Abstract
Wound bed preparation is the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of split‐skin grafting. The formation of a healthy wound bed is a prerequisite to the use of advanced wound care products. Unless this is achieved, even the most sophisticated and expensive materials are unlikely to function correctly. An attempt has been made to use 3% citric acid ointment for wound bed preparation to prepare wound for grafting in five cases of wounds with large raw areas infected with multiple antibiotic‐resistant bacteria.
Keywords: Citric acid treatment, Large infected wounds, Wound bed preparation
Introduction
Some acute large wounds with large raw areas fail to progress through phases of healing and become stalled at some point in the sequence, resulting in infected chronic wounds. The infection and lack of an appropriately vascularised wound bed are detrimental to the wound‐healing process. Split‐thickness skin graft is a simple reconstructive preferred technique used to close such large wounds 1. The proper wound bed preparation is the most critical component in successful skin grafting 2. Failure to establish optimal physiological conditions to accept and nourish the graft is the most important reason for graft rejection. For continuation of the normal repair process, the barrier to healing must be identified and removed through the application of the correct techniques. Wound bed preparation is needed to create an optimal wound‐healing environment by producing a well‐vascularised, stable wound bed with minimal exudate. If wound bed preparation is successful and good wound conditions can be achieved, skin grafting is possible. Debridement, dressing changes, topical or systemic antibiotics are routinely used for wound bed preparation 3. Different methods such as diligent cleansing with antiseptic soaks, application of specific topical antibiotics and oral or parenteral antibiotic therapy are used to augment wound bed preparation by inhibiting and thereby reducing the bacterial count in wound bed 4, so that the good take for grafts could be possible. Some wounds, especially those caused by multiple antibiotic‐resistant bacteria, are hard to respond to the routine treatment modality. The control of infection is a major issue in such cases. Citric acid has been reported to be an excellent topical agent in the management of chronic wound infections 5, 6, 7, 8.
In this study, an attempt has been made to use 3% citric acid ointment as a sole antibacterial agent for wound bed preparation in wounds with large raw areas in five infected orthopaedic cases not responding to conventional treatment.
Materials and methods
Five cases of road traffic accidents admitted for the treatment of different types of fractures and infected wounds (Table 1), which are included in this study.
Table 1.
Clinical and microbiological details
| Case no. | Clinical details | Organism isolated | Susceptibility pattern | No. applications of citric acid ointment |
|---|---|---|---|---|
| 1 | Non‐healing ulcer over left leg | Escherichia coli | Amikacin, colistin, imipenem, meropenem, tigecycline | 15 |
| 2 | Compound fracture Grade IIIB, right tibia | Klebsiella spp. | Colistin | 07 |
| 3 | Compound fracture Grade IIIB, left forearm | Klebsiella spp., Proteus spp. | – | 10 |
| 4 | Right below‐knee amputation with non‐healing stump ulcer | Staphylococcus aureus | – | 20 |
| 5 | Chronic infected non‐union fracture of right tibia with multiple discharging sinuses | Klebsiella spp. | Netilmicin | 10 |
These five cases with wounds with large raw areas, not responding to conventional therapy in which grafting was indicated, were selected for citric acid treatment for wound bed preparation.
A specimen of pus was obtained from the wound bed and processed for isolation and identification of causal bacteria by using conventional techniques 9. Antibiotic susceptibility testing of each isolate was carried out by a modified Kirby–Bauer disc diffusion method 10 using ciprofloxacin (5 µg), gentamicin (10 µg), amikacin (30 µg), imipenem (10 µg), meropenem (10 µg), netilmicin (30 µg), piperacillin + tazobactam combination (100 µg + 10 µg), ceftazidime (30 µg), ceftriaxone (30 µg), cefotaxime (30 µg), colistin (50 µg) and tigecycline (15 µg) discs.
