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Article

Photodynamic Therapy under Diagnostic Control of Wounds with Antibiotic-Resistant Microflora

by
Artem Shiryaev
1,*,
Mikhail Ivankov
1,
Arina Voitova
2,
Nina Kalyagina
3,4,*,
Kanamat Efendiev
3,4,
Tatiana Pisareva
1,
Sergey Zavodnov
1,
Igor Reshetov
1 and
Victor Loschenov
3,4
1
Department of Oncology and Recostructive Surgery and Radiology, I.M. Sechenov First Moscow State Medical University (Sechenov University), 119991 Moscow, Russia
2
BIOSPEC Ltd., 119049 Moscow, Russia
3
Prokhorov General Physics Institute of the Russian Academy of Sciences, 119991 Moscow, Russia
4
Department of Laser Micro-Nano and Biotechnology, National Research Nuclear University MEPhI, 115409 Moscow, Russia
*
Authors to whom correspondence should be addressed.
Photonics 2024, 11(7), 594; https://doi.org/10.3390/photonics11070594
Submission received: 3 May 2024 / Revised: 19 June 2024 / Accepted: 24 June 2024 / Published: 26 June 2024
(This article belongs to the Special Issue Phototheranostics: Science and Applications)
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Versions Notes

Abstract

:
Background: Difficulties in the treatment of purulent wounds are caused by bacterial biofilms, which results in decontamination limitations. Infected wounds are not sufficiently susceptible to existing antibiotics, necessitating the search for alternative approaches to reduce the concentration of pathogenic microflora. Methods: This study describes an approach to the effective treatment of wounds by photodynamic inactivation or therapy (PDI/PDT) of antibiotic-resistant microflora under fluorescence control. For this purpose, laser and LED light (660–680 nm) and different groups of photosensitizers (PS) (1% solutions of methylene blue, aluminum phthalocyanine, chlorine e6 and nanocomposites containing these groups of PS) were used. The study included 90 patients with various wounds. Some patients were subjected to fluorescence diagnosis by laser spectral analysis before the PDT. Results: Positive results were achieved in 76 patients (84%, p < 0.05). After the first PDT session, a decrease in the concentration of microflora was noticeable. By the third and seventh days, a significant to complete inactivation of bacteria was obtained. In all patients who were photo-diagnosed before PDT, a significant PS concentration decrease of more than 75% after PDT was obtained. Conclusion: PDT is an effective method for the inactivation of antibiotic-resistant pathogens, including in long non-healing wounds, contributing also to early tissue regeneration.

