Negative pressure wound therapy with instillation (NPWTi): Current status, recommendations and perspectives in the context of modern wound therapy.
Introduction of negative pressure wound therapy (NPWT) revolutionized the conception of wound healing. Currently, there are an increased number of studies confirmed the high efficiency of this therapy in many clinical scenarios. Moreover, some innovations have been introduced in recent years to improve the management of complex and chronic wound.
NPWT with instillation (NPWTi) combines traditional NPWT with application of topical irrigation solutions within bed of the wound. Bioburden reduction, decrease time to wound closure, promotion in granulation tissue formation, fewer operative visits have been revealed using NPWTi compared to standard NPWT.
However, there are still some questioned aspect of the NPWTi and thus its superiority over standard NPWT has not been fully indicated. Moreover, based on current studies no firm conclusions have been taken concerning the type of instilled solution preferably used, range of dwell- time phase, range of negative pressure and others.
The main goal of the publication is to overview and summarize the current state of art concerning NPWTi. Moreover, mechanisms of action, review of the most common used instilled solution are discussed and clinical evidence of NPWTi are described.
Fleischmann W, Strecker W, Bombelli M, Kinzl L. [Vacuum sealing as treatment of soft tissue damage in open fractures]. Unfallchirurg 1993;96:488–492.
Fleischmann W, Lang E, Kinzl L. [Vacuum assisted wound closure after dermatofasciotomy of the lower extremity]. Unfallchirurg 1996;99:283–287.
Argenta LC, Morykwas MJ. Vacuum-assisted closure: A new method for wound control and treatment - Clinical experience. Ann Plast Surg. 1997;38:563–576; discussion 577.
Baharestani M, Amjad I, Bookout K, Fleck T, Gabriel A, Kaufman D, McCord SS, Moores DC, Olutoye OO, Salazar JD, Song DH, Teich S, Gupta S. V.A.C. Therapy in the management of paediatric wounds: clinical review and experience. Int Wound J. 2009 Aug;6 Suppl 1:1-26.
Beitz JM, van Rijswijk L. Developing evidence-based algorithms for negative pressure wound therapy in adults with acute and chronic wounds: literature and expert-based face validation results. Ostomy Wound Manage. 2012 Apr;58(4):50-69.
Krokowicz L, Borejsza-Wysocki M, Mackiewicz J, Iqbal A, Drews M. 10 years of negative pressure wound therapy [NPWT]: evolution of indications for its use. Negative Pres. Wound Ther. 2014; 1: 27-32.
Kim PJ, Attinger CE, Steinberg JS, Evans KK, Lehner B, Willy C, Lavery L, Wolvos T, Orgill D, Ennis W, Lantis J, Gabriel A, Schultz G. Negative-pressure wound therapy with instillation: international consensus guidelines. Plast Reconstr Surg. 2013 Dec;132(6):1569-79.
Orgill DP, Bayer LR. Update on negative-pressure wound therapy. Plast Reconstr Surg 2011;127:105S–15S.
Gabriel A, Shores J, Bernstein B, De Leon J, Kamepalli R, Wolvos T, Baharestani MM, Gupta S. A clinical review of infected wound treatment with vacuum assisted closure (r) (vac (r)) therapy: experience and case series. Int Wound J 2009;6:1–25.
Ichioka S, Watanabe H, Sekiya N, Shibata M, Nakatsuka T. A technique to visualize wound bed microcirculation and the acute effect of negative pressure. Wound Repair Regen 2008;16:460–5.
Scherer SS, Pietramaggiori G, Mathews JC, Prsa MJ, Huang S, Orgill DP. The mechanism of action of the vacuum-assisted closure device. Plast Reconstr Surg. 2008 Sep;122(3):786-97.
McNulty AK, Schmidt M, Feeley T, Kieswetter K. Effects of negative pressure wound therapy on fibroblast viability, chemotactic signaling, and proliferation in a provisional wound (fibrin) matrix. Wound Repair Regen. 2007;15(6):838–846.
Saxena V, Hwang CW, Huang S, Eichbaum Q, Ingber D, Orgill DP. Vacuum-assisted closure: microdeformations of wounds and cell proliferation. Plast Reconstr Surg. 2004;114(5):1086–1098.
