Goss S G, Schwartz J A, Facchin F, Avdagic E, Gendics C, Lantis J C
St. Luke's-Roosevelt Hospital Center, 1090 Amsterdam Ave., Suite 7A, New York, NY 10025, USA.
University of Padua, Padua, Italy.
J Am Coll Clin Wound Spec. 2014 Feb 20;4(4):74-80. doi: 10.1016/j.jccw.2014.02.001. eCollection 2012 Dec.
An overabundance of bacteria in the chronic wound plays a significant role in the decreased ability for primary closure. One means of decreasing the bioburden in a wound is to operatively debride the wound for wound bed optimization prior to application of other therapy, such as Negative Pressure Wound Therapy (NPWT). We undertook a prospective pilot study to assess the efficacy of wound bed preparation for a standard algorithm (sharp surgical debridement followed by NPWT) versus one employing sharp surgical debridement followed by Negative Pressure Wound Therapy with Instillation (NPWTi).
Thirteen patients, corresponding to 16 chronic lower leg and foot wounds were taken to the operating room for debridement. The patients were sequentially enrolled in 2 treatment groups: the first receiving treatment with operative debridement followed by 1 week of NPWT with the instillation of quarter strength bleach solution; the other receiving a standard algorithm consisting of operative debridement and 1 week of NPWT. Quantitative cultures were taken pre-operatively after sterile preparation and draping of the wound site (POD # 0, pre-op), post-operatively once debridement was completed (POD # 0, post-op), and on post-operative day 7 after operative debridement (POD # 7, post-op).
After operative debridement (post-operative day 0) there was a mean of 3 (±1) types of bacteria per wound. The mean CFU/gram tissue culture was statistically greater - 3.7 × 10(6) (±4 × 10(6)) in the NPWTi group, while in the standard group (NPWT) the mean was 1.8 × 10(6) (±2.36 × 10(6)) CFU/gram tissue culture (p = 0.016); at the end of therapy there was no statistical difference between the two groups (p = 0.44). Wounds treated with NPWTi had a mean of 2.6 × 10(5) (±3 × 10(5)) CFU/gram of tissue culture while wounds treated with NPWT had a mean of 2.79 × 10(6) (±3.18 × 10(6)) CFU/gram of tissue culture (p = 0.43). The mean absolute reduction in bacteria for the NPWTi group was 10.6 × 10(6) bacteria per gram of tissue while there was a mean absolute increase in bacteria for the NPWT group of 28.7 × 10(6) bacteria per gram of tissue, therefore there was a statistically significant reduction in the absolute bioburden in those wounds treated with NPWTi (p = 0.016).
It has long been realized that NPWT does not make its greatest impact by bioburden reduction. Other work has demonstrated that debridement alone does not reduce wound bioburden by more than 1 Log. Wounds treated with NPWTi (in this case with quarter strength bleach instillation solution) had a statistically significant reduction in bioburden, while wounds treated with NPWT had an increase in bioburden over the 7 days.
慢性伤口中细菌过多在影响一期愈合能力方面起着重要作用。减少伤口生物负荷的一种方法是在应用其他治疗方法（如负压伤口治疗（NPWT））之前，通过手术清创来优化伤口床。我们进行了一项前瞻性试点研究，以评估标准算法（锐性手术清创后行NPWT）与采用锐性手术清创后行滴注式负压伤口治疗（NPWTi）的伤口床准备效果。
13例患者（对应16处慢性小腿和足部伤口）被送入手术室进行清创。患者依次被纳入2个治疗组：第一组接受手术清创治疗，随后1周采用滴注四分之一浓度漂白剂溶液的NPWT；另一组接受由手术清创和1周NPWT组成的标准算法治疗。在伤口部位进行无菌准备和铺巾后（术后第0天，术前）、清创完成后（术后第0天，术后）以及手术清创术后第7天（术后第7天，术后）采集定量培养样本。
手术清创后（术后第0天），每个伤口平均有3（±1）种细菌。NPWTi组每克组织培养的平均菌落形成单位（CFU）在统计学上更高，为3.7×10⁶（±4×10⁶），而标准组（NPWT）平均为1.8×10⁶（±2.36×10⁶）CFU/克组织培养（p = 0.016）；治疗结束时，两组之间无统计学差异（p = 0.44）。接受NPWTi治疗的伤口每克组织培养平均有2.6×10⁵（±3×10⁵）CFU，而接受NPWT治疗的伤口每克组织培养平均有2.79×10⁶（±3.18×10⁶）CFU（p = 0.43）。NPWTi组每克组织细菌的平均绝对减少量为10.6×10⁶，而NPWT组每克组织细菌平均绝对增加量为28.7×10⁶，因此，接受NPWTi治疗的伤口绝对生物负荷有统计学意义的降低（p = 0.016）。
长期以来人们已经认识到，NPWT对减少生物负荷的影响并非最大。其他研究表明，单纯清创对伤口生物负荷的降低不超过1个对数。接受NPWTi治疗（在本研究中使用四分之一浓度漂白剂滴注溶液）的伤口生物负荷有统计学意义的降低，而接受NPWT治疗的伤口在7天内生物负荷增加。
