Bacterial isolates from infected wounds and their antibiotic susceptibility pattern: some remarks about wound infection

Wound infection plays an important role in the development of chronicity, delaying wound healing. This study aimed to identify the bacterial pathogens present in infected wounds and characterise their resistance profile to the most common antibiotics used in therapy. Three hundred and twelve wound swab samples were collected from 213 patients and analysed for the identification of microorganisms and for the determination of their antibiotic susceptibility. Patients with diverse type of wounds were included in this retrospective study, carried out from March to September 2012. A total of 28 species were isolated from 217 infected wounds. The most common bacterial species detected was Staphylococcus aureus (37%), followed by Pseudomonas aeruginosa (17%), Proteus mirabilis (10%), Escherichia coli (6%) and Corynebacterium spp. (5%). Polymicrobial infection was found in 59 (27·1%) of the samples and was mainly constituted with two species. The most common association was S. aureus/P. aeruginosa. All Gram‐positives were susceptible to vancomycin and linezolid. Gram‐negatives showed quite high resistance to the majority of antibiotics, being amikacin the most active against these bacteria. This study is mostly oriented to health care practitioners who deal with wound management, making them aware about the importance of wound infection and helping them to choose the adequate treatment options to control microbial infection in wounds.     

The revisit of 2004 tsunami in Thailand: characteristics of wounds

The name, tsunami that was unknown to most Thai people, had hit west southern coast of Thailand on 26 December 2004. Following the disaster, prices have been paid and many lessons have been learnt. The current report provides a historical background of the incident, which was reviewed by documents, brief discussion and observation. Data of the patients from three hospitals involved in the management were collected and reviewed. Some of the illustrations were from the operating rooms of Takuapa, Surat Thani and Songklanagarind hospitals. There were totally 2311 patients. Of these, 45% were males and 40% were multinationals. Nearly 40% suffered from salted water aspiration, while 2% developed complication associated with near drowning. The most common orthopaedic-related injury were minor [559 patients (24%)] and major wounds [586 (25%)]. Around 7% sustained fracture dislocation. Lower extremity fractures were more common. The characteristics of wounds associated with the tsunami were severe contamination, multiple sites and organ involvement. Another characteristic was the early development and spreading of infection. The lessons proposed by the study are that minor wound should be left open, small penetrating wound should be thoroughly explored and observed and lacerated wounds need emergency dressing, debridement and subsequent cleansing procedures. Re-evaluation and closed surveillance of the seriously injured patients are mandatory to eliminate the complicated infection and life-threatening conditions. Medical record of any disastrous event should be completed by health care professionals. The model and reporting system should be internationalised.     

Ulceration and antihypertensive use are risk factors for infection after skin lesion excision

Background: A prospective audit was performed of wound complications of skin lesion excision in a private practice setting. Methods: For 924 consecutive skin lesion excisions performed by a single surgeon, information was collected on tumour size and site, closure method and on risk factors of age, known diabetes, use of steroids, antihypertensives or anticoagulants and ulceration of the lesion. Patients were given written instructions to wet the wound in the shower after one or two days. A wound ‘infection’ event was recorded if the wound appeared inflamed or if the patient had been treated with antibiotics by any practitioner. Wound bleeding was recorded if the patient returned or attended elsewhere for management of bleeding. Results: Sixty‐seven wounds (7.25%) met the broad definition of ‘infection’ and 18 (1.9%) wounds suffered bleeding. Ulceration (odds ratio (OR) 3.15, P= 0.008) and use of antihypertensives (OR 2.5, P= 0.006) were independent risk factors for infection along with site and closure method. The patients who did not wet their wounds post‐operatively were also at an increased risk of infection (OR 2.1, P= 0.018). Aspirin caused a slight, non‐statistically significant increase in bleeding rate, and warfarin caused a larger, but still not statistically significant, increase in bleeding. Use of other anticoagulants caused a significant increase in bleeding (OR 10.9, P= 0.006). Conclusion: Ulceration of the skin lesion and use of antihypertensives are significant risk factors for wound infection. Wetting surgical wounds with clean tap water does not increase, and may even reduce, wound infection rate.     