Wang N, Butler J, Ingber D. Mechanotransduction across the cell surface and through the cytoskeleton. Science. 1993;260(5111):1124–1127.
Ingber DE. Tensegrity: the architectural basis of cellular mechanotransduction. Ann Rev Physiol. 1997;59(1):575– 599.
Buttenschoen K, Fleischmann W, Haupt U. The influence of vacuum-assisted closure on inflammatory tissue reactions in the postoperative course of ankle fractures. Foot Ankle Surg 2001; 7:165–73.
Wimpenny J, Manz W, Szewzyk U. Heterogeneity in biofilms. FEMS Microbiol Rev. 2000 Dec;24(5):661-71.
Gabriel A, Shores J, Heinrich C, Baqai W, Kalina S, Sogioka N, Gupta S. Negative pressure wound therapy with instillation: a pilot study describing a new method for treating infected wounds. Int Wound J 2008;5:399–413.
Percival SL. Hill KE. Williams DW. Hooper SJ. Thomas DW. Costerton JW. A review of the scientific evidence for biofilms in wounds. Wound Repair Regen. 2012;20:647.
Grice EA. Segre JA. Interaction of the microbiome with the innate immune response in chronic wounds. Adv Exp Med Biol. 2012;946:55.
James GA, Swogger E, Wolcott R, Pulcini E, Secor P, Sestrich J, Costerton JW, Stewart PS. Biofilms in chronic wounds. Wound Repair Regen 2008;16:37–44.
Phillips PL, Yang Q, Schultz GS. The effect of negative pressure wound therapy with periodic instillation using antimicrobial solutions on Pseudomonas aeruginosa biofilm on porcine skin explants. Int Wound J. 2013 Dec;10 Suppl 1:48-55.
Allen D, LaBarbera LA, Bondre IL, Lessing MC, Rycerz AM, Kilpadi DV, Collins BA, Perkins J, McNulty AK. Comparison of tissue damage, cleansing and cross-contamination potential during wound cleansing via two methods: lavage and negative pressure wound therapy with instillation. Int Wound J. 2014 Apr;11(2):198-209.
Percival SL, Vuotto C, Donelli G, Lipsky BA. Biofilms and Wounds: An Identification Algorithm and Potential Treatment Options. Adv Wound Care (New Rochelle). 2015 Jul 1;4(7):389-397.
Wolcott RD, Rumbaugh KP, James G, et al. Biofilm maturity studies indicate sharp debridement opens a time- dependent therapeutic window. J Wound Care 2010;19:320.
Attinger C, Wolcott R. Clinically Addressing Biofilm in Chronic Wounds. Adv Wound Care (New Rochelle) 2012;1:127–132.
Leung BK, LaBarbera LA, Carroll CA, Allen D, McNulty AK. The effects of normal saline instillation in conjunction with negative pressure wound therapy on wound healing in a porcine model. Wounds. 2010 Jul;22(7):179-87.
Brinkert D, Ali M, Naud M, Maire N, Trial C, Teot L. Negative pressure wound therapy with saline instillation: 131 patient case series. Int Wound J 2013;10:56–60.
Lessing MC, James RB, Ingram SC. Comparison of the effects of different negative pressure wound therapy modes - continuous, noncontinuous, and with instillation - on porcine excisional wounds. Eplasty 2013;13:e51.
Lessing C, Slack P, Hong KZ, Kilpadi D, McNulty A. Negative Pressure Wound Therapy With Controlled Saline Instillation (NPWTi): Dressing Properties and Granulation Response In Vivo. Wounds. 2011 Oct;23(10):309-19.
Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen. 2003;11:S1–S28.
Wilkes R, Zhao Y, Cunningham K, Kieswetter K, Haridas B. 3D strain measurement in soft tissue: demonstration of a novel inverse finite element model algorithm on MicroCT images of a tissue phantom exposed to negative pressure wound therapy. J Mech Behav Biomed Mater. 2009 Jul;2(3):272-87.
