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Povidone-iodine ointment demonstrates in vitro efficacy against biofilm

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Article  in  International Wound Journal · March 2016

DOI: 10.1111/iwj.12578

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 International Wound Journal ISSN 1742-4801

ORIGINAL ARTICLE

Povidone-iodine ointment demonstrates in vitro efficacy

against biofilm formation
Matthias J Hoekstra1 , Samantha J Westgate2 & Stefan Mueller3
1 Burns Research Institute, Beverwijk, The Netherlands
2 Perfectus Biomed Limited, Sci-Tech Daresbury, Cheshire, UK
3 Mundipharma Research GmbH & Co KG, Limburg, Germany

Key words Hoekstra MJ, Westgate SJ, Mueller S. Povidone-iodine ointment demonstrates in vitro
Biofilm; Candida albicans; efficacy against biofilm formation. Int Wound J 2016; doi: 10.1111/iwj.12578
Methicillin-resistant Staphylococcus aureus
(MRSA); Povidone-iodine ointment (PVP-I); Abstract
Pseudomonas aeruginosa
Anti-infectives used to treat chronic exuding wounds are diluted by wound exudates,
Correspondence to absorbed into dressings, metabolised by proteases and destroyed by pH. In order
Stefan Mueller to mimic such effects of exudates, the efficacy of six topical wound agents was
Mundipharma Pte Ltd assessed undiluted and at 10% concentrations, including povidone-iodine ointment and
12 Marina View
a silver-impregnated wound dressing, to remove biofilms of Pseudomonas aeruginosa,
#22-01 Asia Square
multi-species biofilms of Candida albicans and methicillin-resistant Staphylococcus
Tower 2
Singapore 018 961
aureus (MRSA) in vitro in a Centers for Disease Control and Prevention (CDC) reactor.
E-mail: [email protected] Povidone-iodine was also diluted to 3⋅3% and 33⋅3% of the commercial concentrations.
Viable microorganisms in each preparation were quantified by colony count. No viable
P. aeruginosa biofilm material was recovered after 4 and 24 hours of treatment with
povidone-iodine ointment at the 100% and 10% concentrations. No C. albicans/MRSA
biofilm material was recovered after 4 and 24 hours of treatment with povidone-iodine
ointment at the 100% concentration. In general, following dilution, povidone-iodine
ointment appeared to exhibit greater biofilm removal than the other agents tested.
Further research involving different microorganisms in vitro and in vivo over a longer
period of time will help elucidate the full potential of povidone-iodine ointment and
liposomal hydrogel.

Introduction in a protective extracellular polysaccharide matrix, which

facilitate attachment to surfaces, survival and proliferation
Effective wound treatment requires the establishment of a
(6,7). Microbial biofilms within chronic wounds can be
microenvironment in which the levels of pathogenic microor-
ganisms are reduced to a level that can be appropriately
managed by the host’s immune system, allowing for pro-
gression from the inflammatory phase of wound healing.
Key Messages
Appropriate termination of the inflammatory phase stim-
ulates the progressive stages of wound repair, such as • current anti-infectives used to remove biofilms from
re-epithelialisation, and allows for the wound to heal in a timely chronic wounds may be diluted by wound exudates or
manner (1–3). Wound healing is delayed by infection, which absorbed into dressing materials, potentially reducing
begins when pathogenic bacteria colonise the wound, usually their efficacy and impeding optimal wound healing
within 6 hours following a superficial lesion to the epithelia • six diluted topical anti-infectives, including PVP-I,
(2). This colonisation typically involves aerobic or faculta- a silver dressing and a control, were used to remove
tive gram-negative bacteria such as Pseudomonas aeruginosa CDC-reactor-established biofilms of Pseudomonas
(P. aeruginosa), gram-positive bacteria such as Staphylococcus aeruginosa, Candida albicans and MRSA
aureus (S. aureus) and β-haemolytic streptococci, which cause • PVP-I exhibited the most effective removal of bacterial
extensive deterioration and damage to the wound (4,5). Most and multi-species biofilm following dilution compared to
bacteria live in biofilms, bacterial communities enveloped all other agents tested

