Should You Use Antimicrobial Dressings On Clean, Uninfected Wounds?
The patient’s past medical history was significant for 12 years of diabetes and hypertension. His vascular status was intact with palpable pedal pulses and immediate capillary filling time to all digits. Protective sensation to both feet was absent via the Semmes-Weinstein monofilament. The dermatologic presentation included a pre-ulcerative lesion at the dorsal aspect of the proximal interphalangeal joint (PIPJ) of the second digit with moderate edema and erythema.
Musculoskeletal examination revealed a semi-rigid contracture at the PIPJ of the second digit. Limited joint mobility was also present in the remaining pedal joints. Radiographs were negative for osteomyelitis.
The patient presented to the office after noticing a red, hot, painful mass on the dorsum of his left foot. He was complaining of constitutional symptoms, was admitted to the hospital and underwent an emergent incision and drainage of the abscess. Postoperatively, he received a total of 20 hyperbaric oxygen treatments (HBOT). The wound care regimen included daily dressings with an enzymatic debriding agent.
Four weeks postoperatively, he received a human fibroblast-derived dermal substitute on the wound base and physicians monitored him for two weeks. To expedite healing in this patient at high risk for infection, physicians applied a bilayered cell therapy (Apligraf, Organogenesis). The patient healed completely within three weeks.
This case study is an example of a wound which, following surgery and local wound care, did not receive an antimicrobial dressing and the patient healed without incident. In this acute wound setting, enzymatic debridement, HBOT and other wound care management helped the patient achieve healing. The clinicians were able to reduce the bioburden and manage the wound appropriately.
In regard to clean, uninfected wounds, there needs to be further investigation into the efficacy of antimicrobial dressings given the lack of robust clinical and laboratory research. There are other treatments such as appropriate debridement to utilize in a clean, uninfected chronic wound to aid in closure. We as clinicians need to expand our armamentarium of available modalities.
Despite the reasons listed above, some clinicians may still have the “why not” mentality and argue that while there is a lack of evidence supporting the benefits of antimicrobial dressings, there is also no evidence citing harmful effects. Some may also argue that the higher cost for antimicrobial dressings is a relatively small price to pay for the possibility of preventing infection and possibly amputation. While the argument may seem sensible, the long-term accruing effect of exposing a wound to antimicrobial dressings on a daily basis has yet to undergo examination.
In addition to the concern about the potential toxicity to healthy cells in wound beds, there is little information on the cumulative systemic absorption of chronic use of antimicrobial agents, especially in wounds with a large surface area. Moreover, as modern healthcare providers who are working with limited financial resources, we need to be practicing the best possible evidenced-based medicine, both to ensure the best care as well as fiscal responsibility.
Regardless of one’s position on either side of the debate, wound care should always begin with ensuring adequate debridement, adequate perfusion, removal of any foreign bodies, pressure mitigation and addressing the underlying metabolic pathology. Guidelines are available to help classify the wound and determine the recommended approach to antimicrobial therapy.