1. Introduction

Throughout the history of medicine, the treatment of infected wounds has always presented various challenges. The limited possibilities of using antibacterial drugs, as well as the costly tasks of developing new antibiotics contribute to the introduction of various physical and chemical methods of microflora inactivation. Often these are already long-developed techniques used in various infectious processes, which are now being used with new approaches and equipment.
It is known that there is a certain pool of microorganisms called ESKAPE, which is an acronym for highly virulent and antibiotic-resistant bacterial strains. ESKAPE includes Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter spp. [1].
ESKAPE is the leading cause of life-threatening nosocomial infections in high-risk immunocompromised and critically ill patients worldwide. Meanwhile, P. aeruginosa and S. aureus are among the most common biofilm pathogens encountered in healthcare [2].
Treatment of purulent wounds in soft tissues is one of the most difficult tasks in modern surgery. The difficulties are caused by many factors, including the peculiarities of occurrence, formation, and character over the course of the wound process.
A special place is occupied by a wound, the surface of which has an uneven extent, complex irregular shape and contours, zones of necrotic changes, as well as, often, deep wound channel. All this, in conjunction with various fixing metalloconstructions, contributes to the progression of inflammatory reaction and microflora contamination [3]. The presence of a large amount of pathogenic flora in the wound limits the possibilities of surgical closure of defects, which increases the hospitalization and recovery time of the patients. P. aeruginosa, S. aureus, and K. pneumoniae are among the most widespread pathogens in biofilms that pose the greatest challenge in wound management [4].
The occurrence of a certain concentration of bacteria results in the formation of the so-called quorum sensing (QS), which is the main cause of decontamination limitations [5]. QS plays a key role in many bacterial cell life processes. First of all, it is the formation of a biofilm that exhibits properties that are significantly different from free-living bacterial cells. It is a kind of matrix that ensures social cooperation, resource capture, and increased survival under the influence of antibiotics. The biofilm deactivates the antimicrobial activity of macrophages and neutrophils, and is able to delegate individual bacteria to capture new localizations. Furthermore, in addition to spreading on the wound surface, the biofilm lodges to a depth of up to several millimeters [6]. Thus, the main objective for microflora inactivation is to destroy the biofilm and reduce the number of bacteria by limiting the possibility of QS formation [7].
Infected wounds, particularly by bacterial biofilms, are not sufficiently susceptible to currently available antibiotics, necessitating the search for alternative approaches to reduce the concentration of pathogenic microflora. The proposed new approaches to bacterial biofilm disruption, such as the use of monolithic phages, phage cocktails, or enzymes, appear to effectively disrupt bacterial biofilms. However, despite their successful use, in most cases this is insufficient to destroy all bacterial cells. Nevertheless, combination therapy using phages and/or phage-derived products with other antimicrobial agents, including antibiotics, nanoparticles, and antimicrobial peptides, may improve treatment outcomes [8].
Another method that has demonstrated its effectiveness in disrupting bacterial biofilms is antimicrobial photodynamic inactivation or therapy (PDI or PDT) [9]. A study by de Melo W.C. et al. (2013) showed that many biofilms have been shown to be sensitive to PDT, especially in dental diseases [10]. Recent studies show the efficacy of PDT in wound healing due to its antibacterial activity, effect on biofilms, and remodeling of the extracellular matrix by activation of matrix metalloproteinases, thereby inducing changes in the collagen of the extracellular matrix for the tissue-healing process [11].
The incidence of infectious complications in wounds occurs in up to 40% of cases [12,13,14]. Thus, the problem of choosing a method of inactivation of antibiotic-resistant microflora remains relevant and requires the search for new solutions, development of advanced methods, representing scientific and practical interests.
This study describes the approach and its effectiveness in the treatment of antibiotic-resistant wounds using laser, LED irradiation, and different groups of photosensitizers, with the assessment of their relative concentration and determination of optimal parameters of light exposure.

