsatz unter Beachtung der lokalen Erregerresistenzsituation seit 2011 aus dem Infektionsschutzgesetz ableiten. Ein wichtiges Instrument zur Erfüllung der gesetzlichen Vorgaben, v.u2009a. aber auch zur Optimierung des Infektionsmanagements, ist das Antibiotic-Stewardship- (ABS-)Konzept. Krankenhäuser, die ein ABS-Programm etablieren, beauftragen ein multidisziplinäres Expertenteam mit der Entwicklung und Überwachung von Therapiestandards und der Etablierung eines Visiten- und Beratungsdienstes mit dem Ziel, die individuelle Infektionsbehandlung zu optimieren. Auf längere Sicht soll so auch der ungünstigen mikrobiellen Resistenzentwicklung entgegengewirkt werden. ABS-Programme sollen alle Fachdisziplinen eines Krankenhauses, die Antibiotika anwenden, einschließen. Die Unfallchirurgie ist insbesondere dann betroffen, wenn hochkomplexe Infektionen und solche mit multiresistenten Erregern behandelt werden.AbstractDue to the increasing selection and prevalence of multidrug-resistant gram-negative bacteria and the insufficient development of novel antibiotics, the responsible and prudent use of the available antimicrobial drugs is of major importance. In Germany the rational use of anti-infectives considering the local antimicrobial resistance situation is defined in the infection protection act of 2011. An important tool to follow legal regulations and to improve the treatment of bacterial infections is the antimicrobial stewardship (AMS) concept. Hospitals implementing an AMS program charge axa0multidisciplinary team of experts to develop and monitor treatment standards and to establish axa0system of regular consultations and ward rounds. Objectives of this set of measures are the optimization of the individual treatment outcome and on axa0longer range the improvement of the epidemiological situation. AMS programs include all clinical disciplines that use antimicrobials. Trauma surgery is also affected in axa0special way as soon as complicated infections and those with multidrug-resistant bacteria are treated.