The successful healing effect of local Taurolidine irrigation for treating deep pressure ulcers: a case report

Abstract

Background

Pressure ulcers, particularly stage III and IV lesions, pose a significant healthcare challenge owing to their high morbidity, economic burden, and recalcitrance to conventional therapies. Current management often includes systemic antibiotics, debridement, and advanced wound dressings, yet outcomes remain suboptimal in many cases. Innovative approaches to wound care are needed to address this gap.

Case presentation

We report a case of a 17-year-old Iranian paraplegic male with a stage III sacral pressure ulcer complicated by an underlying abscess and exposed bone. Despite systemic antibiotics, regular debridement, and dressing changes, the ulcer failed to heal. The introduction of serial Taurolidine irrigation, combined with limited application of cryopreserved human amniotic membrane, resulted in progressive wound granulation and complete reepithelialization within 2 months. The patient experienced no adverse effects and maintained complete healing at follow-ups up to 1 year.

Conclusion

This case highlights the potential of Taurolidine as a novel antiseptic and wound-healing agent for recalcitrant pressure ulcers. Taurolidine irrigation demonstrated efficacy in achieving complete ulcer healing, suggesting its role as a promising therapeutic option for challenging wound infections.

Introduction

Pressure ulcers, commonly referred to as bedsores or pressure sores, represent a significant health concern that poses both medical and economic challenges. These localized injuries occur owing to sustained or intense pressure on the skin and underlying tissues, predominantly over bony prominences, leading to tissue damage [1, 2]. When left untreated, pressure ulcers can advance to more severe stages involving extensive tissue damage and even exposure to underlying structures, such as bone, tendon, or muscle. The prevalence of pressure ulcers is alarmingly high, affecting approximately 3 million adults in the USA each year [1, 3, 4]. Despite extensive research and interventions over the past two decades, the incidence rate has largely remained consistent, further exacerbating the healthcare burden, both in terms of patient suffering and economic costs [5, 6].

Standard management of pressure ulcers involves a multifaceted approach. If healing is impossible by secondary intention (i.e., systemic antibiotic administration and frequent dressing changes), treatment includes pressure relief, debridement, and application of proper sterile wound dressing, which may include the topic treatment with antibiotics or antimicrobial compounds and/or negative pressure therapy. Comorbidities, such as heart failure, renal impairment, or diabetes, have to be addressed [7,8,9,10]. A retrospective analysis of Iranian intensive care unit (ICU) patients revealed that treating grade IV pressure ulcers could cost up to $66,834, with the total cost for all affected patients averaging $519,991 [11]. These findings echo global concerns, such as in the USA, where treatment costs range from $37,800 to $70,000 per ulcer, culminating in an estimated annual expenditure of up to $11 billion in the USA alone [12].

Taurolidine, derived from the amino acid taurine, stands as a unique therapeutic agent with a broad spectrum of properties. It is particularly noteworthy for its antimicrobial and antibiofilm capabilities, serving as an effective countermeasure against biofilm formation and various bacterial and fungal infections [13, 14]. Taurolidine has proven to be effective in preventing infections associated with central venous access devices (CVADs). It interferes with bacterial and fungal adhesion and growth, making it an enticing partner for CVAD locks [14, 15]. A distinguishing feature of Taurolidine is its ability to exert its antimicrobial effects irreversibly, ensuring that bacteria and fungi do not develop resistance [14, 16,17,18,19,20]. After all antimicrobial properties have been delivered, taurine is the product of Taurolidine metabolism. Taurine is a nonessential amino acidic compound displaying wound healing properties [21]. Thus, incorporating Taurolidine into treatment plans for pressure ulcers opens the tantalizing prospect of simultaneous treatment of both the main sore and tissue infections.

Pressure ulcers pose significant challenges in healthcare, particularly owing to their association with comorbidities and resistance to conventional treatments [22]. Current approaches, including dressings and support surfaces, often lack robust evidence and are limited in addressing biofilm-associated infections [23]. Taurolidine, with its broad-spectrum antimicrobial and antibiofilm properties, offers a novel therapeutic option, addressing these limitations while minimizing the risks of resistance and systemic toxicity, making it a promising alternative for managing chronic and infected wounds, such as pressure ulcers [24, 25].

Here, we describe the successful management of a 17-year-old adolescent male with paraplegia secondary to a traumatic spinal cord injury complicated with pressure ulcer after a car accident using Taurolidine, which could be considered a promising therapeutic approach.

Case presentation

A 17-year-old Iranian male presented to the emergency department of Namazi Hospital with a preexisting spinal cord injury that had resulted in paraplegia. The patient’s chief complaint was a painful wound over the ischium/os coccygeus region, with drainage and signs of infection, such as redness, swelling, and foul-smelling discharge. This ulcer measured 10 cm × 8 cm with exposed bone and was complicated by an underlying sacral abscess. The patient had initially suffered a C5 and C7 vertebral fracture following a car accident 1 month before this presentation, for which he underwent surgical intervention. He was discharged after a 13-day hospital stay.

