Abstract
Chronic wounds are those wounds that are persistent and do not respond to any sort of treatment. The concept of using topical antiseptics on open wounds is to prevent and treat infections. They also help to shorten the time taken to heal the wounds. The use of topical agents on wounds to prevent infection is a minimal ability to develop resistance to the microorganisms. Pseudomonas aeruginosa is a Gram‐negative opportunistic pathogen with innate resistance to many antibiotics. In places that are economically backward, these problems get compounded by the inability of patients to afford newer expensive drugs. Topically applied dilute acetic acid, which is cheap and easily available, has been found to be effective in such chronic wounds. In the present study, an attempt has been made to use 1% acetic acid as the sole antimicrobial agent for the treatment of pseudomonal wound infections. A control limb was used in which the wounds were treated with normal saline. Our objective was to evaluate the efficacy of acetic acid in low concentration of 1% in chronic wounds infected with P. aeruginosa. This was a prospective study conducted over a period of 6 months. Inclusion criteria: All patients with chronic wounds infected with P. aeruginosa. Exclusion criteria: Wounds due to massive burns, suspected malignancy, immunocompromised individuals and individuals with sepsis. A total of 32 patients enrolled in the study. Subjects were randomised equally to the 1% acetic acid group and saline dressing group. None of the patients received any systemic antibiotics during the study period and received twice daily dressings. The endpoint of the treatment was wounds free of P. aeruginosa. The duration of treatment required to eliminate the Pseudomonas from the wounds in the acetic acid group was on an average 7 days less than that required by the saline group. P value was <0·001. In the 1% acetic acid group irrespective of the sensitivity of the organism to antibiotics, Pseudomonas organisms were eliminated within the same time period – 4·5 days. In the saline group, susceptible organisms were eliminated within 11·5 days and multidrug‐resistant organisms were eliminated by 15·5 days. 1% acetic acid is a simple, safe and effective topical antiseptic that can be used in the elimination of P. aeruginosa from chronic infected wounds.
Keywords: 1% Acetic acid, Multidrug resistant, Normal saline, Pseudomonas aeruginosa
Introduction
Chronic wounds in general are estimated to affect 1–2% of the world's population. They pose a major challenge that is cumbersome in terms of wound healing and also add to the cost in terms of quality of life to the patient and is a financial burden for the hospitals 1. Three main factors have been found to be the causative factors for the development of a chronic wound: firstly, bacterial colonisation or commonly called bioburden; secondly, reperfusion injury; and thirdly, cellular and systemic factors 2, 3.
Most of the wounds if not all of them are contaminated with pathogenic microorganisms, but this itself does not affect the healing of wounds 4, 5, 6. When the contamination increases to a point of critical colonisation or infection, then the infection or the bioburden in the wound becomes a major contributing factor that impedes wound healing 5. Chronic wounds do not progress to the proliferative phase of wound healing and undergo a detention in the inflammatory phase of healing because of which there is a continuous influx of neutrophils into the wound area, with the release of free radicals, cytolytic enzymes and inflammatory mediators that cause damage to the invading pathogens as well as to the host tissue 7. Poor blood supply results in hypoxic conditions in tissues, which can lead to cell death and tissue necrosis. This provides good growing conditions for pathogenic microorganisms leading to the establishment and colonisation of bacteria in the host tissue 7.
Whatever may be the reason, the main cause for an acute wound to get converted into a chronic wound is infection and its prevention and control forms the basis for healing of wounds 8.
Role of biofilm in chronic wounds: The term ‘biofilm’ was coined and described in 1978 9. Pathogenic microorganisms, which are associated with biofilms, have become the major field of interest for further research studies as they have been identified as the causative factor, directly or indirectly, for the development of various infectious diseases 10, 11, 12. Biofilms provide protection from antimicrobial agents by forming a physical barrier and play an important role in infection immunity 12, 13. For example, the Gram‐positive Staphylococcus epidermidis and the Gram‐negative Pseudomonas aeruginosa are the most prevalent pathogens involved in clinical chronic infections 12, 13. Their growth and proliferation within a biofilm provides protection from antibiotics and further provides the biofilm with a host defence mechanism by slowing down or preventing penetration of different agents through the biofilm 11, 12.
Contributing to this is their ability by mutation to develop conventional resistance to antibiotics such as beta‐lactam antibiotics 8. Various mechanisms have been proposed to explain the increased resistance of microorganisms in biofilms against antimicrobials. It is thought to be multifactorial with one factor being the low physiological activity of the bacterial cells deep below the surface of the biofilm where anaerobic conditions exist. Free chromosomal beta‐lactamase in and around the biofilm has been proposed to contribute significantly for being responsible for the increased resistance seen among organisms having biofilms 14.