Abdominal surgical site infections: a prospective study of determinant factors in Harare,Zimbabwe

Surgical site infections (SSIs) are reported in lower frequencies in the developed countries than in the developing world. A prospective evaluation of risk factors in 285 patients undergoing abdominal surgery procedures in Zimbabwe was therefore undertaken. Overall infection rate was 26%. The age group 30–39 years had the highest number of dirty wounds and the highest rate of human immunodeficiency virus (HIV) infection. Multivariate regression analysis showed a correlation between wound class and SSI (P < 0·05). This was also noted for American Society of Anesthesiologists (ASA) score (P < 0·05). HIV‐infected patients had 52% SSIs and non‐infected patients had 26% (P < 0·05). Patients receiving blood transfusion had 51% SSIs and those not transfused had 17% (P < 0·01). Patients receiving pre‐ and intra‐operative prophylactic antibiotics had 18% SSIs and those receiving postoperative administration had 37% (P < 0·01). Treatment ranged from dressings only in 11% to surgical intervention in 30% resulting in prolongation of median hospital stay from 8 to 18 days (P < 0·001). Mortality was 7%. High wound class, high ASA score, blood transfusion, HIV infection and delayed use of prophylactic antibiotics were risk factors for SSIs, resulting in surgical interventions, prolonged hospital stay and mortality.     

Vacuum assisted closure therapy for treatment of complex wounds in replanted extremities

The object of this study was to compare the outcomes of the vacuum assisted closure (VAC) therapy and conventional wound care with dressing change for treatment of complex wounds in patients with replantation of amputated upper and lower extremities. Data of 43 patients with replantation of amputated extremities from May 2004 to December 2011 were reviewed. There were 18 wounds of 18 patients with replantation, which were treated by dressing change and 26 wounds of 25 patients by VAC therapy. The outcomes were evaluated by the survival rate of replanted extremities, growth of granulation tissue, interval between wound treatment and secondary procedure and eventual secondary wound coverage methods. Vascular thromboses were found in 3 patients with wound treatment by dressing change and 5 by VAC. All replants of two groups of patients survived after salvage procedures. The wound score was 3.6 ± 0.7 in the conventional dressing change group and 5.8 ± 0.7 in the VAC group at the sixth day after treatment, respectively. The intervals between wound treatment and secondary wound coverage procedure were 12.0 ± 1.7 days in the dressing change group and 6.1 ± 0.7 days in the VAC group. Flaps were applied for wound coverage in 9 out of 18 (50.0%) wounds in the dressing change group and 5 out of 26 (19.2%) in the VAC group (P < 0.05), when the wounds of rest of patients were covered by the skin graft. The results showed that VAC could promote the growth of granulation tissue of wound, decrease the need of flap for wound coverage, and did not change the survival of replantation. © 2013 Wiley Periodicals, Inc. Microsurgery 33:620–624, 2013.     

Epidermal growth factor vs platelet‐rich plasma: Activity against chronic wound microbiota

The objective was to evaluate Staphylococcus aureus and Pseudomonas aeruginosa colonisation of wounds treated with recombinant epidermal growth factor (EGF) and platelet‐rich plasma (PRP); to analyse the susceptibility profiles of S. aureus and P. aeruginosa isolates from wounds treated with EGF and PRP; and to describe the presence of infection in EGF‐treated and PRP‐treated wounds. Experimental study was performed using clinical specimens collected with swabs. Patients were treated with PRP and EGF in the outpatient clinic of a university hospital. Forty‐three isolates were obtained from 31 patients, 41.9% (13/31) of whom had been treated with EGF and 58.0% (18/31) with PRP. Ten of the 43 isolates were identified as S. aureus, 60.0% (6/10) of which were isolated from PRP‐treated wounds. Among the 33 P. aeruginosa isolates, 66.6% (22/33) were isolated from PRP‐treated wounds. Regarding antimicrobial susceptibility, only one strain isolated from an EGF‐treated wound was identified as methicillin‐resistant S. aureus (MRSA). Among the P. aeruginosa isolates, one obtained from a patient treated with EGF was multidrug‐resistant. Patients treated with EGF had no infections during the follow‐up period, and there was a significant difference between the 1st and 12th week in wound infection improvement in patients treated with PRP (P = .0078).     

