Antimicrobial resistance (AMR) has been highlighted by the World Health Organization (WHO) as the biggest Global Threat going forward (Murray et al, 2022). It is estimated by 2050 that deaths caused by AMR could exceed 10 million, similar numbers to those associated with cancer (Okeke et al, 2024). It is proposed by many AMR action plans across the world (Munkholm and Rubin, 2020; Department of Agriculture, Environment and Rural Affairs, 2024) that new antimicrobials need to be found and antimicrobial stewardship (AMS) programmes which involve strategies and interventions that aim to reduce unnecessary antimicrobial use, need to be introduced (Dyar et al, 2017; Lipsey et al, 2016). This should prevent inappropriate use of antimicrobials and allow new approaches for the introduction of agents that are less likely to develop resistance and other alternatives to be found (Yang et al, 2024).
In wound care, it has been shown that many patients receive antibiotics unnecessarily (Serena et al, 2022) especially when chronic wounds are being treated. Recent studies have shown that some slow to heal and non-healing chronic wounds are still receiving care up to 12 months after initial consultation at an average cost of approximately £7,500 per patient per year (Guest et al 2018). Alternative approaches to diagnostics and treatment are being introduced slowly but failure to heal some wounds remains a problem (Rosenbaum et al 2018; Ongarora, 2022). Many wounds are cared for in the community setting where new approaches, such as biofilm-based wound care, are difficult to introduce as more education and evidence is needed to convince the wound care nurses, podiatrist and doctors (Grothier, 2018). Although AMS policies have been written and introduced there is limited evidence in wound care that alternative approaches are being used and that antibiotic usage is reducing as fast as needed (Ousey et al, 2022).
Wound management is complex and requires evidence to change practice (Flanagan, 2005). In order to significantly reduce inappropriate use of antibiotics it is vital that there is adherence to AMS policies, however, it is known that clinically there is a lack of standardisation and adherence to AMS policies (Doyle et al 2022). Wounds at high risk of infection or where the wound shows signs of deterioration require intervention but with the lack of point of care diagnostic tools and the time taken to receive a result from the laboratory, it is necessary that empirical antibiotics are prescribed (Lipsky et al, 2020). These antibiotics are prescribed based on local policies which follow susceptibility patterns of known pathogens (Brown 2015).
Acute versus chronic wounds
More than 90% of all acute wounds will heal within 10 days provided that the patient has few or no co-morbidities (Canedo-Dorantes and Canedo-Ayala 2019). However, if there is a local infection then oral antibiotics, will be administered and the infection usually resolves (Hurlow and Bowler 2022). Certain complexities such as wound size, presence of foreign bodies, comorbidities etc may extend the healing time, creating immense problems for the patient (Siddiqui and Bernstein, 2010; Bosanquet and Harding, 2014; Sandy-Hodgetts et al 2015). If the wound does become chronic, then the wound care practitioner should try to rectify any comorbidities with appropriate treatment and contemplate using biofilm based wound care to prevent the formation of a biofilm or eradicate it if it has already formed (Leaper et al, 2015). It is very difficult to accurately diagnose a local wound infection and the characteristic inflammatory signs of heat, pain, swelling and redness can sometimes be misdiagnosed as an infection, which again can lead to inappropriate antibiotic use (Williams, 2021).
Several clinical factors have been validated as good indicators of a local wound infection and are presented as the Therapeutic Index for Local Infection (TILI)(Dissemond et al, 2020a;). If at least five of the six non-direct indicator criteria, or at least one direct indicator criteria, is met, this indicates that antiseptic wound therapy could be initiated. [Box 1] (Dissemond et al, 2020a).
This tool has been validated and demonstrates statistical validity across Europe and can help with identification of a local infection (Dissemond et al, 2020b). This enables the clinician to give the appropriate treatment to the patient with more confidence. Antibiotics are not always required to treat a local infection .and it is possible to use topical antimicrobial agents instead (Roberts et al, 2017). The evidence for use of topical antimicrobial agents is increasing and examples commonly used are silver ions, polyhexamethylene biguanide, iodine, chlorhexidine, honey and preparations producing oxygen radicals, (Geng et al, 2025), some allow sustained release of the antimicrobial agent to allow longer wear time (Gámez-Herreraet al, 2020).