© 2016 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd. 1
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
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Povidone-iodine ointment demonstrates in vitro efficacy against biofilm formation M. J. Hoekstra et al.

difficult to eradicate with currently available anti-infectives and remove biofilms of P. aeruginosa and multi-species biofilms of
anti-infective regimes. Candida albicans (C. albicans) and MRSA in vitro.
The role of biofilms in chronic wounds has received much
interest. Chronic wounds contain damaged tissue and pro-
teins, which can allow bacteria to attach and proliferate into Methods
biofilms. Well-known chronic wound pathogens, including
Test microorganisms
methicillin-resistant S. aureus (MRSA) and P. aeruginosa,
are typical biofilm producers. Bacteria encased in biofilms Three microorganisms were tested: P. aeruginosa (NCIMB
are 50-1000 times more resistant to conventional antibiotic 10434), MRSA (308) and C. albicans (ATCC MYA 2876).
treatment because of their resolute physical and physiologi-
cal decrease in susceptibility to antimicrobial agents includ-
Agents tested
ing antibiotics (8). Appropriate antimicrobial management and
wound dressings are required to control microbiological coloni- The agents used are listed in Table 1. They were tested
sation and prevent infection (9). Dressings containing silver at both 100% and 10% concentrations, with the exception
have been shown to help prevent biofilm formation, but not all of PVP-I, which was additionally tested at 3⋅3% and 33%.
have been effective because of the variability in silver concen- Phosphate-buffered saline (PBS) was used as a control.
tration, silver format and delivery mechanisms (10).
Iodine has been shown to disrupt S. aureus biofilms (11,12).
Preparation of inoculum and biofilm formation
Iodine has been used for over 150 years to prevent infection
in the treatment of wounds. Povidone-iodine has been used The test method used throughout this study was a modifica-
as a topical treatment since the 1950s (13) because of its tion of the international standard E2871 (29), a test method
broad antimicrobial spectrum and highly effective treatment in designed to evaluate disinfectant efficacy of biofilms grows
a variety of wounds (14), and to date, no resistance has been in a Centers for Disease Control and Prevention (CDC) reac-
demonstrated (15). Interest in the use of iodine for biofilms in tor. Modifications were made to the test method in order to
chronic wounds has grown over the last two decades. Studies assess a range of microorganisms and the various test agents
have shown povidone-iodine and cadexomer iodine to exhibit described. Twenty-four-hour cultures of P. aeruginosa and
antibacterial activity, particularly against the Pseudomonas MRSA were harvested from tryptone soya agar (TSA) plates
species and S. aureus that are prevalent in biofilms, while and re-suspended in 20 ml of tryptone soya broth (TSB) and
simultaneously facilitating healing (16–18). Povidone-iodine 20 ml of RPMI medium, respectively; a 24-hour culture of
has many characteristics that support its place at the fore- C. albicans was harvested from a Sabouraud dextrose agar