Epidemiological characteristics and clinical analyses of chronic cutaneous wounds of inpatients in China: Prevention and control

The increased incidence of chronic cutaneous wounds is likely to lead to increased mortality, and therefore, deserves greater attention. More insight is needed into the magnitude of the problem of chronic cutaneous wounds and methods for their prevention and treatment in China. A retrospective analysis of data retrieved from an electronic health‐records database on 3300 patients with chronic skin wounds was conducted from 1 January 2018 to 31 December 2018. The patients had been admitted to the medical and surgical wards of 17 third‐grade class‐A hospitals in China. The study's aim was to compare the characteristics (eg, demographic and clinical) associated with different causes and distributions of patients' chronic wounds. Among the 3300 patients, 66.03% were males and 33.97% were females. The mean age was 57 years and the increasing prevalence of chronic skin wounds with aging was quite high. The primary causes of chronic wounds were diabetes or infection, followed by pressure ulcers, trauma, and iatrogenic wounds. The distribution of skin wounds was mainly in the lower extremities (56.1%), followed by the trunk (18.6%). The mean duration of hospital stay was 29 days and the mean recurrence was 3 months. Chronic skin wounds were related to occupation, educational level, lifestyle habits, and income. The main cause of chronic skin wounds has shifted from trauma to chronic disease. Normalization checks, bacterial cultures, and antibiotic use in China need to be standardized and the training of wound specialists should be further strengthened. The association of aging and wound infection was significant. Preventive management and efficient treatment should correspond to the needs of the different regions of China. These results may serve as a reference for other developing countries in their transitional development.     

Clinical evaluation of gauze‐based negative pressure wound therapy in challenging wounds

The aim of this randomised clinical study was to evaluate the effectiveness and safety of gauze‐based negative pressure wound therapy (NPWT) in patients with challenging wounds. A total of 50 consecutive patients who had wound drainage for more than 5 days, required open wound management and had existence of culture positive infection were included the study. In this study, gauze‐based NPWT was compared with conventional dressing therapy in the treatment of patients with difficult‐to‐heal wounds. The patients were randomly divided into two groups. Group I (n = 25) was followed by conventional antiseptic (polyhexanide solution) dressings, and group II (n = 25) was treated with saline‐soaked antibacterial gauze‐based NPWT. The wounds' sizes, number of debridement, bacteriology and recurrence were compared between group I and group II. The mean age of the patients was 59·50 years (range 23–97). In group I, average wound sizes of pre‐ and post‐treatment periods were 50·60 ± 55·35 and 42·50 ± 47·92 cm², respectively (P < 0·001). Average duration of treatment was 25·52 ± 16·99 days, and average wound size reduction following the treatment was 19·99% in this group. In group II, the wounds displayed considerable shrinkage, accelerated granulation tissue formation, decreased and cleared away exudate. The average wound sizes in the pre‐ and post‐treatment periods were 98·44 ± 100·88 and 72·08 ± 75·78 cm², respectively (P < 0·001). Average duration of treatment was 11·96 ± 2·48 days, and average wound size reduction following the treatment was 32·34%. The patients treated with antibacterial gauze‐based NPWT had a significantly reduced recurrence (2 wounds versus 14 wounds, P = 0·001), and increased number of the culture‐negative cases (22 wounds versus 16 wounds, P < 0·047) in a follow‐up period of 12 months. There was a statistically significant difference between two groups in all measurements. As a result, we can say that the gauze‐based NPWT is a safe and effective method in the treatment of challenging infective wounds when compared with conventional wound management.     

Safety and performance evaluation of a next‐generation antimicrobial dressing in patients with chronic venous leg ulcers

The objective of this study was to investigate the safety and performance of AQUACEL? Ag+ dressing, a wound dressing containing a combination of anti‐biofilm and antimicrobial agents, in the management of chronic wounds. Patients (n = 42) with venous leg ulcers exhibiting signs of clinical infection were treated for 4 weeks with AQUACEL? Ag+ dressing, followed by management with AQUACEL? wound dressings for 4 weeks. Wound progression, wound size, ulcer pain and clinical evolution of the wound were assessed for up to 8 weeks. Adverse events were recorded throughout the study. AQUACEL? Ag+ dressing had an acceptable safety profile, with only one patient discontinuing from the study, because of a non‐treatment‐related adverse event. After 8 weeks, substantial wound improvements were observed: 5 patients (11·9%) had healed ulcers and 32 patients (76·2%) showed improvement in ulcer condition. The mean ulcer size had reduced by 54·5%. Patients reported less pain as the study progressed. Notable improvements were observed in patients with ulcers that were considered to require treatment with systemic antibiotics or topical antimicrobials at baseline (n = 10), with a mean 70·2% reduction in wound area. These data indicate that AQUACEL? Ag+ dressing has an acceptable safety profile in the management of venous leg ulcers that may be impeded by biofilm.     

