The Role of Hypochlorous Acid in Managing Wounds: Reduction in Antibiotic Usage

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by Martha Kelso, RN, HBOT

Editor's note:This blog post is part of the WoundSource Trending Topics series, bringing you insight into the latest clinical issues and advancement in wound management, with contributions by the WoundSource Editorial Advisory Board.

Numerous brands of hypochlorous acid have emerged in the last few years and have been marketed as "ideal" products for use in wound cleansing. These statements, of course, should draw speculation because it is rare for a single product to be used on all wounds, all clients, in all care settings, all the time, thus making it "ideal." Let's explore the role of hypochlorous acid in wound management and wound healing and see how it assists with reduction in antibiotic usage.

In its true native natural state, hypochlorous acid is a biocide produced naturally by the human body through the process of phagocytosis during the oxidative burst pathway. Because hypochlorous acid is an oxidant, it leaves nothing behind for bacteria and viruses to create resistance to and therefore does not contribute to the superbug (multidrug-resistant organisms) dilemma. Manufacturers have found a way to create hypochlorous acid outside the human body and bottle it for commercial use. These products are non-cytotoxic when concentrations (parts per million) and pH levels are acceptable for human use.

Why All The Fuss? The Problem of Multidrug Resistance

With the ever-increasing problem of multidrug-resistant organisms, the Centers for Medicare & Medicaid Services have taken notice in hospitals and nursing homes.1,2 Aside from this, more medications (especially antibiotics) create more problems. Often the side effects of antibiotic usage are difficult to manage or require more antibiotic usage, such as in cases of Clostridium difficile infection. If we are to reduce antibiotic usage we need to know what tools in our tool kit are safe and effective for all age ranges and situations. Hypochlorous acid meets these criteria. In a published scientific article describing a study in which hypochlorous acid was tested to look at a variety of its components, the outcome determined that this solution in most cases had a 12-second kill time for numerous bacteria and viruses, helped promote wound healing and cell proliferation, and did not harm current healthy cells. Also of note, this solution disrupted biofilm and increased cell migration.3 What's not to like?

What's the Down Side of Hypochlorous Acid?

Hypochlorous acid is more expensive than saline. Based on the product, some preparations have a rather short shelf life after opening (i.e., 24 hours to 30 days), so research the product before purchase to ensure that it meets your expectations and needs. Some preparations have a shelf life of 18 months after opening. Hypochlorous acid cannot be combined with silver products because the two cancel each other out through the power of oxidization. If you add up the cost associated with antibiotics, the costs of treating the side effects of antibiotics, and the cost of silver products, in general, there are significant cost savings associated with the use of hypochlorous acid (depending on the price of the hypochlorous acid preparation you use, of course). If you do a quick review, we are meeting CMS mandates, reducing antibiotic usage, reducing silver usage, not contributing to the multidrug-resistant organism dilemma, disrupting biofilm, and using a non-cytotoxic agent. I guess it really may be considered an ideal agent for wounds after all.

References
1. CMS' proposed rule for hospitals: reduce antibiotic use or exit Medicare. Becker's Hospital Review. https://www.beckershospitalreview.com/quality/cms-proposed-rule-for-hosp.... Published June 14, 2016. Accessed February 1, 2018.
2. Dall C. New rule mandates antibiotic stewardship in nursing homes. CIDRAP Center for Infection Disease Research and Policy. http://www.cidrap.umn.edu/news-perspective/2016/10/new-rule-mandates-ant.... Published October 4, 2016. Accessed February 1, 2018.
3. Sakarya S, Gunay N, Karakulak M, Ozturk B, Ertugrul B. Hypochlorous acid: an ideal wound care agent with powerful microbicidal, antibiofilm, and wound healing potency. Wounds. 2014;26(12):342-50.

About the Author
Martha Kelso is the founder and Chief Executive Officer of Wound Care Plus, LLC (WCP) and has enjoyed a career as a wound nurse in long-term care, which has given her plenty of experience to draw upon as she continues to work to educate health care professionals today.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

Comments

I recently read this article: The Role of Hypochlorous Acid in Managing Wounds: Reduction in Antibiotic Usage

I have never heard that hyochlorous acid should not be combined w/ silver products. Can you direct me to some documentation about that?

The purpose of HOCl in the wound bed is to react with pathogens and kill them. The function of ROS molecules is to react. HOCl, a Reactive Oxygen Species(ROS) aggressively reacts with most compounds; being about 6x more reactive than Hydrogen Peroxide. The reaction of HOCl with Silver or silver compounds varies depending on composition. The resulting products may not necessarily be harmful to the patient but those reactions have nothing to do with removing pathogens from the wound bed. Combining silver, in most cases if not all cases, with hypochlorous acid results in lowered efficiency for both products. In my opinon, any side reations that do not facillitate the removal of bioburden and the promotion of healing are at best redundant and at worse detrimental to the patient.