front of treating epithelial trauma. It exhibits a pro-oxidant plate using a sterile swab and re-suspended in 20 ml of RPMI
effect in healing (19), is better tolerated than silver sulphadi- medium. P. aeruginosa and MRSA suspensions were diluted
azine or chlorhexidine on histological appraisal of wound heal- to give OD590s of 0⋅13 ± 0⋅03 (∼108 cfu/ml) and 0⋅1 ± 0⋅02
ing (20) and will enhance angiogenesis (21). It also supports (∼108 cfu/ml), respectively; C. albicans was diluted to give
healing by a distinct anti-inflammatory effect on cytokines, T an OD590 of 0⋅14 ± 0⋅02 (∼108 cfu/ml). The microbial sus-
lymphocytes and macrophages and scavenging reactive oxy- pensions were further diluted in their respective buffers (each
gen species (22,23). Povidone-iodine also may inhibit exces- containing 1% foetal bovine serum) and used to inoculate
sive protease levels in chronic, non-healing wounds and, when the single-species CDC reactors containing polycarbonate test
present, is known to further delay wound closure (24). As coupons. The initial concentration for each inoculum was
with many wound healing treatments that face the challenge ∼5 × 107 cfu/ml. The CDC reactor was incubated for 48 hours
of being antimicrobial whilst supporting healthy wound heal- at 37∘ C, with shaking at 50 rpm in order to encourage biofilm
ing, there is some discussion within the literature regard- growth.
ing povidone-iodine. Some in vitro data have indicated 10%
povidone-iodine to be toxic to cells involved in wound repair,
Mixed-species reactor
such as fibroblasts and keratinocytes (25); however, this was not
observed clinically, for example, in a sensitive wound (26). Fur- The MRSA and C. albicans suspensions described above were
thermore, a 3% liposomal povidone-iodine hydrogel has been mixed 1:1 and used to inoculate the mixed-species CDC reac-
shown to promote optimal wound healing (27,28). tors. The CDC reactor was incubated for 48 hours at 30∘ C, with
Topical agents including povidone-iodine will often be shaking at 50 rpm in order to encourage multi-species biofilm
diluted or deactivated by wound exudates, absorbed into growth.
dressings, metabolised by proteases and destroyed by pH. Test coupons were rinsed thrice in PBS to remove planktonic
These agents should not only be tested at marketed concen- isolates. The remaining viable organisms were then recovered
trations but also after dilution to examine their limitations. from the coupons following 15 minutes of sonication and quan-
Antibacterial agents that demonstrate a significant reduction in tified by serial dilution. Multiple rinse steps removed the major-
activity following dilution should be considered with caution ity of planktonic organisms in order to ensure that the study was
for the treatment of chronic exuding wounds. The aim of this carried out on attached microorganisms only. Throughout this
study was to assess the efficacy of diluted povidone-iodine paper, the term ‘biofilm’ refers to bacteria that have attached
ointment PVP-I ointment (PVP-I) versus six diluted topical to a surface so that they are not easily removed by rinsing. Irre-
wound agents and a silver-impregnated wound dressing to versible attachment is the second stage in biofilm formation and