Histopathological comparisons of Staphylococcus aureus and Pseudomonas aeruginosa experimental infected porcine burn wounds

Chronic skin wounds are a significant human health concern and are often complicated by infection with Pseudomonas aeruginosa and Staphylococcus aureus, particularly methicillin resistant S. aureus (MRSA). Translating the knowledge gained from extensive study of virulence mechanisms and pathogenesis of these bacterial species to new treatment modalities has been lacking in part due to a paucity of animal models able to recapitulate human disease. Our groups recently described a novel porcine chronic burn wound model for the study of bacterial infection; however, the histopathology of infection has yet to be described. The objective of this study is to define the histopathology of this model using important human chronic wound bacterial isolates. Porcine full‐thickness burn wounds topically inoculated with P. aeruginosa strain PAO1, MRSA S. aureus strain USA300 or both bacteria were used to define and quantify histopathologic lesions. The development of a systemic, well‐defined rubric for analysis allowed for evaluation of differences between infection groups. These differences, which included epithelial migration and proliferation, stromal necrosis, fluid accumulation and intensity and character of the innate and adaptive inflammatory cell responses, were identified temporally between infection groups. Mono‐species infected wounds developed a hyper‐proliferative wound edge. Coinfected wounds at day 35 had the largest wound sizes, increased amounts of neutrophilic inflammation, immaturity of the wound bed, and retention of necrotic tissue. Infection, regardless of species, inhibited wound contracture at all time points evaluated. Most importantly, this model recapitulated key features of chronic human wounds. Thus, this model will allow researchers to study novel treatment modalities in a biologically relevant animal model while monitoring both host and bacterial responses.     

Animal‐inflicted open wounds in rural Turkey: lessons learned and a proposed treatment algorithm for uncertain scenarios

Uncertainty in the management of animal‐inflicted injuries, especially in rural settings, usually results in a general approach to leave all wounds to heal with secondary intention, which can lead to unsightly scarring and functional loss. This study focusus on different circumstances dealt with by plastic surgeons in a rural setting in Turkey and aims to configure what the general approach should be through an analysis of a wide spectrum of patients. Between June 2013 and December 2014, 205 patients who presented to the emergency department for animal‐inflicted injuries were retrospectively analysed. Patients who consulted for plastic surgery were included in the analysis to determine which wounds require further attention. Patients with past animal‐inflicted injuries who presented to the outpatient plastic surgery clinic with concerns such as non‐healing open wounds or cosmetic or functional impairment were also evaluated. Statistical analysis demostrated a significantly lower rate of infection encountered in animal‐inflicted open wounds (AIOWs) of patients who consulted for plastic surgery from the emergency department than those who presented to the outpatient clinic (P < 0·05). The main concern in the management of animal‐inflicted wounds is their potential for infection, but this does not mean that every wound will be infected. The most important factor is being able to distinguish wounds that have a higher potential for infection and to select the type of wound management accordingly. An algorithm has been proposed as a guidance for the management of AIOWs, which covers the approach towards both domestic and stray animal‐inflicted injuries.     

A pilot study investigating lactic acid bacterial symbionts from the honeybee in inhibiting human chronic wound pathogens

Treatment and management of chronic wounds is a large burden on the health sector and causes substantial suffering for the patients. We believe that 13 lactic acid bacteria (LAB) symbionts isolated from the honey crop of the honeybee are important players in the antimicrobial action of honey, by producing antimicrobial substances and can be used in combination with heather honey as an effective treatment in wound management. A total of 22 patients with chronic ulcers were included; culture‐dependent and molecular‐based (MALDI‐MS and 16S rRNA gene sequencing) techniques were used to identify bacteria from chronic wounds. These clinical isolates were used for in vitro antimicrobial testing with standardised viable LAB and sterilised heather honey mixture. Twenty of the patients' wounds were polymicrobial and 42 different species were isolated. Patient isolates that were tested in vitro were inhibited by the LAB and honey combination with inhibitory zones comparable with different antibiotics. LAB and heather honey in combination presents a new topical option in chronic wound management because of the healing properties of honey, antimicrobial metabolite production from the LAB and their bactericidal effect on common chronic wound pathogens. This new treatment may be a stepping stone towards an alternative solution to antibiotics.     