Biofilm-based wound care
A biofilm is a surface associated community of microorganisms held together in an extracellular polymeric matrix (Percival et al, 2015) and usually consists of a variety of skin organisms and common wound pathogens. Those that are well known for producing biofilms are staphylococci and Pseudomonas sp (Bjarnsholt, 2013). Biofilms can be made of a single species but in chronic wounds they are often multi-species (Bjarnsholt, 2013; Percival et al 2015). Biofilm-based wound care was proposed by Wolcott et al (2010) and includes utilising debridement followed by vigorous cleaning (if the wound is not too painful or vascular) and application of a topical antimicrobial dressing or an alternative that is shown to reduce bioburden through enzymatic reduction or physical removal (Swanson et al, 2022). This process should be repeated as frequently as possible as it has been shown that a biofilm will reform within 24 hours (Phillips et al, 2015) unless appropriately disrupted.
The importance of debridement and cleaning
Debridement and cleaning is an essential part of wound bed preparation. Without the removal of the devitalised tissue and slough, biofilm can persist and inhibit wound healing (Phillips et al, 2015). Frequent debridement and cleaning are advised until there is evidence that the wound is progressing to healing. Sometimes this is every 24 hours but can be bi-weekly or weekly, depending upon availability of the wound care practitioner and the patient. Selection of the method of debridement is based on pain, the surrounding skin and the status of the wound bed (Weigelt et al, 2021; Swanson et al, 2022) and the capability of the clinician as some debridement techniques require specialist training (Elraiyah et al, 2016). Some wounds can be debrided with products that encompass slough trapping fibres and this allows any clinician to use them without the need for extensive training (passive debridement). These dressings can negate the need for sharp debridement (active debridement) (Wounds UK, 2013; Lumbers, 2018; Weir and Swanson 2018; Schultz et al, 2018). These dressings can negate the need for sharp debridement and improve patient outcomes, maintaining patient safety by preventing further complications (Schultz et al, 2018). Where there is no obvious devitalised tissue, a thorough cleaning of the periwound skin and wound bed to reduce contaminants, loose debris, non-attached necrotic tissue and remnants of previous dressing material may suffice (Dowsett 2023). Cleansing removes debris and this may be done by soaking the wound with antiseptics but most commonly the wound is rinsed with sterile saline (Weir and Swanson 2019; Dowsett 2023). Increasingly surfactants are used to remove barriers to wound healing including debris and in some cases, biofilm (Percival et al, 2019). In addition, the use of concentrated surfactant based wound dressings have been shown to loosen, soften and sequester debris and necrotic tissue (Percival et al, 2017).
Novel dressings, such as UrgoCleanTM (UrgoMedical), have been introduced and validated which enable simultaneous debridement and cleansing through the novel fibres used within the dressing (Meaume et al, 2012; Meaume et al, 2014). In addition, UrgoClean AgTM (UrgoMedical) contains silver ions that kill microorganisms entering the dressing, preventing reinfection of the wound bed (Dissemond et al, 2020c). The action of the silver ions will be enhanced as the bioburden in the wound bed is reduced through the cleaning action of the dressing allowing a more effective environment to target susceptible organisms known to cause infection such as Staphylococcus aureus, MRSA, Streptococcus pyogenes and Pseudomonas aeruginosa (Grothier, 2015).
These products are exceptionally useful in the community setting where access to some of the more modern techniques and availability of products are limited. Having one product that can combine techniques will save on cost and give a better quality of life during the healing process for the patient (Grothier, 2015; Dowsett, 2023).