2. Materials and Methods

The study included 90 patients with various wounds treated between February 2022 and September 2023. In all patients, bacteriological cultures of the wound discharge yielded microflora resistant to all types of antibacterial drugs (Figure 1). The study was approved by the Local Ethical Committee of the I.M. Sechenov First Moscow State Medical University (Sechenov University). Before inclusion in the study, most patients (n = 65, 72%) were treated in the department of purulent surgery using various methods of microflora inactivation (local antiseptics, bacteriophages, ultrasound methods, plasma flow, and vacuum therapy). A minor positive effect was noted in 62 patients (95%). Negative dynamics were noted in 3 patients (5%). The remaining 25 hospitalized patients (28%) had relatively new wounds and were treated with routine wound sanitation and surgical cleansing if necessary. The study did not include patients with unclear etiology of the wound process (vascular embolism, foreign bodies, etc.).
All 90 patients underwent PDT (inactivation of pathogenic microflora) locally with laser or LED radiation using photosensitizers (PSs), which were administered locally (by irrigation) (Table 1).
The following PSs were used in the study: methylene blue (MB), photosens (based on aluminum phthalocyanine (AlPc)), chlorine derivative e6 (Fotoran e6 (Ce6)), and microemulsions (nanocomposites) containing the same groups of photosensitizers (nanoMB, nanoAlPc, and nanoCe6, respectively) (Figure 2). The nanocomposites were synthesized using a method similar to the one described in [15]. Pure egg yolk lecithin (Serva, Heidelberg, Germany) and the PS were dissolved in ethanol. Double-distilled water was added slowly in a thin stream while constantly stirring at 700 rpm using a blender for 5 min. The ethosomal system was maintained at 30 degrees during the synthesis and then cooled to room temperature. The therapeutic concentrations of the molecular and ethosomal forms of PSs were consistent. The concentration of MB, AlPc, and Ce6 in the solution was 0,05%. Before PDT, the size of the wound was measured for each patient, according to which the applied amount of PS solution was calculated.
PDT of large and medium-sized superficial wounds (Vwound ≥ 3 cm2) was performed using LED irradiators with wavelengths of 660/680 nm (full width half max less than 40 nm at 25 °C) for MB and Ce6/AlPc, respectively, which provided light irradiation with a power density of about 350 mW/cm2 to an area with a diameter of 8 cm (Figure 3). In turn, for treatment of channels in deep wounds or small wound surfaces, a laser with power up to 1.5 W and wavelengths of 660/675 nm was used for MB and Ce6/AlPc, respectively, and optical diffusers with endface and cylindrical irradiators at the distal end (Figure 3d). The energy dose in the light irradiation area was 120–250 J/cm2. PDT was performed every other day for 7 days. Control bacteriologic seeding of the wound secretion or flush from the wound cavity was performed on the first, third, and seventh day of treatment.
In order to control the accumulation of the photosensitizers in the tissues, at the beginning of the study (February 2022–April 2022), 5 min after the drug application, the patients (n = 43, 48%) were subjected to fluorescence diagnostics by laser spectral analysis in the area of the wound surface before and during the PDT. For this purpose, a laser spectroscopy analyzer LESA-01-BIOSPEC (BIOSPEC Ltd., Moscow, Russia), including a spectrometer, a laser radiation source (He-Ne laser, 632.8 nm), and a diagnostic optical fiber, was used (Figure 4). The distal end of the diagnostic fiber in the soft contact mode recorded the backscattering spectra of laser radiation from the wound surface, which allowed for the estimation of the fluorescence index in numerical expression (r.u.) on the monitor screen in the form of graphs and histograms using the software (UNO 1.0.6.0). In addition to tissue fluorescence, the obtained spectra included diffusely back-scattered laser radiation (632.8 nm), which characterized the scattering and absorption properties of the tissues and also the measurement geometry (the position of the distal end of the diagnostic fiber on the wound surface) (Figure 5). The same measurement geometry was maintained within the same patient. The fluorescence index was calculated as the ratio of the integral intensity of tissue fluorescence in the range 650–750 nm to the integral intensity of diffusely scattered laser radiation in the range 625–640 nm.
In order to eliminate additional errors in fluorescence measurement, the study was performed by preliminary wound sanitation, since wound debris and/or blood can shield the laser radiation or give false fluorescence.
Such fluorescence diagnostics were performed to estimate the intra-tissue distribution of PS and to control the efficiency of photosensitizer photobleaching.
To evaluate the results of the treatment in dynamics, a point rating scale was developed based on the pressure ulcer scale for healing (PUSH) [16], modified for the application of phototherapy evaluation (Table 2).
The healing dynamics were assessed based on the sum of points assigned depending on the change in the wound surface area, the volume of wound discharge, the tissue lining of the wound channel or surface, pain syndrome, and the results of bacteriologic cultures and cytologic examination.