The patient had been in good condition before the car accident. Then, 1 month after discharge the patient was readmitted owing to suspected lower respiratory and wound infection in the coccygeal area. The patient underwent surgical drainage of the sacral abscess. He was initiated on intravenous antibiotics, 500 mg of vancomycin every 6 hours, and 1 g meropenem every 8 hours. Dressings for the pressure ulcer were changed twice daily and wound irrigation was performed. An antibedsore mattress was also provided. Despite these interventions, the ulcer showed no significant improvement.

On the 12th day of hospitalization, the patient was transferred to the author’s service, under whose care he remained until discharge. The ulcer size was remained unchanged at 10 cm × 8 cm with persistent purulent drainage, minimal granulation tissue formation, and no signs of infection resolution. After discussing treatment options, the patient provided informed consent for the comprehensive treatment approach, which involved a systematic wound care process carried out every 72 hours until the patient was discharged. The revised wound care protocol involved normal saline irrigation, allowing the wound to air dry, followed by irrigation with the available Taurolidine solution (TauroLock™, Tauropharm, Bavaria, Germany) and again allowing the wound to air dry before applying the cryopreserved human amniotic membrane (AM) dressing (containing penicillin, gentamicin, and amphotericin B). Overall, this approach was applied twice during hospital admission. Following discharge, the patient’s care transitioned to home-based wound care, accurately adhering to the established protocol for an extended period of 4 months. Home-based wound care approach was executed every 72 hours and entailed initial irrigation of the wound with normal saline, followed by a period of air drying. Subsequently, irrigation was carried out using the available Taurolidine solution, as part of a continuous effort to mitigate infection risk and promote wound healing. The AM dressing was stopped while receiving wound care at home. Within 3 weeks, the wound demonstrated signs of healthy granulation tissue with no further necrosis or drainage. By the end of the third week, granulation was present in more than 90% of the wound area, and complete epithelialization of the peripheral wound edges was present (Fig. 1a–d). Concurrently, the patient was administered an oral antibiotic regimen comprising ciprofloxacin and clindamycin, which was sustained for 2 months post-discharge (Fig. 1e–i). At a 6-month follow-up, the ulcer had completely healed with full epithelial coverage, and no adverse events were recorded (Fig. 1j, Table 1). During long-term observation, the healed wound remained stable. (Fig. 1k). The patient’s family played an active role in his care, ensuring adherence to home-based wound management protocols. Psychologically, the patient reported feelings of frustration and anxiety related to his new paraplegic status and the challenges of wound healing.

Fig. 1

a–k Serial images demonstrating the healing progression of a pressure ulcer over observation period. a A purulent stage III sacral pressure ulcer on initial hospital presentation. b–g Images obtained during weekly wound assessments over a 6-week period illustrating a gradual decrease in purulent drainage along with increasing granulation tissue formation. h–i Additional images from weeks 7–10 showing a complete formation of healthy granulation tissue. j Image at 4 months follow-up exhibiting fully reepithelialized wound. k Long-term follow-up image showing complete wound healing

Table 1 Visual summary of key events during the patient’s treatment

Initial laboratory tests revealed a significantly elevated C-reactive protein (CRP; 130 mg/L) and white blood cell (WBC) count (15,000/µL), consistent with an ongoing infection. Blood cultures were negative, but wound cultures identified Staphylococcus aureus, sensitive to vancomycin but resistant to cephalosporins. Follow-up lab results after the initiation of Taurolidine irrigation showed a progressive decline in inflammatory markers (CRP reduced to 20 mg/L and WBC normalized to 8000/µL within 3 weeks).

Challenges encountered during the patient’s treatment included the persistence of infection and lack of granulation tissue despite systemic antibiotics and daily wound care interventions. Differentiating between superficial and deep infections was complicated by overlapping clinical signs, necessitating frequent reassessment. Additionally, maintaining pressure relief for an immobile patient was a continuous obstacle, despite using an antibedsore mattress. Limited availability of advanced therapeutic options, such as amniotic membrane, further constrained the initial treatment plan, prompting the exploration of Taurolidine irrigation as a novel alternative.

Discussion and conclusions

Here we describe a noninvasive treatment approach utilizing Taurolidine irrigation to promote the healing of a recalcitrant stage III pressure ulcer [26] exhibiting purulent drainage and failure to improve with standard care. By implementing serial Taurolidine irrigation and limited amniotic membrane application (for the first 3 dressings), we achieved gradual reepithelialization and closure of this ulcer over 2 months. Our experiential knowledge extends to administering Taurolidine, both alone and in conjunction with biological dressing (synthetic amniotic membrane), in similar clinical scenarios.

