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WOUND CLEANSING

Antiseptics, iodine, povidone


iodine and traumatic wound
cleansing
Muhammad N Khan
General Surgery, North Hampshire Hospital NHS Trust, Basingstoke.
Abul H Naqvi
General Surgery, St Luke's Hospital Kilkenny, County Kilkenny, Ireland
Key words: antiseptic, iodine, povidone, traumatic wound cleansing
Received 19 July 2005, accepted for publication 1 November 2005
Abstract
Wound cleansing is an integral part of the management of
acute traumatic wounds. There is consensus that it
reduces infection rates. However, the choice of cleansing
agent remains controversial, especially the use of
antiseptics has been questioned. This article reviews the
current literature on the use of antiseptics particularly
povidine iodine in traumatic wound cleansing and
discusses the beneficial and harmful effects of such
practice.
Introduction
Numerous studies have shown the conflicting results of
bactericidal properties, cytotoxicity and suppression of
wound healing with the use of antiseptics. Due to the lack
of powerful clinical studies, a standardised regimen has
yet to be established.
The existing evidence regarding the use of povidone
iodine is complicated by the mixture of laboratory,
human and animal studies. In vitro studies have shown
the toxic effects at a cellular level but clinical studies have
failed to show statistically significant difference compared
with control interventions. With the emergence of
antibiotic resistance, there has been a reappraisal of the
use of povidone iodine especially in the management of
contaminated and infected wounds.
Acute wounds are defined as wounds that heal within
an expected time frame without complications'.
Traumatic wounds are one category of acute wounds that
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account for about 20-25% of the accident and emergency
department workload
2
. Depending upon the mechanism
of injury they can vary from abrasions and contusions to
lacerations and avulsions or degloving injuries] Traumatic
lacerations occur when the body is subjected to a force
that exceeds the strength of skin or the underlying
tissues" Due to the presence of devitalised tissue, foreign
bodies and bacteria, traumatic wounds often predispose
to the development of invasive infection, which may
range from cellulites to deep myositis.
Wound cleansing
Wound cleansing forms a critical part of the management
of these wounds. It applies to the application of fluid to
aid removal of exudate, debris, slough and contaminants'.
Any traumatic wound should be considered
contaminated at presentation
6
. Thorough cleansing of
these wounds has shown to reduce the infection rate
7

The objective of wound cleansing is to remove the


organic and inorganic debris and to create optimum local
conditions for wound healing". However, unnecessary
removal of the exudate may deprive the wound of the
necessary repair agents and enzymes responsible for the
coordinated sequence of wound healing and will result in
drying of the wound, which goes against the principles of
moist wound healing'o,,,.
Different terms including wound cleansing, wound
cleaning and wound irrigation have been used in the
literature. Unfortunately these terms have not been
standardised in studies and are used interchangeably.
Swabbing and irrigation are the usual cleansing
techniques but bathing or showering are other options
VOL 16 NO.4 NOVEMBER 2006
described in the hterature.
Apart from different techniques used for cleaning and
irrigating wounds, there is disparity among the solutions
used for cleansing. Different solutions ranging from tap
water to normal sahne to antiseptics have been used, all
having their own disadvantages and advantages. The
assessment and protocol of management, however, seems
rituahstic rather than evidence based
12

