Polyhexamethylene biguanide and its antimicrobial role in wound healing: a narrative review
A wound offers an ideal environment for the growth and proliferation of a variety of microorganisms which, in some cases, may lead to localised or even systemic infections that can be catastrophic for the patient; the development of biofilms exacerbates these infections. Over the past few decades, there has been a progressive development of antimicrobial resistance (AMR) in microorganisms across the board in healthcare sectors. Such resistant microorganisms have arisen primarily due to the misuse and overuse of antimicrobial treatments, and the subsequent ability of microorganisms to rapidly change and mutate as a defence mechanism against treatment (e.g., antibiotics). These resistant microorganisms are now at such a level that they are of grave concern to the World Health Organization (WHO), and are one of the leading causes of illness and mortality in the 21st century. Treatment of such infections becomes imperative but presents a significant challenge for the clinician in that treatment must be effective but not add to the development of new microbes with AMR. The strategy of antimicrobial stewardship (AMS) has stemmed from the need to counteract these resistant microorganisms and requires that current antimicrobial treatments be used wisely to prevent amplification of AMR. It also requires new, improved or alternative methods of treatment that will not worsen the situation. Thus, any antimicrobial treatment should be effective while not causing further development of resistance. Some antiseptics fall into this category and, in particular, polyhexamethylene hydrochloride biguanide (PHMB) has certain characteristics that make it an ideal solution to this problem of AMR, specifically within wound care applications. PHMB is a broad-spectrum antimicrobial that kills bacteria, fungi, parasites and certain viruses with a high therapeutic index, and is widely used in clinics, homes and industry. It has been used for many years and has not been shown to cause development of resistance; it is safe (non-cytotoxic), not causing damage to newly growing wound tissue. Importantly there is substantial evidence for its effective use in wound care applications, providing a sound basis for evidence-based practice. This review presents the evidence for the use of PHMB treatments in wound care and its alignment with AMS for the prevention and treatment of wound infection.
Various levels of microorganism can be present in wounds. These levels range from wound colonisation, which is characterised by the presence of replicating bacteria in the wound but without causing any detrimental effects on the wound or tissue,1 to wound infection, which is typified by the presence of high levels of proliferating bacteria that cause local tissue damage and delayed healing.2 Wound infection involves the presence of more than one species of microorganism and, for wounds, Staphylococcus and Pseudomonas spp. are the most common.3,4
However, wound infection can be exacerbated by the development of a biofilm—a community of microbial cells organised within a slimy extracellular matrix that is adherent to a surface (e.g., a wound surface).5 The presence of antimicrobial-resistant microorganisms and the increased resistance to antimicrobial agents offered by a biofilm6 means that the removal of antimicrobial-resistant microbes and biofilm are key to promoting wound healing.7 For infected wounds, the inclusion of antimicrobials is a requirement of the treatment regimen, and the use of topical antimicrobial agents is an important component for infection control in wound care.8
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