However, the impetus for presenting this particular case lies in the unique challenges posed by the ulcer’s extensive infection, purulent discharge, and its recalcitrance to prior treatments.

Pressure ulcers pose a significant challenge in healthcare. These wounds are particularly prevalent among disabled and frail patients. In consequence, they promote comorbidity, mortality, and healthcare resource use [6, 27, 28]. Effective management requires a comprehensive approach. Best practice may involve debridement, pressure relief, and negative pressure therapy. Current wound consensus documents promote the employment of different antimicrobial compounds for irrigation and systemic antibiotic administration narrowed to antibiotics able to produce the multiple of minimal inhibitory concentrations in tissues, that display reduced perfusion. However, these measures may not be readily available or not known in different healthcare settings [29, 30].

In the current study, we employed a synergistic approach by incorporating both Taurolidine as irrigation and human amniotic membrane (AM) into the therapeutic regimen for a 17-year-old patient with a pressure ulcer. The utilization of these methods resulted in restitution, without noticeable adverse effects observed. Although cryopreserved human AM dressing was used as a supplementary intervention during the initial three dressing changes to support tissue regeneration, the primary focus and sustained intervention throughout the treatment was Taurolidine irrigation, which proved independently effective in achieving complete wound closure. Taurolidine’s broad-spectrum antimicrobial properties, effective against gram-positive and gram-negative bacterial strains and certain fungi and viruses, provided a proper framework for infection control [16, 31]. This antimicrobial action was further augmented by the wound-healing properties of taurine, a product of Taurolidine metabolism. Lacking negative pressure therapy devices led to supportive care with AM, which is rich in growth factors, cytokines, and innate antimicrobial agents. Previous literature confirms the efficacy of AM in expediting wound healing, enhancing scar quality, and mitigating both pain and inflammation in comparison with traditional treatment modalities [21, 32,33,34].

The mechanism of Taurolidine’s antimicrobial action involves the release of N-methylol groups that interfere with the microbial cell wall and inhibit biofilm formation [21, 31]. This has previously been shown to be effective in preventing catheter-related bloodstream infections and has also been evaluated against several fungal infections [16, 31]. Additionally, Taurolidine demonstrates anti-inflammatory properties, inhibiting proinflammatory cytokines, such as TNF-alpha, IL-1, and IL-6, which are hypothesized to contribute to its wound-healing capabilities [35].

It is important to acknowledge that the bulk of existing literature on Taurolidine focuses primarily on its antimicrobial and anti-inflammatory effects in different contexts, such as its role in cancer treatment or in reducing oxidative stress in liver regeneration models [36, 37]. There is a paucity of data regarding its direct application in treating pressure ulcers, making this case study a potentially groundbreaking direction for future research.

In similar clinical situations, our experience understanding also extends to Taurolidine monotherapy. A 25-month-old child with refractory medulloblastoma was among the best-treated patients, with topical Taurolidine (gel 2%). She was on vincristine, temozolomide, and bevacizumab chemotherapy regimen. She was consulted owing to wound dehiscence at the site of brain surgery in the occipital region. Owing to the intolerance of any oral medication, no antibiotics were prescribed for surgical site infection, and only local antiseptic treatment with Taurolidine gel 2% was applied.

Supplementary Figs. 1a–f show the patient’s magnetic resonance imaging (MRI) before surgery. Supplementary Figs. 2a–i show the course of wound healing during Taurolock treatment.

The full scope of Taurolidine’s potential side effects remains to be investigated, as some adverse effects, such as thrombocytopenia and neutropenia, have been reported with intravenous use of different galenic formulations [16, 38]. When applied in irrigation form, as in this case, no such side effects were recorded, further advocating for its safe topical application in wound care [16]. The adoption of Taurolidine irrigation faces barriers, such as high costs, limited insurance coverage, and accessibility challenges, particularly in underserved areas where regulatory hurdles and distribution issues persist [24, 39]. Healthcare providers may also require additional training to ensure consistent application, and integrating Taurolidine into established treatment regimens adds complexity [25]. Furthermore, the lack of large-scale randomized controlled trials limits definitive evidence of its efficacy, underscoring the need for further research and economic evaluations to support broader implementation.

The need for effective treatment modalities for pressure ulcers remains a significant clinical challenge. The application of Taurolidine in this context could be a step forward in reducing the substantial burden of pressure ulcers on both patients and healthcare systems, pending further research.

Taurolidine is a potent antimicrobial and healing agent that could be considered a good choice for treating infected deep pressure ulcers resistant to standard treatment approaches. Taurolidine exhibits an excellent long-term impact on wound healing in addition to quick, broad-spectrum antibacterial activity. Our findings provide a fresh insight into the therapeutic advantages of the local application of Taurolidine in the treatment of skin and soft tissue infections.