3. Results

All patients who underwent photo-diagnostics (n = 43) showed a significant decrease in their PS concentration of more than 75% after PDT (Figure 5) (p < 0.05).
In addition to monitoring the efficiency of the photobleaching of PSs, spectral fluorescence diagnostics were also carried out in order to identify the optimal parameters of light exposure, namely, to determine the optimal time of irradiation. All used PSs burned out by 75% and more in measured points in 9 min (energy dose ~ 190 J/cm2) after the beginning of irradiation. Therefore, in the future, for patients who were not diagnosed during therapy, the PDT session was carried out within 9 min.
The proposed methodology for the inactivation of antibiotic-resistant wound microflora allowed for the achievement of a positive result in 76 patients (84%, p < 0.05). After the first PDT session, a decrease in the concentration of microflora was already noticeable. By the third and seventh day, a significant to complete inactivation of bacteria was obtained (Figure 6).
In addition to the inactivation of microflora, according to the results of a healing assessment of antibiotic-resistant wounds after phototherapy by means of the proposed modified point scale, a significant reduction in wound healing time was established, which contributed to delayed reconstructive surgeries or wound healing by secondary tension (see examples below). During the first day after phototherapy, there was a decrease in the wound discharge, granulation tissue formation, and edema reduction.
Example 1 (Figure 7). An extensive, irregularly shaped wound of the medial and plantar surfaces of the left foot with the absence of the second, third, fourth, and fifth toes. The wound bed is represented by muscle tendons and subcutaneous fatty tissue, with multiple areas of necrosis. Moderately pronounced perifocal edema and purulent discharge from crypts were noted. Two days after the first session of PDT the wound showed a decrease in the size of necrosis foci up to their complete disappearance, the volume of purulent necrotic discharge, a decrease in the severity of perifocal inflammation, the appearance of areas of pink granulations. The severity of pain syndrome both at rest and under mechanical impact decreased. The wound area decreased in size due to tissue contraction. In 7 days, the wound bottom was represented by pink granulations and the perifocal inflammation regressed. The character of the discharge changed from purulent necrotic to serous hemorrhagic. The wound healed by secondary tension. The patient was discharged for rehabilitation with preservation of the left foot function 1 month after the beginning of treatment with PDT.
Example 2 (Figure 8). On admission, there was an extensive irregularly shaped purulent necrotic wound on the plantar surface of the right foot from the heel area to the base of the toes. The symptoms of perifocal inflammation with abundant purulent discharge were pronounced. After two sessions of PDT, the symptoms of perifocal inflammation regressed, the character of purulent discharge changed from purulent to serous hemorrhagic. There was a decrease in the severity of pain syndrome. The foci of necrosis gradually regressed, in the area of the wound bottom there were signs of pink granulation formation. Seven days after the therapy, the wound was completely cleared of necrosis foci, which allowed for the application of secondary sutures in the calcaneal region and the performance of autodermoplasty with a split skin flap of the middle third of the foot. The patient was discharged from the department of purulent surgery in 3 months.
The overall results of treatment of 90 patients with antibiotic-resistant microflora of wounds, according to the developed evaluation scale, revealed a significant decrease in the total score on the third, fifth, seventh, and eleventh day after the beginning of PDT application (Table 3).
As a result of the treatment, 75 patients (83%) achieved complete inactivation of antibiotic-resistant microflora. There were no statistically significant differences in treatment results among PSs in molecular form (MB, Ce6, AlPc) and separately among preparations in ethosomal form (nanoMB, nanoCe6, nanoAlPc).
However, the results of patients treated with liposomal (nano) forms of PSs were different from those with molecular solutions of PSs. At the beginning of the study, molecular PS solutions were used for photoinactivation. Although photo-diagnosis showed effective photobleaching of all the drugs used (n = 90, 100%), the efficacy of treatment with drugs in molecular form was 72% (of inactivation of microflora, p < 0.05). This prompted the search for a solution, which was the use of PSs in ethosomal (nano) form to ensure deeper tissue penetration. The efficacy of treatment with PSs in liposomal form turned out to be significantly higher (89% inactivation of microflora, p < 0.05). This can be explained by the fact that the use of liposomal PS, carrying a neutral charge, allowed us to use it as an ethosomal delivery of photosensitizer molecules, which, in turn, significantly increased the depth of drug penetration into tissues. Fluorescence confocal microscopy was used to demonstrate the distribution of Ce6 in liposomal (a) and molecular (b) forms in tissue biopsied to a depth of 2 mm before PDT (Figure 9).
No side effects from therapy for the individuals were mentioned. After inactivation of antibiotic-resistant microflora, the patients were discharged for further medical rehabilitation or transferred to specialized departments. Other methods of treatment were applied to the patients whose wounds could not achieve a pronounced result with PDT, and they were also discharged for further medical rehabilitation or transferred to specialized departments.

