The article “Time to Abandon Antimicrobial Approaches in Wound Healing: A Paradigm Shift” published in the November 2018 issue1 presents an account on the use of micropore particle technology (MPPT) for wound infections. Based on the results, it appears MPPT could be explored as an adjunct or alternative therapeutic strategy for certain types of infected wounds. However, the authors go further to propose a radical approach, which is to abandon the usage of conventional antibiotics and antimicrobials, in favor of strategies that support the immune system and native skin microbiome.1 This rather extreme approach fails to take several factors into consideration.
The chronic wound infection microenvironment consists of a dynamic wound bed capillary interface with several key players, including host and immune cells, matrix elements, and microbial components, which communicate via an intricate network of inflammatory mediators, growth factors, and enzymes. For example, certain wound bacteria produce short-chain fatty acids that enhance the migration and activation of neutrophils as well as the production and release of chemokines.2 Therapeutic agents also contribute to this complex interplay; doxycycline (in addition to its antimicrobial effect) decreases the expression of the matrix-degrading enzyme, matrix metallopeptidase 9 (MMP-9), thereby promoting the resolution of wound infections.3 This underscores the complexity of the infected wound microecosystem, eg, maintaining a high microbial burden may be beneficial at an early stage, whereas later in the healing process the composite effects of antibiotics could be leveraged. Hence, oversimplified approaches such as abandoning antibiotics or consistently supporting a high microbial burden are both suboptimal and perilous.
Perhaps, a more comprehensive approach could be to better understand the effects of newer approaches (such as MPPT), with and without current antibiotics, on key factors (ie, host elements, immune signaling, and microbial products). This would provide insights into specific conditions (types of wounds, types of microbes, immune status of patient, and stage of healing) in which these newer approaches can be adopted in favor of or in conjunction with antibiotics. In the process, this could reveal precision-based therapeutic strategies that harness the complexity of the infected wound microecosystem rather than one size fits all approaches, such as administering or abandoning antibiotics.
Karishma Kaushik, MD, PhD; and Snehal Kadam, BS-MS
Ramalingaswami Re-entry Fellowship, Department of Biotechnology, Government of India