Bacteria that are considered ‘opportunists’ become pathogenic when organised as a biofilm. Well‐studied examples are P. aeruginosa and Pseudomonas cepacia, which are known as pathogens of immunocompromised or immunodeficient patients 15, 16. Biofilms of P. aeruginosa contribute to chronic infections in patients with cystic fibrosis or non‐healing wounds. P. aeruginosa in chronic wounds is a very problematic microbe because of its ability to form resistant biofilms 17. The presence of these bacteria in wounds seems to impair or even stop the healing process 18. It has been estimated that about 10% of all hospital‐acquired infections are caused by P. aeruginosa, and for immunocompromised patients, the mortality rate ranges from 20% to 70% 19. It has a natural resistance mechanism to many antibiotics because of a resistance transfer plasmid, extra genetic material carried within the cells with genes that code for proteins that destroy antibiotic substances. The strong persistence of P. aeruginosa in chronic wounds as a result of biofilm production makes the bacteria almost impossible to eliminate from a wound with antibiotics once established.
Open wounds that are infected by P. aeruginosa are difficult to treat and even more so if they are hospital acquired. The treatment is difficult even with the best available newer antibiotics with a broad spectrum of activity. Treatment should be based on blood and pus culture sensitivities and not empirically instituted. Although at times antibiotics have to be started empirically because of various factors such as the general condition of the patient, all efforts should be made to replace the empirically chosen antibiotic to be replaced by a specific antibiotic based on laboratory sensitivities.
P. aeruginosa is one of the most common pathogens in chronic wounds, a very problematic microbe due to its ability to form resistant biofilms 17. Because P. aeruginosa infections in chronic wounds are so common, it is important to ensure that the wound dressing used for treatment should not promote or facilitate bacterial growth 1.
Antibiotic resistance of skin wound flora has emerged as a major problem. Hence, topical antiseptics are preferable to antibiotics on open wounds as they have a broad spectrum of activity and thus reduce the probability of development of antibiotic resistance 20, 21. There are some acquired mechanisms of resistance (especially to heavy metals) which are clinically significant, but in most cases, the results have been speculative 22. Payne et al. stated that the judicious use of antiseptics will help decrease their usage 23, 24. Furthermore, the development of cross resistance and cross allergy is more commonly seen in antibiotics. However, local antiseptics have been used by various medical personnel for all sorts of open wounds to prevent or treat infection. Even though they have been and are being used for a long time now, there are very few studies that explain the advantages and disadvantages of using them 25. Antiseptics are considered as drugs by the Food and Drug Administration (FDA) and are regulated as such 26. Topical antiseptics have a broad spectrum of activity and as such do not have specific targets. They act against both the normal commensal flora and also against the pathogenic ones 27. They have a broader spectrum of activity, which include bacteria, fungi, viruses, protozoa and even prions 3, 25. Both the lower resistance rates and the allergic risks associated with antiseptic compounds give credit to their present popularity 3, 25. Local antiseptics are toxic to multiple components of bacterial cell metabolites unlike antibiotics, which are more specific to certain microbial pathways such as enzyme inhibition. They are believed to be relatively non‐toxic to tissues 28.
Role of acetic acid
Acetic acid (C2H4O2) has a low toxicity and is considered as an antimicrobial agent 29, 30. It has a varied mechanism of action and cannot be explained solely by its acidic nature. Other modes of action include interaction with the cytoplasmic membrane to neutralise the electrochemical potential, lowering of internal pH and denaturation of protein 31.
Acetic acid is bactericidal against many Gram‐positive and Gram‐negative organisms, especially P. aeruginosa. It is frequently used for wounds at concentrations varying between 0·5% and 5%. Various in vitro studies have found that it can disrupt the epithelialisation process, although temporarily, and this effect is not present after the 8th day. The same effect has not been replicated in animal and human models 32. Studies have shown that the tensile strength of the wound is also not affected 33.
A concentration of 2% has been frequently used as a wet dressing to overcome infection in infected burn wounds. More than 2% has not been used clinically because this concentration causes much more pain upon application and because the biochemical disturbance has not been evaluated yet 34.
Furthermore, treatment is being rendered increasingly difficult because of the emergence and spread of resistance to the few agents that remain as therapeutic options, a notable recent development of resistance being the acquisition of carbapenemases by some strains of P. aeruginosa. Given these challenges, it would seem reasonable to identify strategies that would prevent acquisition of the bacterium by hospitalised patients 16.