4. Discussion

4.1. Wound Healing with PDT

The mechanisms of wound healing are usually continuous, moving from the phase of coagulation and hemostasis to inflammatory mediators and growth factors, then to cell proliferation, migration, and differentiation, and finally to wound contraction and remodeling with the formation of scar tissue [17,18].
There are limited reports about antimicrobial PDT in animal models as well as in clinical trials. However, according to the results of a systematic review of the literature found in recent years, in which in vivo PDT was used for the purpose of wound healing in animals, encouraging results were obtained [19,20,21,22]. The majority of articles devoted to PDT for wound healing originated from the United Kingdom, the USA, China, Russia, Brazil, India, Egypt, France, Japan, and Turkey [18,23]. The effect of different PSs on PDT for the inactivation of antibiotic-resistant Streptococcus mutans and Staphylococcus aureus biofilms wound infections, and Acinetobacter baumannii, Vibrio vulnificus, C. albicans, and Pseudomonas aeruginosa wound infections were reported [18,24,25].
The mechanisms leading to wound healing under PDT are not fully understood. However, it is known that after irradiation, PSs enter into a photochemical reaction, generating free radicals which directly destroy bacteria if the photosensitizer is located on the bacterial membrane or inside it. In such a case, in the process of PDT, oxidative damage to the cell and mitochondrial membrane and wall, enzymatic inactivation and an arrest of cellular respiration processes, as well as a caspase cascade triggered by the release of cytochrome C all occur; protein synthesis is disrupted, and DNA mutation is induced. Thus, apoptosis, which plays one of the main roles in this process, is activated [11].
In addition, it is believed that attacking the biofilm PDT provokes a whole complex of reactions and responses: production of matrix metalloproteinases, cytokines and growth factors by fibroblasts, and keratinocytes; a specific, significant immune response [18,23,26,27] through the production of lipids and pro-inflammatory cytokines; the release of dead cell antigens, determining the activation of dendritic cells of the skin, thus promoting the deposition of collagen fibers [18,23,26].
It is known that in the process of photochemical reaction there is a decrease in the concentration of PS, which is clinically expressed in photobleaching [28]. There are many works in the literature indicating the necessity to evaluate photobleaching in the PDT process for the purpose of personalized control [29,30,31,32]. Achieving a photobleaching of 50% or more positively influences treatment outcomes [33]. Owing to the fluorescence spectroscopic diagnosis, this study showed the possibility of in vivo personalized control of PS burnout and, consequently, the effectiveness of light exposure on the wound during the session of pathogenic microflora inactivation.