A PEGylated fibrin hydrogel‐based antimicrobial wound dressing controls infection without impeding wound healing

Combat injuries are associated with a high incidence of infection, and there is a continuing need for improved approaches to control infection and promote wound healing. Due to the possible local and systemic adverse effects of standard 1% cream formulation (Silvadene), we had previously developed a polyethylene glycol (PEGylated) fibrin hydrogel (FPEG)‐based wound dressing for the controlled delivery of silver sulfadiazine (SSD) entrapped in chitosan microspheres (CSM). In this study, we have evaluated the antimicrobial and wound healing efficacy of SSD‐CSM‐FPEG using a full‐thickness porcine wound infected with Pseudomonas aeruginosa. Infected wounds treated with a one‐time application of the SSD‐CSM‐FPEG wound dressing demonstrated significantly reduced bacterial bioburden over time (99·99% of reduction by day 11; P < 0·05) compared with all the other treatment groups. The epithelial thickness and granulation of the wound bed was significantly better on day 7 (150·9 ± 13·12 µm), when compared with other treatment groups. Overall, our findings demonstrate that the SSD‐CSM‐FPEG wound dressing effectively controls P. aeruginosa infection and promotes wound healing by providing a favourable environment that induces neovascularisation. Collectively, sustained release of SSD using fibrin hydrogel exhibited enhanced benefits when compared with the currently available SSD treatment, and this may have significant implications in the bacterial reduction of infected wounds in military and civilian populations.     

The use of keratin‐based wound products on refractory wounds

Keratin proteins have been shown to play a key role in wound healing. Controlled keratin gene (KRT) expression promotes cell growth, migration and differentiation, and as an example of the importance of keratin proteins, absence of KRT17 has been shown to delay wound closure. In addition, downregulation of KRT6 and KRT16 in non‐healing chronic venous ulcers suggests that deregulation of keratin expression contributes to non‐healing phenotype. A sample of 45 chronic wounds of mixed aetiologies presenting in 31 patients were treated with keratin‐based novel topical wound healing products. Thirty‐seven wounds or 82% of wounds were either healed or reduced in size of >50% during treatment, with 29 (64%) healing completely and an additional 8 wounds experiencing 50% wound size reduction or greater. Of the wounds that responded, 15 required antimicrobial treatment during their course of treatment, suggesting that keratin dressing treatment should be interrupted briefly and then restarted when wound infection occur.     

Cat And Dog Bites. What To Do?

Inroduction: Domestic animal bites are quite common, but mostly cause minor lesions, for which no medical help is sought. The objective of this study is to define the complications resulting from cat and dog bites that lead to hospital admission. This analysis led to updated guidelines for the treatment of dog and cat bites in humans. Patients and methods: The emergency department (ED) data of our hospital for the year 2004 were retrospectively analysed, seeking patients that presented with bite wounds from either cat or dog. The patient files were reviewed. Results: 34 patients, bitten by cats or dogs, presented to our ED in 2004. 73.5% of them (n = 25) consulted within 24 hours after the bite. In 11 of these patients (44.0%), primary closure of the wound was performed after thorough rinsing and evaluation of the dead space. All these patients were given prophylactic antibiotics. In none of these did the wounds need to be reopened afterwards. Nine patients (26.5%) did not present to the ED until after the day they were bitten. In all these patients, the bite wounds were located on the hand (n = 6) or forearm (n = 3). They all consulted because of complications. The main symptoms were limited and there was painful mobilisation of fingers and wrist, and swelling and redness in the area of the bite wound. Their wounds were thoroughly explored and in 6 of these nine late-presenting patients, a tendon lesion or a purulent flexor tenosynovitis was diagnosed. These six patients needed admission for further management. The mean admission duration was 6 days (range 4 to 10 days). None of the admitted patients showed any signs of limited mobility or disability during follow-up after discharge. Conclusion: While cat and dog bites often cause minor lesions that can be treated by thorough wound care if presented early, the importance of possible late complications should not be overlooked. Patients that present with the symptoms of tissue infection due to a cat or dog bite should be examined adequately and may need admission. Due to aggressive treatment, we had no serious or disabling complications in our population after discharge.     

Postdischarge clean wound infections: incidence underestimated and risk factors overemphasized

Background: Wound infections are a leading cause of postoperative morbidity and a cost to both the individual and community. The surgeon now has a reduced appreciation of wound‐infection rates because of shorter hospital stays and an increasing reliance on the primary care physicians. The incidence of wound infections which occurred following clean surgical procedures, as well as whether they could have been predicted by the known risk factors, were analysed in the present prospective study. Methods: A prospective audit of the first 30 postoperative days following clean general surgical wounds was undergone, with inpatient assessment by a research nurse, and subsequent outpatient follow up by patient telephone interview. Results: Of 1964 clean wounds over a 30‐month period, 98.5% were traced. The overall clean‐wound infection rate was 12.6% (inpatient: 4.5%; outpatient: 8.1%). Inpatient infection rates (but not postdischarge wound‐infection rates) were significantly cor­related (P < 0.05) to the American Society of Anesthesiologists’ rating, operation duration, preoperative day stay, and age. Infection rates varied with operation type: vascular (18.3%), breast (16.0%), abdominal (10.3%), hernia (8.0%), head and neck (7.1%). Conclusions: The overall wound‐infection rate is higher than previously described with two thirds of infections occurring after discharge. While inpatient wound‐infection rates fit known risk factors, postdischarge wound‐infection rates do not. Certain clean‐wound operations have a higher incidence of infection than others. Consideration needs to be given to the identification of risk factors for postdischarge wound infections, and to further trials of prophylactic antibiotics in clean surgery.     

