Wound infection – an expert snapshot

It’s time for woundcare to be counted

On passing the 500 member milestone, we touched base with Dr Douglas Queen and Professor David Leaper (secretary of the IWII, pictured) at the Wound Healing Research Unit in Cardiff, Wales. This was an opportunity too good to miss.

Tapping Doug’s experience as a journal editor and consultant working internationally in wound care, along with David’s considerable policy forming experience in the field gives us an expert snapshot of wound infection at the end of 2009.

Q: What direction is wound care going in as we near the end of the 1st decade of the 21st century?

Doug: Over the last 10 years the emergence of silver dressings has heightened awareness of wound infection and the problems it generates, helping wound care to emerge as a clinical speciality. Where will it take us? I think the emergence of point of care diagnostics for infection will be the next big development, with routine assessments being made on a technological as much as an expertise basis.

David: I agree. In addition to silver we are seeing the emergence of biguanides, already well established in Europe, and the emerging evidence that they could be as good as silver and possibly cheaper. There will also be a big focus on biofilms and our understanding of them. Some biofilm detection diagnostic is required such as a device that can brush wounds, for example, before you start putting antiseptics on them to make their antibacterial activity more extensive. There is huge pressure to innovate in this area. But one area where I would really like to see change is political, on the positioning of wound care and on the role of randomised control trials (RCTs).

Doug: RCTs will never be the gold standard for wound care because the patients are too complex. We should get round this with individual clinicians coming up with and publishing real live data on wounds that will be more effective.

David: That’s right. Compression, for example, corrects an underlying vascular (venous) problem, so RCTs can be very useful, but wound care has multiple causes.

There is a well designed RCT that suggests that on wounds, any dressings can be used, and that silver is no better for wound healing than any other dressing. It’s a good RCT but with a flawed hypothesis in my view. Silver was never marketed to heal wounds, it’s there to treat infection. the rigid idea that everything has to be RCT driven is wrong, at least for wound care, and someone should go to government and state that case. The outcome of this recent study was predictable and it will have been an extensive use of Department of Health (UK) generated funds.

Also, the government must accept the whole concept of reducing the use of antibiotics. In primary care, if you get a wound complication you will almost certainly be given an antibiotic. A major role for the International Wound Infection Institute, for example, could be developing a political agenda that addresses these issues.

Doug: It’s true that wound care has been too passive. Governments are becoming interested in treating wounds, but from other aetiological perspectives. For example Scottish Enterprise has funded an infection diagnostic for Diabetic Foot Ulcers for £8 million. It’s not wound care but who cares?

Q: So you think that harnessing individual clinical experience is the way forward?

David: Yes, and there are some journals that are doing that. But an educative group supported by governments, a 7 or 8 nation push would be good.

Doug: Ultimately a body like the IWII could be able to influence these bodies; the IWII needs to get critical mass, because wound care needs to have a voice that can influence decision makers.

Q: If you are a decision maker in a government organisation, able to influence the provision of wound care services, what would you be looking for in a web site like ours?

David: Concrete recommendations like those generated by NICE or SIGN are what many practitioners want. Any organisation that tackled dressings in a similar way would make a great contribution. That would be a major job, 2 or 3 years, and then perhaps we would really progress.

In terms of other ideas, a roadshow would be wonderful. Having joined one on surgical site infections with the Infection Protection Society I think you can reach many people that way, handing out useful material. With our international committee and our 500 members, we have a lot more clout than we might think.

Q: Going back to where we started, are there any other agents that will emerge for wound infection in the future? Iodine, for example?

Doug: Yes, that is coming back into fashion because of its action on biofilm but also due to concerns with resistance.

David: Sugar is another agent that has a known antibacterial effect and I’d like to see a comparison with honey, because specific honeys are marketed for wound care!

Q: And the focus on biofilms?

David: This is because it’s seen as a new concept. Dentists have known about them for a long time and in the past few years these have been recognised in wounds. As I mentioned, diagnostic tools for biofilms are going to be a big focus in the next few years.

Q: We have had a great deal of comments on biofilms and critical colonisation, what the connection is, whether they are one and the same thing. Do you have any thoughts on this?

David: There is probably a link between biofilms and critical colonisation, but there is no diagnostic for this.

Doug: I agree with David, it sounds very exciting but has not been validated clinically.

Q: So the big things for the IWII are?

David: Education and politics

Doug: The cost of wound care is far more than the cost of dressings. The expenditure on treating wounds worldwide is at least $70 billion, and infection management is central to wound management. So politics, yes, it’s time for wound care to be counted.