As a part of treatment, 3% citric acid prepared using white soft paraffin (100% pure paraffin jelly) as a base was applied to wound bed after irrigation and cleaning of wound with normal saline. The citric acid ointment was used once daily until the wound bed showed healthy granulation tissue. This study was approved by the Institutional Ethics Committee, and a written consent of the patient was obtained before the application of 3% citric acid ointment.
Results
A total of six isolates with multiple antibiotic resistance were obtained (Table 1). Application of 3% citric acid ointment resulted in the formation of healthy granulation tissue in four cases (80%) (Figures 1, 2, 3). In one case, healthy granulation tissue was formed partially because of deep infection pockets where the ointment could not reach, multiple discharging sinuses and presence of devitalised tissue, which could not be debrided because of risk of exposure of bone as the devitalised tissue was exactly present over the bone (Figures 4 and 5).
Figure 1.
Case 1: Non‐healing ulcer over left leg – before application of citric acid.
Figure 2.
Case 1: Non‐healing ulcer over left leg – after 15 applications of citric acid.
Figure 3.
Case 1: Non‐healing ulcer over left leg – after rotation flap with skin graft.
Figure 4.
Case 5: Chronic infected non‐union fracture of right tibia with multiple discharging sinuses – before application of citric acid.
Figure 5.
Case 5: Chronic infected non‐union fracture of right tibia with multiple discharging sinuses – after 10 applications of citric acid.
Discussion
The overall goal of wound management in wounds with large raw areas is to achieve a stable wound with healthy granulation tissue and a well‐vascularised wound bed. This would involve the removal of factors that delay healing 2. Understanding and removing the barriers to healing will help to produce a wound bed with healthy granulation tissue that is ready for the next stage of repair. The main barrier to healing in a chronic wound is bacterial imbalance, which create after barriers such as necrotic tissue and altered exudate levels and composition. Wound bed preparation aims to remove these barriers to healing, and this is carried out by on‐going debridement, reduction of bacterial burden and effective exudate management 11.
The currently used methods for wound bed preparation have limitations as far as the safety, efficacy and time duration of treatment are concerned. Cadexomer‐iodine preparations are effective, but take longer time 12; however, betadine preparations have a broad antimicrobial spectrum, but may interfere with wound‐healing process 13. Phenytoin ointment is safe and effective, but it takes a longer duration of 2–8 weeks 14. In comparison with this, only 7–20 applications of citric acid are sufficient for wound bed preparation. In addition, it has been proved to be safe, non‐toxic, reliable and economical.
It has been reported that a complex process of healing of an infected wound can be affected by surface pH. The environment of acute as well as chronic wounds progresses from an alkaline state, to a neutral and then to acidic state, when healing begins 15, 16, 17. Citric acid has been found to be highly effective in the treatment of a variety of wounds including those caused by bacteria resistant to multiple antibiotics 5, 6, 7. It has also been reported that citric acid not only controls infection but also promotes formation of healthy granulation tissue 8. Considering this, an attempt was made to use 3% citric acid ointment for wound bed preparation for grafting.
In the present cases also, the infection was controlled effectively and wound granulated rapidly and covered by healthy granulation just after 7–20 applications, suggesting that citric acid is highly effective in the elimination of wound‐healing barriers, especially in controlling infections by multiple antibiotic‐resistant bacteria, which are otherwise very difficult to control. Thus, by controlling infection it halts further deterioration of wound by preventing creation of other barriers, such as formation of necrotic tissue, altered exudate levels and composition, which result following infection. Further studies involving suitable control group will help to achieve more useful and concrete conclusion.
Acknowledgements
The authors wish to thank Mr Dayanand Ghante, Mr Vinod Jogdand, Mr Vishwananth Mane and Mr M. J. Kaule for technical support. The authors have no funding and conflicts of interest to declare.
