Antiseptics in Surgery

Publisher:Open Science Company, LLC,,Tobias Hirsch, MD, Hans-Martin Seipp, PhD, Frank Jacobsen, PhD, Ole Goertz, MD, Hans-Ulrich Steinau, MD and Lars Steinstraesser, MD

Antiseptics in Surgery

Publisher:Open Science Company, LLC
Tobias Hirsch, MD, Hans-Martin Seipp, PhD, Frank Jacobsen, PhD, Ole Goertz, MD, Hans-Ulrich Steinau, MD and Lars Steinstraesser, MD

Antiseptics in Surgery
Tobias Hirsch, MD,^a Hans-Martin Seipp, PhD,^b Frank Jacobsen, PhD,^a Ole Goertz, MD,^a Hans-Ulrich Steinau, MD,^a and Lars Steinstraesser, MD^a
^aDepartment of Plastic Surgery, Ruhr-University Bochum, Bochum, Germany; and ^bDepartment of Environmental Engineering and Biotechnology, University of Applied Science Giessen-Friedberg, Giessen, Germany
Correspondence: lars.steinstraesser@ruhr-uni-bochum.de

Background: Wound healing is a complex process, with many potential factors that can delay or complicate healing. Bacterial infection is one of the most dangerous complications once the skin barrier is destroyed. The search for optimal treatment of chronic and infected wounds is an ongoing challenge for healthcare professionals. Methods: This article discusses recent findings in the field of wound antiseptics, its antibacterial efficacy, cell toxicity, and compatibility with wound dressings. Results: Skin antiseptics are daily used for wound cleansing to reduce the bacterial burden. However, there is little evidence concerning the antimicrobial efficacy, cytotoxicity of host cells, and compatibility with commonly used wound dressings. Recent findings show high toxicity and significant incompatibilities with wound dressings for some antiseptics. Conclusion: Antiseptics are widely used in hospitals worldwide to reduce, inactivate, or eliminate potentially pathogenic microorganisms. Current studies show that widely used wound antiseptics show relevant cytotoxicity and cross-reactivity with certain wound dressings. Future research should particularly focus on cytotoxicity, mechanisms of bacterial resistance toward skin antiseptics and wound irrigants, as well as compatibility and cross-reactivity with wound dressings.

Surgeons are constantly challenged to find the optimal treatment of difficult-to-heal wounds, such as chronic ulcers, trauma-induced wounds, and deep burns. Open wounds, particularly in diabetic and immunosuppressed patients, are susceptible to invading pathogens such as bacteria. Chronic wounds present an attractive environment for bacterial infection, and more than 80% of leg ulcers are colonized by bacteria.¹^,² Bacterial colonization is associated with delayed wound healing and causes severe morbidity from sepsis and multiorgan failure.³^,⁴ In the United States, delayed wound healing and bacterial infection due to diabetes are the leading causes of nontraumatic amputations (approximately 71,000 per year or 190 per day).⁵^,⁶ At present, Staphylococcus aureus is the most common single isolate in chronic wounds (76% in foot ulcers) leading to impaired wound healing.⁷ Methicillin-resistant S aureus (MRSA) has become endemic in some hospitals,⁸ and in 2002, the first clinical isolate of vancomycin-resistant S aureus was identified in a diabetic patient with a foot ulcer.⁷^,⁹

Primary strategies used to prevent and treat wound infection include systemic antibiotics and topical antiseptics/antibiotics. Insufficient accumulation in the soft tissue is still a major limitation of systemic antibiotics. Furthermore, systemic antibiotics struggle with increasing bacterial resistance and wound colonization with multiresistant strains.³^,⁸ Thus, their clinical employment remains controversial.¹⁰

Topical antiseptics therefore play a key role for the treatment of wounds in current clinical practice. The philosophy behind local delivery of skin antiseptics is to raise tissue levels of antimicrobials to a level where sensitive and relatively insensitive organisms are inhibited and to avoid potential systemic side effects of high-dose antibiotics.

The first modern, chemically derived antiseptic agent was discovered by Friedlieb Ferdinand Runge in 1834, describing the structure and properties of carbolic acid (phenol).¹¹ A further monumental advance toward the improvement of wound-healing outcome came from the work of Joseph Lister. The famous surgeon was the first to employ this striking agent in March 1865 in a complicated case of tibia fracture.¹²^,¹³ In 1867, he described his technique for the use of carbolic acid spray for surgical antisepsis and direct prophylaxis of high-risk wounds.¹²^,¹³ Within approximately 20 years, the aseptic techniques of Semmelweis and surgical antisepsis based on Lister's principles became the standard of care. In 1919, Alexander Fleming stated, “Antiseptics will only exercise a beneficial effect in a septic wound if they possess the property of stimulating or conserving the natural defensive mechanism of the body against infection.”^{(p. 127)} He further proclaimed that in estimating the value of an antiseptic, it is more important to study its effects on tissues than any effects on bacteria.¹⁴

Because antiseptics often have to be applied on human skin and wounds for therapy, it is important to evaluate their efficacy and the possible cytotoxicity. However, this important fact has been neglected in the past and still little is known about the cytotoxicity of clinically used skin antiseptics to date. Furthermore, compatibility of wound dressings with skin antiseptics is hardly investigated to date. This fact seems to be alarming since wound dressings present a huge market and these products are used widely by different healthcare professionals.

ANTIBACTERIAL EFFICACY

In a recent study, we investigated antibacterial efficacy of 5 commonly used local antiseptics.¹⁵ Octenisept (octenidine), Lavasept, Prontosan (polyhexamethylene biguanide [PHMB]), Braunol, and Betaisodona (povidone-iodine) were tested for their antibacterial activity against 2 gram-positive (S aureus and Enterococcus faecalis) and 2 gram-negative (Pseudomonas aeruginosa and Escherichia coli) strains. Therefore, different dilutions (1%–20%) of the antiseptic solutions were investigated and minimal inhibitory concentration was determined. The analyzed bacterial strains were susceptible, in different degrees, to all the antibiotics tested, showing that all 5 antiseptics possess antibacterial effects. However, differences in their specific effectiveness were evident: Lavasept, Prontosan, and Octenisept show a strong antibacterial effect in every concentration tested (1%–20%), whereas povidone-iodine–based antiseptics require higher concentrations to completely inhibit bacterial growth (3%–7.5%; Table 1).

Table 1. Antibacterial testing of local antiseptic against gram-positive and gram-negative bacteria*

Concentration, %

17.5

12.5

7.5

Control

Braunol

Staphylococcus aureus ATCC 29213