Given the possible consequences of P. aeruginosa infection, particularly for vulnerable patients, and the continued emergence of MDR strains, which hamper effective antimicrobial therapy, it is clear that strategies to prevent infection and reduce the likelihood of antimicrobial resistance should become a key priority 16.
Materials and methods
This was a prospective study conducted over a period of 6 months from 1 October 2013 to 31 March 2014 in the Department of Plastic Surgery, Christian Medical College and Hospital, Vellore. This study was approved by the Institutional Review Board of Christian Medical College and Hospital, Vellore.
Inclusion criteria: All patients with chronic wounds infected with P. aeruginosa
Exclusion criteria: Wounds due to massive burns and suspected malignancy and those in immunocompromised individuals and individuals with sepsis
A total of 32 patients with chronic wounds infected with P. aeruginosa were enrolled in the study after obtaining proper consent. Subjects were randomised (16 patients each) to the 1% acetic acid group and saline dressing group. (Method of randomisation used was permuted block randomisation of size 2, 4 or 6 generated using SAS 9.1.3). All the patients in the study did not receive any systemic antibiotics during the study period and received twice daily dressings. Cultures were obtained by blinded independent wound evaluators. Cultures were performed by Levines Technique (on every 3rd day) to ensure uniformity and consistency and to prevent erroneous results. The culture was semi‐quantitative.
Patients in the test group were subjected to twice daily dressings with 1% acetic acid. Gauze soaked in 1% acetic acid solution was placed over the wound without squeezing. Control group patients were dressed in a similar fashion but with normal saline.
Patients who were culture proven to be infected with P. aeruginosa were included. The culture was qualitative and semi‐quantitative. The infection density was assessed by measuring the number of organisms in each high power fields and was named ‘H’ for high density wherein the colony‐forming units (CFU) were more than 100, ‘M’ for moderate density (CFU 20–100) and ‘L’ for low density (CFU <20). On the 4th day and every third thereafter, regular pus cultures from the patient samples was performed using Levines method.
The endpoint of the treatment was wounds free of P. aeruginosa.
All clinical records were reviewed retrospectively. Data recorded included patient demographics, site of the wound, density of P. aeruginosa in the wound before starting the treatment and treatment time.
Variables from both groups were analysed. Statistical significance was accepted for P values <0·05. Outcome between the two groups was evaluated by an independent observer (Figures 1 and 2).
Figure 1.
Case 1. (A) Before. (B) After.
Figure 2.
Case 2. (A) Before. (B) After.
Results and analysis
This study included 32 patients with varying sizes of chronic wounds infected with P. aeruginosa. Of the 32 patients, 16 were randomised to the 1% acetic acid group and the remaining 16 to the saline group by permuted block randomisation method. All the patients completed the study. The test group and the control group were compared and analysed.
Summary
This was a 6‐month prospective study to evaluate the efficacy of 1% acetic acid in the treatment of Pseudomonas infection in chronic wounds compared with the conventional normal saline dressings. A total of 32 patients were included in the study who were randomised into two groups of 16 each.
Mean age of the study patients was 42 years. In the 1% acetic acid group, the mean age was 41·25 years and in the saline group, the mean age was 42·40 years.
Among the study subjects, 24 were males and 8 were females.
About 65% of the patients were in the working age group.
Most of the wounds had high density of bacterial growth, with 58·8% in the test group and 41·7% in the control group.
Multidrug resistance was observed in 38% of the wounds, and 66·7% of them was in the test group and 33·3% in the control group.
The mean duration of time required for the elimination of P. aeruginosa from the wounds in the 1% acetic acid group was 5·50 days while that of the saline group was 12·25 days.
In the 1% acetic acid group irrespective of the sensitivity of the organism to antibiotics, Pseudomonas organisms were eliminated within the same time period, that is 4·5 days. In the saline group, susceptible organisms were eliminated on an average within 11·5 days and those organisms that were multidrug resistant were eliminated by 15·5 days.
Even though the percentage of multidrug resistance and heavy bacterial growth in the 1% acetic acid group was more than that in the saline group, the mean duration of treatment was less compared with the saline group.
Wounds treated with 1% acetic acid were free of P. aeruginosa at a significantly faster rate when compared with those treated with normal saline dressings.
Chronic infection was found in 40% of the wounds, which were polymicrobial in nature, followed by trauma and burns (22% each).
There were no major complications in the study. Minor complications such as pain and stinging sensation, which is commonly seen in higher concentrations of acetic acid, were not observed in the study as a very low concentration of 1% was used.