UrgoClean and UrgoClean Ag
UrgoClean contains unique technology that is effective at dealing with sloughy wounds. It is an advanced wound care dressing made of cohesive poly-absorbent acrylate fibres and a lipido-colloid matrix (Technology Lipido-ColloidTM (TLC) layer that is in contact with the wound (Desroche et al, 2016). When the dressing is in contact with wound exudate, the TLC forms a gel, creating a moist wound environment and the sloughy residues bind to the fibres facilitating autolytic debridement. UrgoClean Ag is the same technology but with silver ions incorporated in a lipido-colloid layer (TLC-Ag) giving it added antimicrobial activity and improved efficacy against biofilms in the wound bed (Desroche et al, 2016; Percival et al, 2017). In vitro studies showed that UrgoClean Ag reduced the biofilm population by more than 99.99% (4.6 log reduction) which was maintained for seven days (Desroche et al, 2016).
In the EARTH randomised controlled trial where UrgoClean was compared to a commonly used hydrofiber dressing, it showed improved desloughing properties, especially in the management of venous ulcers at the sloughy stage (Meaume et al, 2014). Another study where 2,270 patients with acute and chronic wounds were treated with UrgoClean -Ag showed that all clinical signs of infection were substantially reduced in 2 weeks after initial consultation (Dissemond et al, 2020c). In addition, the value of TLC-Ag healing matrix in UrgoClean Ag was shown to be good at preventing infection in high-risk wounds as demonstrated in two RCTs (Harding et al, 2012; Lazareth et al, 2012). UrgoCleanwas shown to provide a continuous cleaning action for up to seven days, which can be necessary under a compression bandage in chronic ulcers (Dalac et al, 2016)
Clinical applications of UrgoClean and UrgoClean Ag
Case Study 1: In December 2022, an 83-year-old female presented at the local health care setting with a right anterior ankle ulcer just at the ankle joint. A diagnosis of vasculitis was made and the patient was commenced on systemic steroids, neutral dressing and referred to the vascular team for review. The patient had a past medical history of congestive cardiac failure (CCF), pulmonary embolism (PE), aortic valve replacement and chronic kidney disease.
On vascular review, 3 weeks later, gentle sharp debridement was completed, and a combined topical antimicrobial dressing and hydrogel were used to continue debridement and treat suspected local infection with twice weekly dressing changes. Six weeks later, the patient presented with new bilateral lower limb oedema and pain at the ulcer site scoring 5/10. The existing topical dressing regimen was continued with short-stretch bandaging applied bilaterally to manage the new oedema. A referral was made to cardiology to assess her CCF and this was actively treated. Over the following 6 weeks, the bilateral lower-limb oedema increased resulting in bilateral blistering and resulted in the patient attending the emergency department as they were systemically unwell. A diagnosis of infected vasculitic ulcer exacerbated by chronic poorly controlled oedema was made and the patient was admitted and treated with intravenous (IV) antibiotics and management of infected ulcer and bilateral lower-limb oedema. Over the following 4-week hospital stay, acute vasculitis and pyoderma were excluded and the ulcer and associated lower-limb oedema were treated ensuring her CCF was optimally managed. During this time, the patient continued to have challenges with bilateral lower limb pain and also slept in her chair with legs dependent despite advice to the contrary.
The wound was treated with various topical regimens including hydrofiber, hydrocolloid gels, antimicrobials, anti-inflammatory/antibiotic ointment and short-stretch bandaging. Broken areas to the skin on the contralateral leg were also treated with various dressings including antimicrobials. Short-stretch bandaging was used to treat the oedema. Pain increased when the swelling increased. [Figure 1a and b]
Despite treatment and compression the wound did not improve and after a further 5 weeks a tendon was exposed within the wound base. After a further 4 weeks of topical treatment, including antimicrobial use, marginal progress was observed [Figure 2a and b]. This meant the patient was on multiple antibiotics for almost 8 weeks with little improvement.
