Negative Pressure Wound Therapy of Chronically Infected Wounds Using 1% Acetic Acid Irrigation

Background Negative-pressure wound therapy (NPWT) induces angiogenesis and collagen synthesis to promote tissue healing. Although acetic acid soaks normalize alkali wound conditions to raise tissue oxygen saturation and deconstruct the biofilms of chronic wounds, frequent dressing changes are required.

Methods Combined use of NPWT and acetic acid irrigation was assessed in the treatment of chronic wounds, instilling acetic acid solution (1%) beneath polyurethane membranes twice daily for three weeks under continuous pressure (125 mm Hg). Clinical photographs, pH levels, cultures, and debrided fragments of wounds were obtained pre- and posttreatment. Tissue immunostaining (CD31, Ki-67, and CD45) and reverse transcription-polymerase chain reaction (vascular endothelial growth factor [VEGF], vascular endothelial growth factor receptor [VEGFR]; procollagen; hypoxia-inducible factor 1 alpha [HIF-1-alpha]; matrix metalloproteinase [MMP]-1,-3,-9; and tissue inhibitor of metalloproteinase [TIMP]) were also performed.

Results Wound sizes tended to diminish with the combined therapy, accompanied by drops in wound pH (weakly acidic or neutral) and less evidence of infection. CD31 and Ki-67 immunostaining increased (P<0.05) post-treatment, as did the levels of VEGFR, procollagen, and MMP-1 (P<0.05), whereas the VEGF, HIF-1-alpha, and MMP-9/TIMP levels declined (P<0.05).

Conclusions By combining acetic acid irrigation with negative-pressure dressings, both the pH and the size of chronic wounds can be reduced and infections be controlled. This approach may enhance angiogenesis and collagen synthesis in wounds, restoring the extracellular matrix.

Keywords

Acetic acid - Biofilm - Negative pressure wound therapy

This article was presented at 72nd Congress of The Korean Society of Plastic and Reconstructive Surgeons on November 7-9, 2014 in Seoul, Korea.

Publication History

Received: 21 October 2014

Accepted: 15 December 2014

Article published online:
05 May 2022

• References

• 1 Arias CA, Murray BE. Antibiotic-resistant bugs in the 21st century: a clinical super-challenge. N Engl J Med 2009; 360: 439-443
• 2 Merckoll P, Jonassen TO, Vad ME. et al. Bacteria, biofilm and honey: a study of the effects of honey on 'planktonic' and biofilm-embedded chronic wound bacteria. Scand J Infect Dis 2009; 41: 341-347
• 3 de Laat EH, van den Boogaard MH, Spauwen PH. et al. Faster wound healing with topical negative pressure therapy in difficult-to-heal wounds: a prospective randomized controlled trial. Ann Plast Surg 2011; 67: 626-631
• 4 Kim BS, Choi WJ, Baek MK. et al. Limb salvage in severe diabetic foot infection. Foot Ankle Int 2011; 32: 31-37
• 5 Scherer SS, Pietramaggiori G, Mathews JC. et al. The mechanism of action of the vacuum-assisted closure device. Plast Reconstr Surg 2008; 122: 786-797
• 6 Milner SM. Acetic acid to treat Pseudomonas aeruginosa in superficial wounds and burns. Lancet 1992; 340: 61
• 7 Ryssel H, Kloeters O, Germann G. et al. The antimicrobial effect of acetic acid: an alternative to common local antiseptics?. Burns 2009; 35: 695-700
• 8 Ryssel H, Gazyakan E, Germann G. et al. Antiseptic therapy with a polylacticacid-acetic acid matrix in burns. Wound Repair Regen 2010; 18: 439-444
• 9 Ryssel H, Germann G, Riedel K. et al. Suprathel-acetic acid matrix versus acticoat and aquacel as an antiseptic dressing: an in vitro study. Ann Plast Surg 2010; 65: 391-395
• 10 Wedam SB, Low JA, Yang SX. et al. Antiangiogenic and antitumor effects of bevacizumab in patients with inflammatory and locally advanced breast cancer. J Clin Oncol 2006; 24: 769-777
• 11 Gill SE, Parks WC. Metalloproteinases and their inhibitors: regulators of wound healing. Int J Biochem Cell Biol 2008; 40: 1334-1347
• 12 Beidler SK, Douillet CD, Berndt DF. et al. Multiplexed analysis of matrix metalloproteinases in leg ulcer tissue of patients with chronic venous insufficiency before and after compression therapy. Wound Repair Regen 2008; 16: 642-648
• 13 Leonardi A, Cortivo R, Fregona I. et al. Effects of Th2 cytokines on expression of collagen, MMP-1, and TIMP-1 in conjunctival fibroblasts. Invest Ophthalmol Vis Sci 2003; 44: 183-189
• 14 Ladwig GP, Robson MC, Liu R. et al. Ratios of activated matrix metalloproteinase-9 to tissue inhibitor of matrix metalloproteinase-1 in wound fluids are inversely correlated with healing of pressure ulcers. Wound Repair Regen 2002; 10: 26-37
• 15 Bosanquet DC, Harding KG. Wound duration and healing rates: cause or effect?. Wound Repair Regen 2014; 22: 143-150
• 16 Rippke F, Schreiner V, Schwanitz HJ. The acidic milieu of the horny layer: new findings on the physiology and pathophysiology of skin pH. Am J Clin Dermatol 2002; 3: 261-272
• 17 Leveen HH, Falk G, Borek B. et al. Chemical acidification of wounds. An adjuvant to healing and the unfavorable action of alkalinity and ammonia. Ann Surg 1973; 178: 745-753
• 18 Percival SL, McCarty S, Hunt JA. et al. The effects of pH on wound healing, biofilms, and antim icrobial efficacy. Wound Repair Regen 2014; 22: 174-186
• 19 Mah TF, O'Toole GA. Mechanisms of biofilm resistance to antimicrobial agents. Trends Microbiol 2001; 9: 34-39
• 20 Kim PJ, Attinger CE, Steinberg JS. et al. Negative-pressure wound therapy with instillation: international consensus guidelines. Plast Reconstr Surg 2013; 132: 1569-1579
• 21 Schneider LA, Korber A, Grabbe S. et al. Influence of pH on wound-healing: a new perspective for wound-therapy?. Arch Dermatol Res 2007; 298: 413-420
• 22 Kiyokawa K, Takahashi N, Rikimaru H. et al. New continuous negative-pressure and irrigation treatment for infected wounds and intractable ulcers. Plast Reconstr Surg 2007; 120: 1257-1265
• 23 Ugaki S, Kasahara S, Arai S. et al. Combination of continuous irrigation and vacuum-assisted closure is effective for mediastinitis after cardiac surgery in small children. Interact Cardiovasc Thorac Surg 2010; 11: 247-251
• 24 Greener B, Hughes AA, Bannister NP. et al. Proteases and pH in chronic wounds. J Wound Care 2005; 14: 59-61
• 25 Leonardi A, Cortivo R, Fregona I. et al. Effects of Th2 cytokines on expression of collagen, MMP-1, and TIMP-1 in conjunctival fibroblasts. Invest Ophthalmol Vis Sci 2003; 44: 183-189