Mortally wounded

There have great strides in the treatment of wounds and wound infections with recent advances in technology, however infections remain responsible for a high rate of mortality. James Woodburn looks at the history of wound care and at two complimentary wound care products that are making a comeback after years in limbo.

The treatment of wounds and wound infection is as old as mankind and yet with all the medical knowledge available to modern physicians wound infections remain responsible for a disturbingly high rate of mortality, particularly among post-surgery patients.

Some of the first documented evidence describing wound treatments dates back to the ancient Egypt-ians who were the first civilisation to have trained physicians to treat physical aliments. Medical papyri, such as the Edwin Smith papyrus (circa 1600 BC) and the Ebers papyrus (circa 1534 BC), provided detailed information about the management of disease, including wound management with the application of various potions and grease to assist healing.

Aulus Cornelius Celsus (circa 25BC-50AD), considered one of the greatest Roman medical writers, described the four principal signs of inflammation and recommended cleanliness and the washing of wounds with antiseptic substances, such as vinegar.

The father of surgery, Claudius Galen (c129-216AD), a Greek physician to the Roman gladiators, was prolific with over 500 medical treatises to his name. However, much of his work was later discredited. It was centuries later during the Renaissance that his ‘pus bonum et laudabile’ (good and commendable pus) theory, which incorrectly asserted that the development of pus in a wound was a positive part of the healing process, was discredited.

In the 19th century physicians developed methods for skin grafts to cover open non-healing wounds thereby decreasing the amount of time the wound is exposed to bacteria and reducing the chance of infection.

By the middle of the 19th century, post-operative sepsis infection accounted for the death of almost half of the patients undergoing major surgery

During the 1860’s Joseph Lister (1827-1912), a British Professor of Surgery, began experimental work with antisepsis and when Louis Pasteur (1822-1895), a French bacteriologist, sug-gested in 1865 that decay was caused by living organisms in the air, which on entering matter caused it to ferment, Lister made the connection with wound sepsis revolutionising the entire concept of wound infection. In 1867 Lister placed carbolic acid into open fractures to sterilise the wound and prevent sepsis and the need for amputation, until then a common treatment for chronic wound infections.

It was only in the late nineteenth century that ascetic surgery came into practice with the sterilisation of instruments and the wearing of gowns, masks, and gloves.

Penicillin first was used clinically in 1940 by Howard Floery and with the use of antibiotics, a new era in the management of wound infections began.

However, surgical-site in-fections (SSI) and hospital acquired infections (HAI) are still a major problem, largely due to antibiotic-resistant bacteria.

The United States-based Centers for Disease Control and Prevention (CDC) “Guideline for Prevention of Surgical Site Infection, 1999,” notes that SSIs are the “third most frequently reported nosocomial infection, representing 14 per cent to 16 per cent of all nosocomial infections among hospitalised pa-tients”. The guideline also states that hospitals in the CDC’s National Nosocomial Infection Surveillance Sys-tem who conducted SSI surveillance from 1986 to 1996 reported 15,523 (2.6 per cent) SSIs resulting from 593,344 operations. SSIs were the most common nosocomial infection among surgery patients, accounting for 38 per cent of infections. Of these, two thirds of the infections were confined to the incision, with one third affecting organs or spaces accessed during the operation. The deaths of 77 per cent of the patients with SSI were reportedly related to the infection.

“Patients incur a 20-25 per cent increase in costs due to HAI and SSI. Most of these costs are for nursing care and hospital overheads,” Dr Osama Beltagi, Franchise Director of Ethicon, Johnson & Johnson Middle East, points out, adding: “Simple preventative measures can drastically reduce these costs.”

In a study by Leape et al, patients experiencing SSI have their hospital stay prolonged by 7.3 days on average. The study notes that SSI’s clearly cause substantial morbidity and mortality and create a financial burden on healthcare systems.

l Check the CDC Guidelines for SSI and Recommendations for the Prevention of SSI:

Demanding better products

As the world’s population ages so is there an expected increase in the incidence of chronic wounds, which is fuelling the demand for in-novative wound-care products.

According to recent analysis by Frost & Sullivan the US$1.1 billion Euro-pean wound-care market is slated to grow at an annual average of 10-12 per cent over the next five years.

Similar to the United States, the demand for wound-care products is expected to increasingly swing from traditional to advanced dressings and treatments.

Minakshi Krishnan, Re-search Analyst for Frost & Sullivan notes that “an aging population, advancement in technology, emphasis on efficient healing methods and in-creasing patient awareness are keen drivers for the advanced wound- care market”.

Dr Beltagi says in the Middle East the demand for innovative wound care products is growing rapidly and gives as an example one of Ethicon’s new products, Promogran - a treatment for chronic and acute wounds. Launched in the region last October, he says sales have grown 50 per cent in Q1 2004.

He points out that although these products may be more expensive than the traditional ones, healthcare institutions and patients will save money in the long term as the new treatments heal wounds faster, meaning patients spend less time in hospital and can return to families and work sooner.

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