It should be pointed out that the use of silver, in it's different enbodyments, for wound care is not precluded from a wound care protocol using hypochlorous acid. It is, however, not recommended the two compounds be used at the same time e.g. do not soak silver empregnated wound cover with HOCl, do not add HOCl solution to Agx solution. But cleansing or debriding with HOCl solution THEN covering with a Ag(x) product would be acceptable. The other concideration is that HOCl has no reported adverse affects and can be used as a stand alone product.
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The reaction of hypochlorous acid (HOCl) solutions with silver oxide only liberates oxygen and produces AgCl.

When chlorine reacts with silver oxide diffused in water, a mixture of silver chloride and silver chlorate is formed.

Silver nitrate can react with sodium hypochlorite to form silver chloride and silver I,III oxide, Ag2O2, is formed, both of which are precipitated. An unknown substance, with bleaching properties, is left behind in the solution. This substance is unstable, and quickly decomposes after several minutes, leaving behind silver chlorate in the solution, which does not bleach. If sodium hydroxide is added to the bleaching substance, oxygen gas is evolved.

However, silver hypochlorite may also be formed from the reaction between silver nitrate and sodium hypochlorite, according to the same book.

If a solution of chlorine is added to excess Ag2O, silver hypochlorite can be formed in solution. AgOCl partially decomposes in darkness, or rapidly if heated above 60degC, into AgCl and AgClO3.

A comprehensive treatise on inorganic and theoretical chemistry, Volume 2 By Joseph William Mellor. p271

In my point of view, Hypochlorous may be expensive than saline but considering its role in wound management, opting for it won't be a bad idea.

I would be grateful if you could supply a source for the statement "Hypochlorous acid cannot be combined with silver products because the two cancel each other out through the power of oxidization". In order to fully understand this statement I would like to see an in-depth chemical explanation. I would have thought that the state/form of Ag used would have a bearing as elemental Ag 'behaves' quite differently to Ag+, to nano Ag .......etc. When anything breaks down over time it moves to a more stable chemical state i.e lower energy > less reactive.

The purpose of HOCl in the wound bed is to react with pathogens and kill them. The function of ROS molecules is to react. HOCl, a Reactive Oxygen Species(ROS) aggressively reacts with most compounds; being about 6x more reactive than Hydrogen Peroxide. The reaction of HOCl with Silver or silver compounds varies depending on composition. The resulting products may not necessarily be harmful to the patient but those reactions have nothing to do with removing pathogens from the wound bed. Combining silver, in most cases if not all cases, with hypochlorous acid results in lowered efficiency for both products. In my opinon, any side reations that do not facillitate the removal of bioburden and the promotion of healing are at best redundant and at worse detrimental to the patient.

It should be pointed out that the use of silver, in it's different enbodyments, for wound care is not precluded from a wound care protocol using hypochlorous acid. It is, however, not recommended the two compounds be used at the same time e.g. do not soak silver empregnated wound cover with HOCl, do not add HOCl solution to Agx solution. But cleansing or debriding with HOCl solution THEN covering with a Ag(x) product would be acceptable. The other concideration is that HOCl has no reported adverse affects and can be used as a stand alone product.
---------------------------------------------------------------------------------------------------------------------------------------------
The reaction of hypochlorous acid (HOCl) solutions with silver oxide only liberates oxygen and produces AgCl.

When chlorine reacts with silver oxide diffused in water, a mixture of silver chloride and silver chlorate is formed.

Silver nitrate can react with sodium hypochlorite to form silver chloride and silver I,III oxide, Ag2O2, is formed, both of which are precipitated. An unknown substance, with bleaching properties, is left behind in the solution. This substance is unstable, and quickly decomposes after several minutes, leaving behind silver chlorate in the solution, which does not bleach. If sodium hydroxide is added to the bleaching substance, oxygen gas is evolved.

However, silver hypochlorite may also be formed from the reaction between silver nitrate and sodium hypochlorite, according to the same book.

If a solution of chlorine is added to excess Ag2O, silver hypochlorite can be formed in solution. AgOCl partially decomposes in darkness, or rapidly if heated above 60degC, into AgCl and AgClO3.

A comprehensive treatise on inorganic and theoretical chemistry, Volume 2 By Joseph William Mellor. p271

Hi Martha, I saw you speak at the wound care conference in Wichita the last week of April. I have been trying to find hypochlorous acid to use in our clinic since then, but I haven't been able to find much by googling, other than the Vashe which is only good for 30 days after opening. Could you list some brands of hypochlorous here and maybe tell us what your favorite brand is? I'm anxious to get started using it since I've heard so many good things about it!

On our website at www.mywoundcareplus.com there is a page called "Our Affiliates". There are two companies there that sell hypochlorous acid. If you click on their logos it will take you to their website where you can get in touch with them. More than likely they would be willing to send samples if you are new to their product. The first company is Angelini. The second company is Pure and Clean. Let me know if you need assistance procuring product.

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