2 © 2016 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.
M. J. Hoekstra et al. Povidone-iodine ointment demonstrates in vitro efficacy against biofilm formation

Table 1 Test agents and agent concentrations used in the study

Agent name Agent format Active agent Concentration tested (%)

Mupirocin Ointment 2% mupirocin 10 and 100

Fusidic acid Cream/ointment 2% fusidic Acid 10 and 100
Bacitracin, neomycin, and polymyxin B Ointment Bacitracin polymyxin B neomycin 10 and 100
Polyhexanide/betaine Hydrogel 0⋅1% Polyhexanide/betaine PVP-iodine 10 and 100
Octenidine dihydrochloride Hydrogel Octenidine 10 and 100
Povidone-iodine ointment (PVP-I) Ointment 10% PVP-iodine 3⋅3, 10, 33 and 100
PVP-I liposomal hydrogel Hydrogel 3% PVP-iodine 10 and 100
Chlorhexidine gluconate Liquid 0⋅1% chlorhexidine 10 and 100
Silver dressing Dressing Silver nanocrystals 100
Phosphate-buffered saline (PBS) Liquid N/A 100

is used in international test methods E2647-13 (30), E2799-12 P. aeruginosa was recovered at both 100% and 10% concentra-
(31) and E2871-13 (29) as a repeatable indicator of biofilm for- tions after 4 and 24 hours. Furthermore, no viable P. aeruginosa
mation. These methods do not attempt to measure metabolic was recovered following PVP-I treatment at the 3⋅3% and 33%
reduction or to quantify the glycocalyx. concentrations. Mupirocin treatment resulted in no recovery of
viable bacteria following 4 and 24 hours at the 100% concen-
tration, but its efficacy was negated at the 10% concentration
Biofilm treatment because no difference was observed in the colony count versus
Agents were used to treat 48-hour P. aeruginosa, MRSA and the PBS control at both time points. Fusidic acid showed no
C. albicans biofilms. All agents were applied to encase the recovery of biofilm bacteria following 24 hours of treatment at
biofilm within the treatment. All agents except the control, the 100% concentration, but its efficacy also was negated at the
chlorhexidine gluconate and the nanocrystalline silver dressing 10% concentration because no difference was observed versus
were applied as gel formulations (1 g aliquots of each agent the PBS control at both 4 and 24 hours. Treatment with the sil-
were weighed into a petri dish, a coupon was placed onto the ver dressing did not reduce bacterial recovery after 4 hours of
agent and then covered by another 1 g aliquot); chlorhexidine treatment, with a 1-log reduction versus the PBS control, but
gluconate and PBS controls were used as 2 ml aliquots, and the there was a significant 3-log reduction versus the PBS control
silver dressing was cut into 2 cm2 pieces. The silver dressing at 24 hours.
was activated prior to testing by the addition of 250 μl of
sterile distilled water (P. aeruginosa) and PBS (MRSA and
C. albicans) to each 2 cm2 sample. The test agents were diluted Candida albicans/MRSA biofilms
in PBS to obtain the 3⋅3%, 10% and 33% samples and used as No C. albicans/MRSA biofilm material was recovered after 4
2 ml aliquots. The agents were left in contact with the biofilm and 24 hours of treatment with PVP-I at the 100% concentration
for either 4 or 24 hours at 37∘ C (P. aeruginosa) and 30∘ C (Figures 3 and 4). Treatment with PVP-I showed a >5-log
(MRSA and C. albicans). While the test agent formats varied, reduction versus the PBS control. Similar results were seen
all agents were applied as per manufacturer’s instructions and with PVP-ILH, BNP, PHB, octenidine dihydrochloride and
then diluted as described above. All samples were tested in chlorhexidine gluconate, where no viable C. albicans/MRSA
triplicate. was recovered at the 100% concentration after 4 and 24 hours.
Mupirocin and fusidic acid were considerably less effective in
removing viable cultures from the multi-species biofilm at 4 and
Statistical methods 24 hours at 100% concentrations.
Data were reported as log reductions, and, where appropriate, At the 10% concentration, the efficacy of PVP-I was reduced
a two-tailed Student’s t-test was used to determine significant at 4 hours, but after 24 hours, negligible viable biofilm material
results. was detected. At the 10% concentration, PVP-ILH showed
a >1-log reduction in mixed biofilm material at both 4 and
24 hours, similar to findings with the other topical preparations.
Results Compared with 10% PVP-I, mupirocin, fusidic acid, BNP,
PHB, octenidine dihydrochloride and chlorhexidine gluconate
Pseudomonas aeruginosa biofilms at 10% concentrations were up to 3 logs less effective in
No viable P. aeruginosa was recovered after 4 and 24 hours removing viable cultures from the multi-species biofilm at 4
of treatment with PVP-I at the 100% and 10% concentra- and 24 hours.
tions (Figures 1 and 2), displaying a >6-log reduction versus
the PBS control at 24 hours. Similar results were seen with
Comparison of PVP-I across concentrations
PVP-I liposomal hydrogel (PVP-ILH), polyhexanide/betaine
(PHB), bacitracin, neomycin, polymyxin B (BNP), octenidine No viable P. aeruginosa biofilm was found at either time point
dihydrochloride and chlorhexidine gluconate, where no viable across all concentrations for PVP-I. However, this was not

© 2016 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd. 3
Povidone-iodine ointment demonstrates in vitro efficacy against biofilm formation M. J. Hoekstra et al.