13
Although there is evidence to suggest that wound
cleansing is not always necessari
4
, there is no diagnostic
test that would allow healthcare professionals to identify
the bacterial load in the wound capable of causing wound
infection". The situation is further complicated by studies
showing that bacterial colonisation of the wound does not
necessarily indicate infection and there is no need to
remove the bacteria in the absence of clinical signs of
infection'6.".
Antiseptics
The use of antiseptics, particularly povidone iodine, in the
management of acute traumatic wounds has remained a
controversial issue over the last two decades. It is also
important to realise that the term iodine has sometimes
been used to describe all formulations including povidone
iodine, cadexomer iodine and others. These preparations
have different iodine concentrations and different
characteristics of their component parts. This raises the
question of whether they should be grouped and studied
separately.
The term antiseptic was first used by Pringle in 1750'"'
An antiseptic is a substance that inhibits the growth and
development of micro-organisms causing sepsis in
wounds'9. They may be either bactericidal or
bacteriostatic. Commonly used antiseptics for wound
cleansing include chlorhexidine, iodine compounds,
alcohol, benzalkonium chloride and hydrogen peroxide.
The use of antiseptics in wound care is controversial.
The debate started after Fleming's lecture in 1919 about
his work on antiseptics in septic wounds. The use of
antiseptics began to decrease in 1929 after the discovery
of penicillin. Stringer et al showed that antiseptics confer
no benefit as compared to sahne in cleansing wounds'o In
vitro experiments by Brennan and Leaper
2
' demonstrated
antiseptics were detrimental to the production of
collagen, impairing epithehal migration and inhibiting
microcirculation. Furthermore antiseptics are inactivated
by contact with body fluids, blood, and proteins'
However, they need to be in contact long enough to
reduce bacterial numbers
23
This evidence led to a decrease in the popularity of
antiseptics for wound cleansing and there was a decline in
their use with more emphasis on antibiotics in the
treatment of contaminated/infected wounds. However,
with the emergence of bacterial resistance to antibiotics,
there has been a reappraisal in the use of antiseptics, and
especially iodine compounds.
VOL 16 NO.4 NOVEMBER 2006
Iodine is one of the long established antiseptics. Early
preparations caused local pain and tissue reaction.
Povidine iodine was introduced 40 years ago. It contains
polyvinylpyrrolidone iodine, which is a water soluble
complex of elemental iodine with a synthetic polymer.
10% solution in water is the most commonly
manufactured form.
It has a bactericidal action and is effective against a
wide range of bacteria, fungi and even spores
24
. The killing
action occurs in seconds and is thought to be from
inactivation of vital cytoplasmic substrates, which are
necessary for bacterial viability25. l s m ~ proteins can bind
up to 80% of free iodine'6
The presence of organic matter has a marked
depressant effect on the minimum lethal concentrations
of iodine. In the absence of inhibitors the disinfection is
rapid, probably less than 10 seconds
27

