SLR - January 2021 - Elizabeth A. Ansert

Infected Chronic Ischemic Wounds Topically Treated with Multi-Strain Probiotic Formulation: A Novel Tailored Treatment Strategy

Reference: Venosi, S., Ceccarelli, G., De Angelis, M., Laghi, L., Bianchi, L., Martinelli, O. & Trinchieri, V. (2019). Infected Chronic Ischemic Wounds Topically Treated with Multi-Strain Probiotic Formulation: A Novel Tailored Treatment Strategy, J Transl Med. 2-10 Nov 9;17(1), 364.

Level of Evidence: Level 5

Scientific Literature Review

Reviewed By: Elizabeth A. Ansert, DPM
Residency Program: St. Vincent Hospital – Indianapolis, IN 

Podiatric Relevance: Chronic, infected, ischemic wounds are a very common and difficult problem to podiatric physicians. Not only are these wounds usually polymicrobial, but patients can often have other comorbidities, limiting the treatment options available to these patients. By using probiotics to treat ischemic, infected wounds locally, the probiotics can bring the microbial biome back into balance and reduce the bioburden within the wound. The local delivery of the probiotics also bypasses the need for blood flow to the area that is necessary for antibiotic therapy. 

Methods: A case study of an 83-year-old female with a chronic, infected ulceration is presented. The patient suffers from critical limb ischemia, type 2 diabetes, hypertension, atrial fibrillation, and has a smoking history. The patient developed a cutaneous right lower extremity ulceration. The wound bed showed anterior to posterior eschars and distal pulses were nonpalpable. Wound swabs were collected before and after 12, 21 and 24 days of bacteriotherapy. The swabs were plated for aerobic and anaerobic growth. A probiotic mixture consisting of L. plantarum, L. acidophilus, and S. thermophilus was applied to the wound after systemic antibiotic therapy was determined to be ineffective and halted. The mixture was applied three times a week. The overall course of the probiotic therapy was 24 days. 

Results: Initial wound swabs showed growth of K. pneumoniae, E. faecalis, and P. mirabilas despite systemic antibiotic therapy. After 2 weeks of probiotic therapy, slowly progressive healing of the lesion was noted. After 12 days of probiotic therapy, swabs no longer noted the growth of E. faecalis. After 21 days of probiotic therapy, K. pneumoniae and P. mirabilas ceased growth. After probiotic therapy was ceased after 24 days, the following 90 days of treatment showed slow wound improvement until complete healing was achieved. Metabolomics were also analyzed, and 17 showed a change in concentration from the time the wound was infected to after probiotic therapy. The changing metabolomics included propionate, 2-hydroxyisovalerate, 2-oxoisocaproate, 2,3-butanediol, putrescine, thymine, and trimethylamine.

Conclusions: Authors concluded that probiotic therapy was an effective treatment modality in this case study against K. pneumoniae, E. faecalis, and P. mirabilas. This is of significant importance since these bacteria are notoriously difficult to remove from chronic wounds. Additionally, the metabolomics were noted to be associated with cell lysis from aerobic and anaerobic bacteria activity. Authors concluded that the change in the metabolomics were due to the decreased bioburden of the wound and general improvement of the wound. This could give hope that patients can clinically benefit from the use of probiotics to treat wounds. Clinical trials should be pursued in this area. Even though clinical trials may be lacking in this area, it may give physicians an additional option for these patients when traditional methods fail. 

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