Figure 1 Quantity of viable Pseudomonas aerug-

inosa recovered from coupons following 4-hour
treatment with all agents, at the commercial con-
centrations (100%) and at 10% of the commercial
concentration. Silver dressing was tested at 100%
only. MUP, mupirocin; FUA, fusidic acid; BNP, bac-
itracin, neomycin, and polymyxin B; PHB, poly-
hexanide/betaine; OCT, octenidine dihydrochloride;
PVP-I, povidone-iodine ointment; PVP-ILH, PVP-I
liposomal hydrogel; CHG, chlorhexidine gluconate;
PBS, phosphate buffer solution.

Figure 2 Quantity of viable Pseudomonas aerugi-

nosa recovered from coupons after 24-hour treat-
ment with all agents, at the commercial concen-
trations (100%) and at 10% of the commercial
concentration. Silver dressing was tested at 100%
only. MUP, mupirocin; FUA, fusidic acid; BNP, bac-
itracin, neomycin, and polymyxin B; PHB, poly-
hexanide/betaine; OCT, octenidine dihydrochloride;
PVP-I, povidone-iodine ointment; PVP-ILH, PVP-I
liposomal hydrogel; CHG, chlorhexidine gluconate;
PBS, phosphate buffer solution.

the case for the multi-species C. albicans/MRSA biofilm. At However, following dilution, PVP-I was shown to be equiva-
4 hours (Figure 5), the antibacterial activity of PVP-I was the lent to, and in many cases better than, its competitors in the
lowest at the 33% concentration and at the 3⋅3% concentra- eradication of bacterial biofilm over 24 hours. This highlighted
tion was <2-log lower versus the PBS control. At 24 hours its potential to be used as treatment of choice of highly exuding
(Figure 6), the antibacterial activity of PVP-I was the lowest chronic biofilm-infected wounds.
at the 10% concentration and at the 3⋅3% concentration was PVP-I was highly efficacious when tested against P. aerug-
>1-log lower versus the PBS control. Furthermore, the antibac- inosa, C. albicans and MRSA at both 4 and 24 hours.
terial activity of 10% PVP-I was greater than the 3% concen- Extrapolating these data into the clinical setting indicates
tration after 24 hours. that a single application need only be applied in a 24-hour
period; however, this would require further clinical investiga-
tion for confirmation. This would not only support the efficient
Discussion treatment of infected wounds with PVP-I but also demon-
Many anti-infectives adequately eradicate bacterial biofilms strate the potential improvement in the quality of life of the
from wounds at their original concentrations. However, effi- patients being treated. All agents were less effective against C.
cacy is challenged following dilution, for example, by chronic albicans/MRSA biofilms compared to P. aeruginosa biofilms,
wound exudates, especially with prolonged increased moisture probably because of the physical and physiological superiority
in the wound, heightened risks of an infection and compro- of the multi-species biofilms. In vivo, bacteria and fungi can
mised efficacy of the diluted antimicrobial product. This study coexist in wounds to form multi-species biofilms. The efficacy
was performed to assess the efficacy of PVP-I against biofilm of PVP-ILH in wound healing of colonised wounds has already
formation in vitro, at its original concentration and in diluted been reported (27). The PVP-ILH formulation showed a faster
form, versus six other anti-infectives and a silver-impregnated wound-healing time with a better quality of wound healing
wound dressing. Most of the agents tested were effective (27,28). In our study, PVP-ILH worked effectively at all
against biofilm formation at their original concentrations concentrations across both time points. However, PVP-I was
(except mupirocin, fusidic acid and the silver dressing). again more effective at removing both biofilms after 24 hours

4 © 2016 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.
M. J. Hoekstra et al. Povidone-iodine ointment demonstrates in vitro efficacy against biofilm formation

Figure 3 Quantity of viable Candida albicans/MRSA

recovered from coupons following 4-hour treatment
with all agents, at the commercial concentrations
(100%) and at 10% of the commercial concentra-
tion. Silver dressing was tested at 100% only. The
33% and 3⋅3% concentrations of PVP-I are also pre-
sented. MRSA, methicillin-resistant Staphylococcus
aureus; MUP, mupirocin; FUA, fusidic acid; BNP,
bacitracin, neomycin, and polymyxin B; PHB, poly-
hexanide/betaine; OCT, octenidine dihydrochloride;
PVP-I, povidone-iodine ointment; PVP-ILH, PVP-I lipo-
somal hydrogel; CHG, chlorhexidine gluconate; PBS,
phosphate buffer solution.