Introduction of UrgoClean Ag
After further review of the patient’s treatment plan, UrgoClean Ag was introduced to give continued debridement, microbial control and biofilm treatment. A superabsorbent dressing was used as a secondary dressing with short stretch bandaging continued to provide compression and treat oedema. After only 7 days, there was a significant improvement in peri-wound margins, with reduced slough and the pain was reportedly reduced. Although lower-limb oedema remained an issue, the wound continued to improve after a further 9 days [Figure 3a and b].
The compression utilised was changed from a short stretch bandage system to a compression wrap due to a skill deficit in the clinical area. Over the next 4 months the topical Urgoclean Ag, super-absorbent and compression wrap continued. The wound reduced in size and the tissue quality improved. Pain was also further reduced. UrgoClean Ag treatment continued long term to continue to manage microbial load and biofilm prophylactically. After 9 months, the patient was discharged home with weekly dressings by the community nurses and monthly reviews in the vascular clinic [Figure 4]. The patient remained off antibiotics while the ulcer continued to improve and it was completely healed at 16 months.
In summary, the multi action of the UrgoClean Ag dressing in conjunction with continued compression had a positive impact on the healing trajectory of this challenging wound. The combined action of continuous debridement/cleaning along with the antimicrobial/antibiofilm action was able to maintain a positive wound healing environment. The patient also experienced a marked decrease in pain when using UrgoClean Ag, which was one of the factors that facilitated her discharge from hospital.
Case study 2: Treatment with UrgoClean
A 66-year-old woman was referred to the vascular clinic with a history of a left lateral malleolar ulcer for more than 12 months. She had experienced an ulcer at the same location 5 years’ previously. This was treated with a skin graft which resulted in some shape distortion of her lower limb [Figure 5]. She had been caring for her wound herself with input from the GP. Previous treatments had included antimicrobial and antifungal topical creams and iodine based dressings. She had received one course of antibiotics as a result of the wound failing to progress. The patient was awaiting surgery to her left knee but this could not take place until the ulcer had healed. She was also concerned about potential lower-limb amputation. The patient’s only past medical history was arthritis, previous right total knee replacement, hypertension and previous right varicose vein surgery. She lived at home with her husband and mobilised with two crutches due to the pain experienced from the ulcer.
On presentation, the wound was swabbed, biopsies taken and bloods sent, including a vasculitic screen. All were normal. Therefore, the treatment aim was to improve tissue type by debriding the wound. UrgoClean was selected as a primary dressing to facilitate debridement while being atraumatic on removal and reducing pain which was an issue for this patient. A super-absorbent pad was used as a secondary dressing to manage exudate and compression applied via a short stretch bandage. Treatment continued with the community team with review in the vascular clinic every 8 weeks.
During this time, the wound demonstrated positive progression. However, the biggest impact was on the patient’s quality of life. By observing the improvement, her mood began to lift being less fearful of the potential consequences of having the ulcer. Her associated pain levels decreased. She attended her next clinic appointment walking with only one crutch instead of two and the following appointment, she was crutch free as the pain had virtually resolved.
Conclusion
There is considerable concern about the levels of AMR in wounds globally and it is necessary to exercise good AMS practices wherever possible. Even where there is a complex wound, it is possible to move away from systemic antibiotics and implement topical treatment and management procedures instead. In this case review, it is highlighted that accurate assessment of the wound is essential to identify or exclude local infection and implement good AMS strategies to deal with complex wound healing. The importance of debriding and cleaning has been emphasised and the use of modern dressings to facilitate this has been demonstrated with the case studies described. Removing/reducing biofilm/bioburden from chronic wounds is known to facilitate wound healing and progression and the two cases described above show emphatically that even the most complex wounds can be moved onto healing, allowing improved patient quality of life and reduced pain.
In these two cases, UrgoClean and UrgoClean Ag reduced the need for antibiotics, thus complying with AMS policies. Also, because of the novel mode of action of the polyabsorbent fibres, which was the basis of the products (with and without Ag ions), debridement and cleaning continued throughout the treatment period, removing biofilm and keeping the bioburden at levels which allowed the Ag ions to work more efficiently as an antimicrobial.
