Case Study #3 - AM Xcell Antimicrobial Case Study

A 66 y/o Hispanic female presents for consultation for a non healing ulcer to the plantar aspect of the left hallux. She was being treated by general surgery since 1996 for this condition. Patient has undergone several debridements, hospitalizations with IV antibiotic therapy, as well as orthotics to reduce pressure to this area. The ulceration was biopsied and showed squamous epithelial hyperplasia, parakeratosis and marked inflammation. Past medical history includes IDDM x 16 years, HTN, Hyperlipidemia and depression. History of left breast mastectomy undergoing chemotherapy at this time. Currently patient is also with renal failure undergoing renal dialysis, with the fistula in the left upper arm.

Current medications include Insulin and a HTN medication, that patient did not know the name. Patient denies use of tobacco and alcohol. Orders for x-rays, lab work with CBC w/diff, A1c and non invasive vascular studies are scheduled. Random BS 120-140 as reported by patient. Exam reveals a frail, Hispanic female, cooperative and oriented. She is concerned that her toe will need to be amputated, this is adding to her stress and depression. Exam of the lower extremity: pulses non palpable, skin temperature is warm proximal to distal with equal and adequate hair distribution to bilateral limbs and toes. No foot deformities are noted, other than the ulceration to the left plantar hallux, and edema to the entire left hallux. No cellulitis is noted, only mild erythema is present distal to the 1st metatarsal phalangeal joint. The wound is 3.0 cm in diameter with a thick callus rim, and 2 mm deep. The base of the wound appears macerated with white and yellow fibrotic tissue with bleeding within the hyperkeratosis layer. The wound did not bleed with debridement, there is foul odor noted during the debridement but no drainage is expressed.

Initial home care regimen is initiated with enzymatic debridement ointment applied daily with saline moistened gauze and Kling wrap. Patient is ordered a wheel chair to off load. The x-ray findings do not show evidence of acute or chronic osteomyelitis; only diffuse osteopenia. Labs were normal, and as expected the non invasive vascular study is abnormal with moderately severe occlusive disease, femoral-popliteal disease. ABI left is 0.41 mmHg. Patient lives 1 hour from the clinic and has missed several appointments, but phone contact was maintained weekly to stress to patient the need for follow up and to remind patient of signs of worsening of the condition. Two months later the wound is unchanged. Wound biopsy is performed and qualitative analysis is requested and XCell® wound dressing with antimicrobial is initiated 9/26/03, along with continued sharp debridement. Patient is performing dressing changes herself with the XCell® followed by normal saline moistened gauze and Kling, every other day. Results of quantitative analysis was 2.2 x 10^6 bacertia, gram positive cocci. No oral antibiotic is initiated based on clinical exam and clinician's experience. 10/29/03 showing resolution of the ulceration. Wound care regimen is discontinued and if fitted for multi-density insoles and extra depth shoes. Patient was encouraged to continue non weight bearing until her new insoles and shoes are received, to prevent reoccurrence.

Initial Wound		9/26/2003
Initiation of XCell ® with antimicrobial		Ulceration completely resolved 10/29/03

Conclusions

Biosynthesized cellulose wound dressing with dual moisture handling capability to donate moisture to dry surfaces and absorb fluid from highly hydrated environment shows promise in caring for diverse wounds presenting to the every day clinical setting. The ease of application, and the ability to leave the dressing in place for up to 7 days allows the private practice clinician to be able to offer wound care services within their own practice, scheduling follow up care is more manageable on a weekly basis. The need for home care nursing services and or wound care clinic referral can be minimized, as the application of the dressing is relatively easy; the patient and or a family member can be taught how to perform once or twice weekly dressing changes. The overall cost to the health care system may also be reduced in this manner as well. Does this really mean then that we only need to have one type of wound care dressing available in our clinics? I'm not sure as yet, but the concepts that originated this material are founded in sound science and with continued use of the product in a wide variety of cases, its application appears useful in almost every case. As always we cannot forget the need for sharp debridement when appropriate, as well as a complete and comprehensive history, physical and clinical as well as laboratory assessment of the patient and the wound to determine why the wound has gone from an acute wound to a chronic wound. All wounds need some sort of dressing, and XCell® may be able to play a more significant role as the first choice, regardless of the wound type, due to its pure nature to hydrate dry necrotic areas, cleanse wound margins and to absorb excess exudates when present.

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