Buruli Ulcer Wound Bed Preparation in Rural West Africa: Is Pulsed Pressurized Irrigation Mightier than the Knife?
Buruli ulcer (BU) caused by Mycobacterium ulcerans is largely a problem of the poor in remote rural areas and is a significant cause of human suffering. Where prevalence reaches 16% in some African villages, BU is the third commonest mycobacterial disease, after tuberculosis and leprosy. Buruli ulcer is one of many infectious diseases classified as a “neglected” tropical diseases by the WHO. Treatment may include wide surgical debridement, antibiotics, traditional or pinch skin grafting and/or dressings used to prevent scar contractures and disability. Smaller BU wounds heal by 2 intention but larger wounds frequently require surgical sharp debridement and wound bed preparation before skin grafting to hasten healing and achieve the best possible functional result. We present a novel wound bed preparation technique using a portable self-contained pulsed pressurized irrigation system (PPI) using low pressure (8- 15 psi) pulsed water-jet without suction within an easy-to-use disposable collection system with minimal risk. Portability improves access to daily selective hydro-mechanical debridement for patients in these poor rural areas. PPI is atraumatic, less painful and a tissue preserving hydro-mechanical debridement with relatively low cost, very effective and can be easily performed in poor rural outpatient settings.
0.9 % Normal Saline is prepared daily using a portable filtration system at the rural wound clinic. This represents a tremendous improvement in access to effective treatment of BU with potential healthcare cost savings compared to antibiotics and other conventional products and modalities.
We present 3 cases of non-healing BU that were successfully treated using PPI wound bed preparation followed by pinch skin grafting in a sustainable rural African wound clinic setting. Care givers were trained to perform ongoing daily PPI. PPI was quickly adopted by community care givers and patients. Internet access (when available) used to advise the on-site Interdisciplinary Wound Team using online telemedicine between Boston, Massachusetts and West Africa for the most difficult BU cases.
Our results show that PPI can be delivered as a safe, minimally invasive, sustainable, hydro-debridement modality that can successfully achieve wound bed preparation in remote villages for BU patients.