References
- 1. Zekri A, King W. Success of skin grafting on a contaminated recipient surface. Eur J Plast Surg 1995;18:40. [Google Scholar]
- 2. Enoch S, Harding K. Wound bed preparation: the science behind the removal of barriers to healing. Wounds 2003;15:7. [Google Scholar]
- 3. Sibbald RG, Williamson D, Orsted HL, Campbell K, Keast D, Krasner D, Sibbald D. Preparing the wound bed – debridement, bacterial balance, and moisture balance. Ostomy Wound Manage 2000;46:14–22, 24–8, 30–5; quiz 36–7. [PubMed] [Google Scholar]
- 4. Dowsett C, Newton H. Wound bed preparation: TIME in practice. Wounds UK 2005;1:58–70. [Google Scholar]
- 5. Nagoba BS, Gandhi RC, Wadher BJ, Deshmukh SR, Gandhi SP. Citric acid treatment of severe electric burns complicated by multiple antibiotic resistant Pseudomonas aeruginosa . Burns 1998;24:481–3. [DOI] [PubMed] [Google Scholar]
- 6. Nagoba BS, Wadher BJ, Rao AK, Kore GD, Gomashe AV, Ingle AB. Simple and effective approach for the treatment of chronic wound infections caused by multiple antibiotic resistant Escherichia coli . J Hosp Infect 2008;69:177–80. [DOI] [PubMed] [Google Scholar]
- 7. Nagoba BS, Gandhi RC, Wadher BJ, Gandhi SP, Selkar SP. Citric acid treatment of necrotizing fasciitis: a report of two cases. Int Wound J 2010;7:536–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Nagoba BS, Gandhi RC, Wadher BJ, Potekar RM, Kolhe SM. Microbiological, histopathological and clinical changes in chronic wounds after citric acid treatment. J Med Microbiol 2008;57:681–2. [DOI] [PubMed] [Google Scholar]
- 9. Collee JG, Miles RS, Watt B. Tests for identification of bacteria. In: Collee JG, Fraser AG, Marmion BP, Simmons A, editors. Mackie and McCartney practical medical microbiology. New York: Churchill Livingstone, 1996:131–49. [Google Scholar]
- 10. Bauer AW, Kirby WMM, Sherris JC, Turck M. Antibiotic susceptibility testing by a standardized single disc method. Am J Clin Pathol 1966;45:493–6. [PubMed] [Google Scholar]
- 11. Schultz GS, Sibbald RG, Falanga V, Ayello EA, Dowsett C, Harding K, Romanelli M, Stacey MC, Teot L, Vanscheidt W. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen 2003;11(Suppl 1):S1–28. [DOI] [PubMed] [Google Scholar]
- 12. Prather I. Preparing the wound for grafting. Ostomy Wound Manage 2003;49(2A Supp):1–2. [PubMed] [Google Scholar]
- 13. Goldenheim PD. An appraisal of povidone‐iodine and wound healing. Postgrad Med J 1993;69(Suppl 3):S97–105. [PubMed] [Google Scholar]
- 14. Younes N, Albsoul A, Badran D, Obedi S. Wound bed preparation with 10‐percent phenytoin ointment increases the take of split‐thickness skin graft in large diabetic ulcers. Dermatol Online J 2006;12:5. [PubMed] [Google Scholar]
- 15. Gethin G. The significance of surface pH in chronic wounds. Wounds 2007;3:52–6. [Google Scholar]
- 16. Tsukada K, Tokunga K, Iwama T, Mishima Y. The pH changes of pressure ulcers related to the healing process of wounds. Wounds 1992;4:16–20. [Google Scholar]
- 17. Leveen HH, Falk G, Borek B, Diaz C, Lynfield Y, Wynkoop BJ, Mabunda GA, Rubricius JL, Christoudias GC. Chemical acidification of wounds. An adjuvant to healing and the unfavorable action of alkalinity and ammonia. Ann Surg 1973;178:745–53. [DOI] [PMC free article] [PubMed] [Google Scholar]