Figure 4 Quantity of viable Candida albicans/MRSA

recovered from coupons after 24-hour treatment
with all agents, at the commercial concentrations
(100%) and at 10% of the commercial concentra-
tion. Silver dressing was tested at 100% only. The
33% and 3⋅3% concentrations of PVP-I are also pre-
sented. MRSA, methicillin-resistant Staphylococcus
aureus; MUP, mupirocin; FUA, fusidic acid; BNP,
bacitracin, neomycin, and polymyxin B; PHB, poly-
hexanide/betaine; OCT, octenidine dihydrochloride;
PVP-I, povidone-iodine ointment; PVP-ILH, PVP-I lipo-
somal hydrogel; CG, chlorhexidine gluconate; PBS,
phosphate buffer solution.

following dilution. Furthermore, at the 10% concentration, The efficacy and tolerability of PHB in bacterial bur-
PVP-I showed better biofilm removal than PVP-ILH. The den control has previously been demonstrated (39,42). In
lower efficacy in this in vitro model may differentiate the 3% our study, PHB was shown to be highly efficacious at its
PVP-I formulation for wounds with a low burden of pathogens original concentration and at the 10% concentration against
and the 10% PVP-I formulation for wounds with clinical signs P. aeruginosa at both time points. However, dilution to 10%
of infection. negated its activity against the multi-species biofilm at both
Fusidic acid is a topically applied bacteriostatic antibi- time points, highlighting its potential shortcomings in the
otic; however, its use has been controversial based on many treatment of exuding wounds.
studies that have reported the development of resistance to Mupirocin is an antibiotic particularly effective against
S. aureus, thereby negating its use against MRSA (32–38). gram-positive bacteria, including MRSA (43); however, it
After 4 hours, 100% fusidic acid exhibited the least anti-biofilm must be used with caution because prolonged use may lead to
efficacy among the agents tested, showing similar bacterial bacterial resistance (44). At the 10% concentration, mupirocin
biofilm recovery to the PBS control. Efficacy improved to com- exhibited similar results to the PBS control at both time points
plete the elimination of bacteria material after 24 hours, demon- against both biofilms, lessening the potency for treatment of
strating the slow antimicrobial onset of action compared to chronic exuding wounds.
some of the other agents. At the 10% concentration, again, the Chlorhexidine gluconate is a widely used antiseptic and has
results were similar to the PBS control at both time points. previously been compared to PVP-I in prevention of infection
The efficacy of BNP topical against P. aeruginosa has previ- following a caesarean section, where it was associated with
ously been reported (39,40), and again, it was highly effective in lower rates of bacterial growth after 18 hours (45). In our
our study against P. aeruginosa and C. albicans/MRSA biofilms study, chlorhexidine gluconate again displayed efficacy against
at its original concentration at both time points. However, dilu- both biofilms over both time points. However, at the 10%
tion to 10% negated its activity against the multi-species biofilm concentration, PVP-I again showed superior biofilm-removal
at both time points, highlighting its limitations in the treatment capacity compared with chlorhexidine gluconate. This supports
of chronic exuding wounds. Furthermore, resistance to BNP has the clinical observation made in venous leg ulcers where PVP-I
also been reported in MRSA (41). was also more efficacious than chlorhexidine gluconate (20).

© 2016 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd. 5
Povidone-iodine ointment demonstrates in vitro efficacy against biofilm formation M. J. Hoekstra et al.

dressings have been shown to prevent biofilm formation.