1% acetic acid has been found to be more effective than normal saline in the elimination of P. aeruginosa from infected wounds.
Conclusion
1% acetic acid is a simple, safe and effective topical antiseptic that can be used in the elimination of P. aeruginosa from chronic infected wounds. It is also inexpensive and easy to administer.
It helps eliminate Multidrug resistant (MDR) P aeruginosa from chronic wounds without the use of expensive antibiotics and also helps decrease the incidence of drug resistance.
It can be used on an outpatient basis thereby reducing the economic and social burden of the patients and also reduces the inpatient burden of the hospitals.
| Results and analysis | ||||
|---|---|---|---|---|
| Variables | 1% Acetic acid (n = 16) | Saline (n = 16) | ||
| Age | 41·2 ± 13·5 | 42·4 ± 17 | ||
| Gender: male (%) | 68·8 | 81·2 | ||
| Aetiology | ||||
| Burns | 5 | 31·25 | 2 | 12·5 |
| Trauma | 3 | 18·75 | 4 | 25·0 |
| Cellulitis | 5 | 31·25 | 8 | 50·0 |
| Others | 3 | 18·75 | 2 | 12·5 |
| Growth | ||||
| Scanty | 2 | 12·5 | 5 | 31·2 |
| Moderate | 0 | 0·0 | 1 | 6·2 |
| Heavy | 14 | 87·5 | 10 | 62·5 |
(a) Age:
The mean age of the patients in both the groups was almost the same.
| Age | 1% Acetic acid | Saline |
|---|---|---|
| Minimum | 20 | 14 |
| Maximum | 65 | 75 |
| Mean | 41·25 | 42·4 |
(b) Gender distribution:
Majority of the patients included in both the study groups were males.
| Solution | Male | Female |
|---|---|---|
| 1% Acetic acid | 68·8 | 31·2 |
| Saline | 81·2 | 18·8 |
(c) Aetiology:
Greater percentage of burn patients were admitted in the acetic acid group but still they received an effective treatment and in shorter duration as compared with the saline group.
| Aetiology | 1% Acetic acid | Saline |
|---|---|---|
| Burns | 31·25 | 12·5 |
| Trauma | 18·75 | 25 |
| Cellulitis | 31·25 | 50 |
| Others | 18·75 | 12·5 |
(d) Growth pattern:
About 58·3% of the isolates were included to the 1% acetic acid group as compared with the 41·7% isolates in the saline group.
| Solution | Scanty growth | Moderate growth | Heavy growth |
|---|---|---|---|
| 1% Acetic acid | 28·6 | 0 | 58·3 |
| Saline | 71·4 | 100 | 41·7 |
(e) Sensitivity pattern:
The cultures isolated had MDR and susceptible organisms. About 50% of the MDR isolates were included in the test group as compared with the control group, which had 25% isolates.
| Sensitivity pattern | 1% Acetic acid | Saline |
|---|---|---|
| Multidrug resistant | 50·0 | 25·0 |
| Sensitive | 50·0 | 75·0 |
(f) Time period:
The duration of treatment required to eliminate the Pseudomonas from the wounds in the acetic acid group was on an average 7 days less than that required by the saline group. P value was <0·001. This was a very significant factor.
| Duration | 1% Acetic acid | Saline |
|---|---|---|
| Minimum | 3 | 8 |
| Maximum | 11 | 17 |
| Mean | 5·5 | 12·25 |
(i) In the 1% acetic acid group irrespective of the sensitivity of the organism to antibiotics, Pseudomonas organisms were eliminated within the same time period, that is 4·5 days. In the saline group, susceptible organisms were eliminated on an average within 11·5 days and those organisms that were multidrug resistant were eliminated by 15·5 days.
| Sensitivity | 1% Acetic acid | Saline |
|---|---|---|
| Sensitive | 4·5 | 11·5 |
| MDR | 4·5 | 15·5 |
(ii) Duration of treatment in Pseudomonas isolates sensitive to antibiotics.
| Duration | 1% Acetic acid | Saline |
|---|---|---|
| 25th percentile | 3·25 | 8·25 |
| 50th percentile | 4·5 | 11·5 |
| 75th percentile | 6·75 | 12·75 |
(iii) Duration of treatment in MDR cases.
| Duration | 1% Acetic acid | Saline |
|---|---|---|
| 25th percentile | 4·0 | 14·25 |
| 50th percentile | 4·5 | 15·5 |
| 75th percentile | 7·5 | 16·75 |
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