CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 2, March/April 2022 46 AFRICA Demographic and clinical characteristics of the patients were recorded. Before the procedure, quantitative woundculture samples were collected from all ulcers, and systemic antibiotic therapy was initiated according to the isolated strains. The wounds were washed with isotonic saline before the placement of the VAC sponge and necrotic tissue was removed. No local antiseptic agents were used for dressing changes. A VAC device (Smith & Nephew RENASYS EZ MAX NPWT device, Switzerland AG, Baar, Switzerland) was utilised at 125 mmHg continuous negative pressure for the first six consecutive applications and at 80 to 125 mmHg (mean: 100 mmHg) intermittent negative pressure for the subsequent applications.19 The wound was examined for signs of infection during every dressing change. The length and width of the wound were measured by the classical method and the results were recorded in cm.20 Wound healing, formation of granulation tissue and epithelialisation were evaluated and captured by photography. No surgical debridement or surgical corrective procedure was applied in any patient. None of the patients received venotonic agents during the hospitalisation period. Wound healing was defined as the complete closure of the ulcer, while rapid wound healing was defined as a ≥ 30% reduction in the ulcer size by week four.21 Primary outcome measures included wound healing as assessed by local wound examination at every dressing change,22 and the rate and velocity of ulcer reduction. Statistical analysis Statistical data were evaluated using Windows-compatible Statistical Package for Social Sciences 13.0 (SPSS 13.0) (SPSS Inc, Chicago, IL). Descriptive data are expressed as medians (interquartile ranges) or as numbers and frequencies. Significant differences between mean values were analysed using the Mann–Whitney U-test, the Wilcoxon signed ranks test and the Kruskal–Wallis test, and subgroups with significant differences from each other were analysed using the Bonferroni corrected Mann–Whitney U-test. The chi-squared test was used to evaluate the relationships between categorical variables. In all analyses, p < 0.05 was considered significant. Results The mean number of VAC therapies for each case was 17.8 (range 12.4–26.8) and the mean time between dressing changes was 72.3 hours (range 61.1–83.4). The mean length of hospital stay was 32.3 days (range 24.2–38.6). The wound surfaces of all ulcers were measured before VAC therapy, and the mean length and width were found to be 9.2 cm (range 6.1–12.6) and 8.1 cm (range 3–14.2), respectively. The mean pre-procedural wound surface area was 68.2 cm2 (range 22.5–154.6). Pre-procedural local wound and infection examination results and wound surface area measurements are summarised in Table 1. Compared to baseline, the mean reduction rates of ulcers were 46.4% for the first six applications and 72.8% for the subsequent applications (Fig 3). In addition, all ulcers were colonised by a variety of bacteria at baseline (Figs 4–7). MDR P aeruginosa and methicillin-resistant S aureus (MRSA) were detected in three and four patients, respectively (Table 1). Before VAC therapy, the mean dosage of antibiotic therapy was three times daily (range 1–8) for each patient. Quantitative wound culture results became negative after a mean duration of Table 1. Pre-procedural wound assessments and wound surface measurements (n = 14) No. Location Size and decollation (cm2) Bacterial spp. Wound edges/surroundings Wound bed/ surface Exudate/drainage Pain 1 Right medial malleolus 90.92 MSSA Regular/indurated Fibrinous Fibrinous/moderate Transient 2 Right lateral malleolus 45.15 Pseudomonas aeruginosa Regular/erythematous Fibrinous Purulent/moderate Persistent 3 Mid-anterior of right leg 78.98 Pseudomonas aeruginosa Regular/erythematous Fibrinous Purulent/severe Persistent 4 Left medial malleolus 49.51 MRSA Irregular/indurated Fibrinous Serous/moderate Transient 5 Right lateral leg 53.05 Beta-haemolytic streptococci Irregular/indurated Fibrinous Fibrinous/severe Transient 6 Medial malleolus 83.62 MRSA Regular/indurated Fibrinous Serous/moderate Transient 7 Anterior leg, inferior 55.81 Actinomyces israelii Irregular/increase temperature Fibrinous Purulent/moderate Persistent 8 Anterior leg, middle 29.63 Eubacterium rectale Irregular/erythematous Fibrinous Purulent/severe Persistent 9 Anterior leg, middle 22.52 MRSA Irregular/erythematous Fibrinous Fibrinous/moderate Transient 10 Lateral leg, inferior 37.96 Escherichia coli Regular/indurated Fibrinous Serous/moderate Transient 11 Medial malleolus 66.04 Escherichia coli Regular/macerated Fibrinous Serous/moderate Transient 12 Anterior and posterior leg 154.56 Pseudomonas aeruginosa Irregular/increase temperature Fibrinous Purulent/moderate Persistent 13 Medial, middle 145.88 MRSA Irregular/erythematous Fibrinous Fibrinous/moderate Persistent 14 Medial, inferior 41.17 Propionibacterium acnes Regular/erythematous Fibrinous Purulent/moderate Persistent MRSA: methicillin-resistant Staphylococcus aureus; MSSA: methicillin-sensitive Staphylococcus aureus. Treatment duration Baseline Week 2 Week 4 Week 6 Week 8 Wound surface area (cm2) (width × length) 80 70 60 50 40 30 20 10 0 Fig 3. Ulcer reduction rate according to treatment weeks
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