Rycerz AM, Slack P, McNulty AK. Distribution assessment comparing continuous and periodic wound instillation in conjunction with negative pressure wound therapy using an agar-based model. Int Wound J. 2013 Apr;10(2):214-20.
Scimeca CL, Bharara M, Fisher TK, Giovinco N, Armstrong DG. Novel use of doxycycline in continuous-instillation negative pressure wound therapy as “wound chemotherapy”. Foot Ankle Spec 2010;3:190–3.
Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: A new method for wound control and treatment. Animal studies and basic foundation. Ann Plast Surg. 1997;38:553–562.
Kim PJ, Attinger CE, Oliver N, Garwood C, Evans KK, Steinberg JS, Lavery LA. Comparison of Outcomes for Normal Saline and an Antiseptic Solution for Negative-Pressure Wound Therapy with Instillation. Plast Reconstr Surg. 2015 Nov;136(5):657e-64e.
Fluieraru S, Bekara F, Naud M, Herlin C, Faure C, Trial C, Téot L. Sterile-water negative pressure instillation therapy for complex wounds and NPWT failures. J Wound Care. 2013 Jun;22(6):293-4, 296, 298-9.
Davis K, Bills J, Barker J, Kim P, Lavery L. Simultaneousmirrigation and negative pressure wound therapy enhances wound healing and reduces wound bioburden in a porcinemmodel. Wound Repair Regen. 2013;21:869–875.
King M: Our historical roots: Dr Richard Drysdale Dakin, DSc, and his solution. J Wound Ostomy Continence Nurs. 2008;35:289–292.
McCullough M, Carlson GW. Dakin's solution: historical perspective and current practice. Ann Plast Surg. 2014 Sep;73(3):254-6.
Doughty D. A rational approach to the use of topical antiseptics. J Wound Ostomy Continence Nurs. 1994;21:224-231.
Agostinho AM, Hartman A, Lipp C, Parker AE, Stewart PS, James GA: An invitro model for the growth and analysis of chronic wound MRA biofilms. J Appl Microbiol. 2011;111:1275–1282.
Cooper ML, et al. The cytotoxic effects of commonly used topical antimicrobial agents on human fibroblasts and keratinocytes. J Trauma. 1991; 31:775-784.
Heggers JP, Sazy JA, Stenberg BD, et al: Bactericidal and wound-healing properties of sodium hypochlorite solutions: the 1991 Lindberg Award. J Burn Care Rehabil. 1991;12:420–424.
Kozol RA, et al. Effects of sodium hypochlorite (Dakin’s solution) on cells of the wound module. Arch Surg. 1988;123:420-423.
Lineaweaver W, et al. Topical antimicrobial toxicity. Arch Surg. 1985;120: 267-270.
Sauer K, Thatcher E, Northey R, Gutierrez AA. Neutral super-oxidised solutions are effective in killing P. aeruginosa biofilms. Biofouling 2009;25:45–54.
Landa-Solis C1, González-Espinosa D, Guzmán-Soriano B, Snyder M, Reyes-Terán G, Torres K, Gutierrez AA. Microcyn: A novel super-oxidized water with neutral pH and disinfectant activity. J Hosp Infect. 2005;61:291–299.
Goretti C, Mazzurco S, Nobili LA, Macchiarini S, Tedeschi A, Palumbo F, Scatena A, Rizzo L, Piaggesi A. Clinical outcomes of wide postsurgical lesions in the infected diabetic foot managed with 2 different local treatment regimes compared using a quasi-experimental study design: a preliminary communication. Int J Low Extrem Wounds. 2007 Mar;6(1):22-7.
Landsman A, Blume PA, Jordan DA Jr, Vayser D, Gutierrez A. An open-label, three-arm pilot study of the safety and efficacy of topical Microcyn Rx wound care versus oral levofloxacin versus combined therapy for mild diabetic foot infections. J Am Podiatr Med Assoc. 2011 Nov-Dec;101(6):484-96.
Minnich KE, Stolarick R, Wilkins RG, Chilson G, Pritt SL, Unverdorben M. The effect of a wound care solution containing polyhexanide and betaine on bacterial counts: Results of an in vitro study . Ostomy Wound Manage. 2012;58:32–36.
