Significant historical advances in wound management

1. The introduction of the halogen, iodine, to control wound infection during the American Civil War (1861-1865).

2. The recognition of the need to create an aseptic wound environment, led by Johnson and Johnson. Inspired by a speech by antiseptic advocate Joseph Lister, Robert Wood Johnson and his brothers created a line of ready-to-use surgical dressings in 1885.

3. The introduction of the heavy metal, silver, to control battlefield wound infections in the First World War. Subsequently, other heavy metals, like mercury have been used but are now seen as just too toxic.

4. The development of antibiotics, accelerated by the Second World War dramatically improved the life expectancy of injured personnel, particularly those with systemic infections. However, they had limited ability to deal with topical wound infections since they don’t reach the site of the infection, the wound bed, and the sub-optimal doses reaching the wound actively stimulate bacterial resistance. The widespread use of broad spectrum antibiotics as a front line treatment for military personnel suffering traumatic injuries has selected multiply resistant strains, resulting in a formerly harmless bacterial species such as Acinetobacter being placed on the WHO crisis list.

5. In the 1960’s research conducted by Dr George Winter, led to the realisation that keeping a wound base moist was key to effective healing, as opposed to the conventional wisdom of drying a wound. Virtually all modern dressings, no matter what technology they use and how they are marketed, essentially control wound moisture.

The evolution of Acinetobacter baumanii from harmless soil borne bacterium to WHO critical pathogen

Acinetobacter baumanii is a Gram-negative bacterium found in soil, where it plays an important role in the breakdown of organic chemical compounds to release nutrients in soluble inorganic forms that can be absorbed by plants. Acinetobacter species are found widely in nature and thrive in a broad range of temperatures and hence environments.

Acinetobacter is a key source of infection in immune compromised patients in hospital where it is associated with bacteremia, urinary tract infections, meningitis, infective endocarditis, and wound and burn infections. It is often associated with hospital-acquired pneumonia and has also been reported to infect skin and soft tissue in traumatic injuries and postsurgical wounds.

It is known colloquially as ‘Iraqibacter’ because of its presence in soft tissue infections experienced by soldiers returning from Iraq and Afghanistan. Furthermore, the use of broad spectrum antibiotics on the battleground has led to a rapid growth in resistance, leading the World Health Organisation in 2017 to name multidrug-resistant A. baumannii as one of its top three threats.

This has the potential to become a serious problem in military and veterans hospitals, where soldiers returning from active duty worldwide are treated in the same environment as other patients, however, the development of resistance is a global issue not just a problem for the military.