Antiseptics were the main stay of wound management


until the mid-1980s, when research by Brennan and
Leaper showed the effects of antiseptic solutions on
wound healing physiology. They evaluated the effects of
various antiseptics on wound micro-circulation in the
rabbit ear chamber model of healing. The action of
antiseptics on micro-circulation within the granulation
tissue was examined with a laser Doppler flow meter. In
wounds exposed to Eusol and chloramines T, the tissue
perfusion ceased immediately and even after several days
of observation these vessels did not re-open. Sahne and
hydrogen peroxide did not result in any change in the
pattern of blood flow. Chlorhexidine caused a few
capillaries to close down. The effect of povidine iodine
was concentration dependent. At a concentration of 5%,
blood flow ceased in small blood vessels but a 1%solution
was innocuous. This study is quoted as the strongest
evidence against the use of antiseptics.
However, the sample size was small, with only two
wounds for each cell type. In order to be statistically
significant this study needs to be rephcated. There should
also be some concern in transferring the data from an
experimental model to a clinical situation. Furthermore
there is no strong evidence on human models of wound
healing. The authors have shown that the apphcation of
antiseptics irreversibly destroys angiogenesis, however it
should be remembered that angiogenesis is just one step
in the complex healing cascade. The Doppler flow meter
used by the authors to monitor the micro-circulation
could not be calibrated in order to provide a reading of
flow per unit time. This may have affected the rehabihty
of measurements. They also used the term 'flooding the
ear chambers with antiseptic', which needs clear
definition.
Further in vitro studies have shown that the weaker
solutions of hypochlorites, compatible with the
preservation of fibroblast function, can still inhibit the
growth of bacteria including Staphylococcus aureus,
Pseudomonas, Bacteriodes, and Eschericia colf
8
7
WOUND CLEANSING
But it must be remembered that in vivo the presence
of pus, blood and exudate can further dilute the
concentrations of these antiseptics and decrease their
efficacy. Hypochlorites also result in skin irritation and
are harmful to granulation tissue
29
. Research by Tatnall et
a13
0
has shown that at concentrations recommended for
wound cleansing, hypochlorite, hydrogen peroxide and
chlorhexidine, all result in 100% killing of cultured
keratinocytes and fibroblasts, with the hypochlorites
being the most toxic. Hence the routine use of
hypochlorites in wound cleansing is not advisable.
Iodine
There have been conflicting studies regarding the
usefulness of iodine in managing traumatic wounds",n
Clinical trials have shown mixed success
33
,34,35.
Roberts et a13
6
published a series of 418 patients with
hand lacerations who were randomly allocated to a group
where the injury was treated with povidone iodine before
suturing and to a control group. They found no adverse
effects of iodine on healing and the overall infection rate
was significantly lower in the group treated with
povidone iodine.
Similar results were seen by Gravett et al (1987) when
they compared 1% povidone iodine to normal saline in
the management of traumatic lacerations and found a
statistically significant difference between the two groups
with an infection rate of 5.4% and 15.4% respectively''.
Gordon (1993) found iodine very effective against
MRSA and its value in helping control MRSA outbreaks
is well recognised
38
,39.
Similarly Goldenheim (1993) demonstrated that
povidine iodine .preparations do not have a deleterious
effect on healing, It is useful in the treatment of burns
because of its broad-spectrum activity and high
penetration power'o. However, he recommended that it
should not be used in pregnant women, newborns and
those with thyroid disorders.
Research by Cooper and Lawrence" found that
wound cleansing with povidone iodine or cetrimide did
not significantly reduce the number of bacteria present in
contaminated lacerations.
The mere presence of bacteria in a wound does not
necessarily mean infection as wounds are usually
colonised by bacteria. However, if the bacterial count
reaches a certain level where the host defences cannot
maintain the balance of organisms in the wound, it is
referred to as critical colonisation
42
and it can be a
predecessor of invasive infection,
Timely and appropriate use of topical antiseptics may
return a wound from critical colonisation back to the
state conducive to wound healing. Bacteria in the wound
not only delay healing but also produce malodour; their
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toxins can be destructive to the wound bed and they can
result in an increase in the amount of exudate.
Medicated wound dressings impregnated with iodine
have also been evaluated in the management of acute
wounds and have met with m.i..,'Xed success. Cadexomer
iodine ointment has been found to be highly efficacious
and has been reported to accelerate epithelisation as
compared to air exposed wounds, with out any deleterious
effects". It has also proven effective against proliferation of
MRSA in wounds. Davison and Keenan" have reported a
randomised trial of three different wound dressings after
nail matrix ablation with phenol. Povidone-iodine dressing,'
amorphous hydrogel dressing and a paraffin gauze dressing
were compared, The main outcome measure was clinical
infection rate and there was no statistically significant
difference between the three groups.
Iodine released from cadexomer iodine has been
shown to have a pro-oxidant effect, which could
stimulate fibroblast proliferation in vitro". It also induces
tumour necrosis factor alpha and inhibits the production
of Interleukin-6 (IL-6) from macrophages, growth factors
that are important for inflammation induction'6.
Development of resistance to antiseptics is thought to
be rare. However, certain species such as bacterial spores,
mycobacteria and gram-negative bacteria possess intrinsic
resistance and several bacteria can acquire plasmid
mediated resistance".
Development of resistance to povidone iodine is very
unlikely because it requires alteration in the bacterial cell
proteins'8. Povidone iodine also has an effect on the
bacterial exotoxins and enzymes, which can cause further
tissue damage'9. Yasuda et al's study' looked at the
antiseptic resistance of 20 bacterial strains and found that
povidone iodine killed all bacteria within 20 seconds,
This study showed that iodine is effective against
intrinsically resistant and non-resistant gram negative
bacteria. Studies have shown that the acquisition of
resistance to the long-term use of povidone iodine is not
observed".
Iodine solutions are deactivated in the presence of
organic material, pus, slough and necrotic tissue in the
wound
52
,53,5'. In vitro experiments by Lawrence
5s
have
shown that although the presence of exudate deactivates
povidone iodine dressings, they can reduce the bacterial
counts of the wounds to a very low level as compared to
controls.
Studies by others have shown different results.
Kunisada et a1'6 tested povidine iodine, chlorhexidine and
benzalkonium chloride solutions against different
nosocomial bacteria. They used solutions of different
concentrations and exposed them for varying lengths of
time, The bacteria were suspended in different
concentrations of neutralising plasma serum. The results
showed that povidine iodine was highly effective against
all the test organisms at a very low concentration and
over a short period of time. However, the in vitro
VOL 16 NO.4 NOVEMBER 2006
evaluation of the antibacterial activity of an antiseptic
may not necessarily be a good guide to its activity in
clinical use. Its effects on the immune system, toxic
effects on wound healing and inactivation by the body
fluids should also be taken into accounf
5