Romanelli M, Dini V, Barbanera S, Bertone MS. Evaluation of the efficacy and tolerability of a solution containing propyl betaine and polihexanide for wound irrigation. Skin Pharmacol Physiol. 2010;23 Suppl:41-4.
Hübner NO, Matthes R, Koban I, et al. Efficacy of chlorhexidine, polihexanide and tissue-tolerable plasma against Pseudomonas aeruginosa biofilms grown on polystyrene and silicone materials. Skin Pharmacol Physiol. 2010;23(Suppl):28–34.
Sibbald RG, Coutts P, Woo KY. Reduction of bacterial burden and pain in chronic wounds using a new polyhexamethylene biguanide antimicrobial foam dressing-clinical trial results. Adv Skin Wound Care. 2011 Feb;24(2):78-84.
Lehner B, Weiss S, Suda AJ, Witte D. Application of V.A.C. Instill therapy in case of periprosthetic infection in hip arthroplasty. Infection 2009;37:13–17.
Koster G. Management of early periprosthetic infections in the knee using the vacuum-instillation therapy. Infection 2009;37:18–20.
Yin HQ, Langford R, Burrell RE. Comparative evaluation of the antimicrobial activity of ACTICOAT antimicrobial barrier dressing. J Burn Care Rehabil 1999;20:195–200.
Cooper ML, Laxer JA, Hansbrough JF. The cytotoxic effects of commonly used topical antimicrobial agents on human fibroblasts and keratinocytes. J Trauma 1991;31:775–82; discussion 782–4.
Wright JB, Lam K, Buret AG, Olson ME, Burrell RE. Early healing events in a porcine model of contaminated wounds: effects of nanocrystalline silver on matrix metalloproteinases, cell apoptosis, and healing. Wound Repair Regen 2002;10:141–51.
Schreier H., Erdos G, Fleischer W, et al. Molecular effects of povidone-iodine on relevant microorganisms: an electron-microscopic and biochemical study. Dermatology. 1997;195(2):111–116.
Kunisada T, Yamada K, Hara O, et al. Investigation on the efficacy of povidone-iodine against antiseptic-resistant species. Dermatology. 1997;195(2):14–18.
Kaysinger KK, Nicholson NC, Ramp WK, et al. Toxic effects of wound irrigation solutions on cultured tibiae and osteoblasts. J Orthop Trauma. 1995;9(4):303–311.
Fumal I, Braham C, Paquet P, et al. The beneficial toxicity paradox of antimicrobials in leg ulcer healing impaired by a polymicrobial flora: a proof-of-concept study. Dermatology. 2002;204(1):70–74.
Yalanis GC, Liu EW, Cheng HT.Efficacy and Safety of Povidone-Iodine Irrigation in Reducing the Risk of Capsular Contracture in Aesthetic Breast Augmentation: A Systematic Review and Meta-Analysis. Plast Reconstr Surg. 2015 Oct;136(4):687-98.
Niedner R. Cytotoxicity and sensitization of povidone-iodine and other frequently used anti-infective agents. Dermatology. 1997;195 Suppl 2:89-92.
Chang FY, Chang MC, Wang ST, Yu WK, Liu CL, Chen TH. Can povidone-iodine solution be used safely in a spinal surgery? Eur Spine J. 2006 Jun;15(6):1005-14.
Liu Y, Zhang X, Zhang Z, Fang PY, Xu WS. [Effects of topical application of insulin on the wound healing in scalded rats]. Zhonghua Shao Shang Za Zhi 2004; 20: 98–101.
Zhang XJ, Chinkes DL, Sadagopa Ramanujam VM, Wolfe RR. Local injection of insulin-zinc stimulates DNA synthesis in skin donor site wound. Wound Repair Regen 2007; 15: 258–65.
Wilson JM, Baines R, Babu ED, Kelley CJ. A role for topical insulin in the management problematic surgical wounds. Ann R Coll Surg Engl. 2008 Mar;90(2):160.
Rezvani O, Shabbak E, Aslani A, Bidar R, Jafari M, Safarnezhad S. A randomized, double-blind, placebo-controlled trial to determine the effects of topical insulin on wound healing. Ostomy Wound Manage. 2009 Aug 1;55(8):22-8.