Efficacy of 1% acetic acid in the treatment of chronic wounds infected with Pseudomonas aeruginosa: prospective randomised controlled clinical trial

Chronic wounds are those wounds that are persistent and do not respond to any sort of treatment. The concept of using topical antiseptics on open wounds is to prevent and treat infections. They also help to shorten the time taken to heal the wounds. The use of topical agents on wounds to prevent infection is a minimal ability to develop resistance to the microorganisms. Pseudomonas aeruginosa is a Gram‐negative opportunistic pathogen with innate resistance to many antibiotics. In places that are economically backward, these problems get compounded by the inability of patients to afford newer expensive drugs. Topically applied dilute acetic acid, which is cheap and easily available, has been found to be effective in such chronic wounds. In the present study, an attempt has been made to use 1% acetic acid as the sole antimicrobial agent for the treatment of pseudomonal wound infections. A control limb was used in which the wounds were treated with normal saline. Our objective was to evaluate the efficacy of acetic acid in low concentration of 1% in chronic wounds infected with P. aeruginosa. This was a prospective study conducted over a period of 6 months. Inclusion criteria: All patients with chronic wounds infected with P. aeruginosa. Exclusion criteria: Wounds due to massive burns, suspected malignancy, immunocompromised individuals and individuals with sepsis. A total of 32 patients enrolled in the study. Subjects were randomised equally to the 1% acetic acid group and saline dressing group. None of the patients received any systemic antibiotics during the study period and received twice daily dressings. The endpoint of the treatment was wounds free of P. aeruginosa. The duration of treatment required to eliminate the Pseudomonas from the wounds in the acetic acid group was on an average 7 days less than that required by the saline group. P value was <0·001. In the 1% acetic acid group irrespective of the sensitivity of the organism to antibiotics, Pseudomonas organisms were eliminated within the same time period – 4·5 days. In the saline group, susceptible organisms were eliminated within 11·5 days and multidrug‐resistant organisms were eliminated by 15·5 days. 1% acetic acid is a simple, safe and effective topical antiseptic that can be used in the elimination of P. aeruginosa from chronic infected wounds.     

An open‐label trial of cryopreserved human umbilical cord in the treatment of complex diabetic foot ulcers complicated by osteomyelitis

Clinical trials of potential new therapies for diabetic foot ulcers rarely enroll patients whose wounds extend to muscle, fascia, or bone with clinical and radiographic evidence of underlying osteomyelitis. An open‐label, multicenter trial of cryopreserved human umbilical cord (TTAX01) was undertaken in 32 subjects presenting with such complex wounds with a mean duration of 6.1 ± 9.0 (range: 0.2–47.1) months and wound area at screening of 3.8 ± 2.9 (range: 1.0–9.6) cm². Aggressive surgical debridement at baseline resulted in 17 minor amputations and an increase in mean wound area to 7.4 ± 5.8 (range: 1.1–28.6) cm². All subjects were placed on systemic antibiotics for at least 6 weeks in conjunction with baseline application of TTAX01. Repeat applications were made at no less than 4‐week intervals over the 16‐week trial. Initial closure occurred in 18 of 32 (56%) wounds, with 16 (50%) of these having confirmed closure in 16 weeks with a median of one‐product application. Cases with biopsy confirmed osteomyelitis (n = 20) showed initial closure in 12 (60%) wounds and confirmed closure in 10 (50%) wounds. Four of the five ulcers presenting as recurrences experienced confirmed closure. Mean overall time to healing was 12.8 ± 4.3 weeks. Mean wound area reduction from baseline was 91% for all wounds. Of the 16 wounds without confirmed closure during the 16‐week treatment period, five (31.3%) achieved 99–100% wound area reduction by their final visit. The product was well tolerated. Two minor amputations occurred during the study period due to recurrent or persistent osteomyelitis; however, there were no major amputations.