Animal studies involving antiseptics have shown


chlorhexidine, iodine and hydrogen peroxide to be toxic
to fibrobiasts'l. Povidine iodine even at low
concentrations has been shown to be toxic to
granulocytes and monocytes" and results in decreased
chemotaxis
5
". It is also capable of suppressing lymphocyte
functions
59
.
Mulliken et al
60
studied the tensile strength of heahng
wounds in winstar rats and found no statistical difference
in the rate of gain of tensile strength and histological
appearance between the control and experimental
groups. They concluded that apphcation of 1% povidone
iodine solution to clean incised wounds does not affect
fibroplasia or collagen cross-linking. In vivo studies have
shown that application of 5% povidone iodine solution
inhibits polymorphonuclear leukocytes and fibroblast
migration and activity61.
In contrast, research in 2001 by Bennett et a1
62
on
porcine models of wound healing has shown that
apphcation of 10% povidone iodine solution is associated
with increase in the number of proliferating fibroblasts at
day four and enhanced angiogenesis at day seven as
compared to the controls
6
'. However, different research
methodologies make the comparison of these studies
difficult.
Work in 2002 by Balin and Pratt has shown that even
dilute solutions of povidone iodine can be toxic to
human fibroblasts as at concentrations of 0.1 % and 1%,
human fibroblast growth is totally inhibited"3.
Concentrations lower than 0.1 %progressively retard the
growth. However, they have also noted that there was
partial recovery of cell growth after limited exposure.
The results of the above studies are conflicting,
however it must be remembered that the relationship
between povidone iodine and free iodine concentrations
is not linear, as it forms a bell shaped curve, which peaks
at 0.7% concentration. Higher concentration of povidone
iodine can paradoxically bind more free iodine to the
carrier molecule, thereby lowering the available free
iodine
6
'.
Iodine compounds are not hazard free. Toxic
symptoms can result from systemic absorption. These
include nervousness, depression, insomnia, myxoedema,
hypersensitivity and skin reactions
6s
. The absorption
depends upon the concentration and the particular use of
iodine.
Absorption is increased in the presence of damaged
tissue, hence its use is not recommended in burns
involving more than 20% of the body surface area
66
.
Metabolic acidosis and hypernatremia are the other
possible toxicities
6
'.
VOL 16 NO.4 NOVEMBER 2006
Conclusion
Wound cleansing remains a corner stone in the
management of acute traumatic wounds". Due to the
lack of powerful clinical studies, a standardised regimen
has yet to be established
54

The existing evidence regarding the use of povidone


iodine is complicated by the mixture of laboratory,
human and animal studies. In vitro studies have shown
toxic effects at cellular level but clinical studies have
failed to show statistically Significant differences with
control groups.
With the emergence of antibiotic resistance, there has
been a re-appraisal of the use of povidone iodine
especially in the management of contaminated and
infected wounds. Well designed in vivo studies are
required to prove its efficacy, however the debate seems
to be far from resolved.
Acknowledgements
We are grateful to Dr. Sadaf Rafique for her generous
help with the hterature search and proofreading.
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