However, not all silver dressings are the same because of the dif-
ferent forms of silver used within the dressings (10). Although
the nanocrystalline silver dressing was more efficacious
against the multi-species biofilm of C. albicans and MRSA
at both time points, its lack of efficacy against P. aeruginosa
highlighted its shortcomings in broad spectrum antibacterial
activity.
The ultimate goal of using anti-infective agents in wound
care is to control and balance the bacterial bioburden in the
wound bed. Bioburden is the amount and types of bacteria in
a wound. In this in vitro study, PVP-I lowered the bioburden of
bacteria and biofilm formation in the wound bed across all con-
centrations at all time points. Translating this efficacy in vivo,
the potency of PVP-I becomes ever more prominent, reducing
bacterial biofilm formation while correcting other non-bacterial
wound-healing parameters. However, although low-grade con-
taminated wounds are considered a requisite for optimal wound
Figure 5 Quantity of viable Candida albicans/MRSA recovered from healing, it has been suggested that sub-infective levels of bac-
coupons after 4-hour treatment with PVP-I at standard concentration and teria accelerate healing in acute wounds by heightening the
different percentage concentrations. PVP-I, povidone-iodine ointment. immune response with an excess of inflammation and increase
of protease production but with risk of damage to the dermal
matrix architecture (47). In order to be confident that a suffi-
ciently low pathogen count conducive for wound healing can
be achieved in vivo, a significant reduction must be observed in
vitro. It should then be considered that the additional variations
observed within an in vivo scenario may further decrease the
efficacy of any wound care product.
The success of diluted PVP-I over 24 hours against aero-
bic microorganisms is an important advantage in its potential
to being the anti-infective agent of choice in the treatment of
chronic exuding wounds. Interestingly, the 10% PVP-I per-
formed better than the 3% concentration against P. aeruginosa
after 24 hours. This may not have been a significant result; how-
ever, the experiment must be repeated to elucidate whether this
outcome was an anomaly or a phenomenon of a lower con-
centration performing better than those higher. Future research
could focus on testing PVP-I in vitro, ex vivo and in vivo
versus biofilms from both aerobic and anaerobic microorgan-
isms. Anaerobic microorganisms make up a large proportion
Figure 6 Quantity of viable Candida albicans/MRSA recovered from
of the microbial population of chronic wounds (48), especially
coupons after 24-hour treatment with PVP-I at standard concentration wounds close to orifices that contain microbes consistent with
and different percentage concentrations. PVP-I: povidone-iodine oint- those found at those sites (49). Furthermore, adding bovine
ment. serum albumin or sheep erythrocytes in vitro or to an ex vivo pig
skin biofilm model will further assess the efficacy of PVP-I in
Chlorhexidine gluconate showed excellent activity against both the treatment of chronic exuding wounds. Another study eval-
biofilms at both time points at its original concentration and uating the effect of single applications of original and diluted
following 10% dilution. However, compared with PVP-I at the preparations of PVP-I beyond the 24 hours studied here, for
10% concentration, it was <1-log less effective at removing the example, 36 and 48 hours, would be of interest in terms of cost
P. aeruginosa biofilm. benefits to health care authorities and quality of life benefits to
Octenidine dihydrochloride has been highly successful in patients. Any guideline on biofilm testing should consider prob-
vivo, significantly lowering bacterial colonisation of skin graft ing various exposure times and concentrations in order to asses
donor sites (46). However, the octenidine group required more potential limits of a product, as already implemented in sus-
time to full wound closure and was statistically not significant. pension testing (50). Assessing the dilution ratio of products
In a similar wound, PVP-I showed a reduction in bacterial count clinically is not a practical option as wounds vary significantly
with a better trend for wound closure (26). in their size, structure, location and the amount and type of exu-
The nanocrystalline silver dressing in our study could only date produced. As such, this study and studies such as this are
be used at its 100% concentration. Nanocrystalline silver critical to aid the understanding of the potential changes that can

6 © 2016 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.
M. J. Hoekstra et al. Povidone-iodine ointment demonstrates in vitro efficacy against biofilm formation

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