Greenway SE, Filler LE, Greenway FL.Topical insulin in wound healing: a randomised, double-blind, placebo-controlled trial. J Wound Care. 1999 Nov;8(10):526-8.
Fleischmann W, Russ M, Westhauser A, Stampehl M. [Vacuum sealing as carrier system for controlled local drug administration in wound infection]. Unfallchirurg 1998;101:649–54.
Wolvos T. Wound instillation--the next step in negative pressure wound therapy. Lessons learned from initial experiences. Ostomy Wound Manage. 2004 Nov;50(11):56-66.
Bernstein BH, Tam H. Combination of subatmospheric pressure dressing and gravity feed antibiotic instillation in the treatment of post-surgical diabetic foot wounds: a case series. Wounds 2005;17:37–48.
Gabriel A, Kahn K, Karmy-Jones R. Use of negative pressure wound therapy with automated, volumetric instillation for the treatment of extremity and trunk wounds: clinical outcomes and potential cost effectiveness. Eplasty 2014;14:e41.
Goss SG, Schwartz JA, Facchin F, Avdagic E, Gendics C, Lantis JC II. Negative pressure wound therapy with instillation (NPWTi) better reduces postdebridement bioburden in chronically infected lower extremity wounds than NPWT alone. J Am Coll Clin Wound Spec 2014;4:74–80.
Wolvos T. The use of negative pressure wound therapy with an automated, volumetric fluid administration: an advancement in wound care. Wounds 2013;25:75–83.
Schintler MV, Prandl EC, Kreuzwirt G, Grohmann MR, Spendel S, Scharnagl E. The impact of V.A.C. Instill in severe soft tissue infections and necrotizing fasciitis. Infection 2009;37:31–32.
Leffler M, Horch RE, Dragu A, Kneser U. Instillation therapy and chronic osteomyelitis: Preliminary results with the V.A.C. Instill therapy. Infection 2009;37:24–30.
Gabriel A. Integrated negative pressure wound therapy system with volumetric automated fluid instillation in wounds at risk for compromised healing. Int Wound J. 2012 Aug;9 Suppl 1:25-31.
D’Hondt M, D’Haeninck A, Dedrye L, Penninckx F, Aerts R. Can vacuum-assisted closure and instillation therapy (VAC-Instill therapy) play a role in the treatment of the infected open abdomen? Tech Coloproctol (2011) 15:75–77.
KCI. V.A.C. Therapy Clinical Guidelines and V.A.C. Instill Recommended Guidelines Supplement. 2004.
Weinstein A, McHenry M, Gavan T. Systemic absorption of neomycin irrigating solution. JAMA. 1977;238:152–153.
Netland PA, Baumgartner JE, Andrews BT. Intraoperative anaphylaxis after irrigation with bacitracin: case report. Neurosurgery 1987; 21: 927–8.
Sprung J, Schedewie HK, Kampine JP. Intraoperative anaphylactic shock after bacitracin irrigation. Anesth Analg 1990; 71: 430–3.
Eedy D, McMillan J, Bingham E. Anaphylactic reactions to topical antibiotic combinations. Postgrad Med J. 1990;66:858–859.
D’Auria J, Lipson S, Garfield J. Fatal iodine toxicity following surgical debridement of a hip wound: case report. J Trauma. 1990;30:353–355.
Bassan, M, Dudai M, Shalev O. Near-fatal systemic oxygen embolism due to wound irrigation with hydrogen peroxide. Postgrad Med J. 1982;58:448–450.
Matiasek J, Djedovic G, Mattesich M, Morandi E, Pauzenberger R, Pikula R, Verstappen R, Pierer G, Koller R, Rieger UM. The combined use of NPWT and instillation using an octenidine based wound rinsing solution: a case study. J Wound Care. 2014 Nov;23(11):590, 592-6.
Copyright (c) 2016 Adam Bobkiewicz, Adam Studniarek, Michał Drews, Tomasz Banasiewicz
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).
We require authors to sign a Publication Agreement prior to publication of the manuscript in NPWTJ. The link to this form may be found below.
PUBLICATION AGREEMENT FORM