4.2. Photosensitizing Agents for PDT for Antibiotic-Resistant Microorganisms

A variety of photosensitizing agents are discussed for PDT use at different concentrations with different incubation periods, irradiation doses, and wavelengths: chlorine-based (phenothiazine chlorine, meso-tetra-hydroxyphenyl-chlorin (mTHPC), fotoditazin alone and in complexes, polyethylenimine–chlorine p6 (PEI-ce6), poly-lysine-conjugated chlorine p6 (pl-cp6)); methylene blue (MB); toluidine blue; indocyanine green (ICG); 5-aminolevulinic acid (5-ALA); methyl-aminolevulinate (MAL); pyropheophorbide-a; 3,7-bis (N, N-dibutyl-amino) phenothiazin-5-ium bromide; Rose Bengal; toluidine-O (TBO); methoxypolyethylene glycol-pheophorbide a (mPEG-Pba), and others [18,23,25,34,35,36].
Recently, the field of creating various nanocarriers for antimicrobial PDT applications has been developing [24,37]. Such nanomaterials in wound healing can be used, for example, for targeting cells through on-demand release, target-specific delivery, and in vivo visualization of the treatment [24]. Various nanomaterials can be used for wound-healing purposes: quantum dots, nanotubes, fullerenes, nanopores, metallic, liposomes, and ceramic, metallic, magnetic, or polymer nanoparticles, etc. [24,38,39].
In our study, the applied nano-PSs in the ethosomal form allowed the agent to penetrate deeper into the wound tissues, leading to a more effective influence on the areas affected by pathogenic microflora and promoting faster wound healing.

4.3. Chronic Wounds

Although it was not the aim of the study, it was noted that the treatment results of patients with fresh wounds with microflora resistant to all types of antibacterial drugs were better than patients with chronic wounds with no healing within 5–8 weeks. This may be explained by the fact that in chronic wounds there is a dysregulation of matrix metalloproteinases responsible for epithelialization and proliferation [11]. In addition, although the concentration of pathogens was comparable in these two groups of patients, chronic wounds are more likely to contain mature biofilms (with QS) [40,41], which are more difficult to disrupt than simple monolayers or colonies of bacteria. For such cases, additional PDT sessions may be considered. Session variation was not performed in this study, as this would have compromised the comparison of results across drugs. The sample of patients was not specialized in this study on the criterion of “freshness” of wounds, and statistically reliable results were not obtained in this issue. Therefore, separate studies with the possibility of adjusting the number of sessions for different patients and cases are required for this aspect.

4.4. PDT for Wound Healing

Despite the difficulties in explaining the mechanisms of wound healing in chronic processes, it was found that after PDT treatment, mast cells can send signals for recruitment and differentiation of fibroblasts, which, in turn, participate in the healing process of chronic wounds [11]. In addition, the effects of PDT on chronic wounds could probably be due to the activation of neurons. This may play an important role in the action of the immune system for wound healing, which is modulated by the nervous system [42,43,44], including through the activation of different cell types such as mast cells [45,46].

5. Conclusions

Photodynamic inactivation is an effective method of purulent wound treatment in conditions of antibiotic-resistant microflora. Due to their properties, as well as deeper penetration into tissues, ethosomal forms of PSs (MB, Ce6, AlPc) during PDT are able to destroy bacterial biofilm more effectively, reducing the number of bacteria, which prevents the existence of QS. In addition, PDT can improve tissue trophism, thus reducing the time of wound healing and contributing to faster reconstructive surgeries. Diagnostic analysis carried out during PDT sessions allowed us to estimate the relative PS concentration in tissues, as well as to determine the optimal time of light exposure. Nevertheless, the question of finding the optimal parameters for PDT and the number of sessions remains open, including for each class of drugs.

Author Contributions

Conceptualization, A.S., M.I., I.R. and V.L.; methodology, A.S., N.K. and K.E.; software, N.K. and K.E.; validation, A.S., M.I., A.V., N.K., K.E. and I.R.; formal analysis, T.P. and S.Z.; investigation, A.V., N.K., K.E. and V.L.; resources, I.R., M.I. and V.L.; data curation, A.V., T.P. and S.Z.; writing—original draft preparation, A.S., A.V., N.K., T.P., S.Z. and K.E.; writing—review and editing, M.I., I.R. and V.L.; visualization, A.V., T.P. and S.Z.; supervision, I.R. and V.L.; project administration, A.S. and N.K.; funding acquisition, M.I., I.R. and V.L. All authors have read and agreed to the published version of the manuscript.

Funding

This work was supported by the Ministry of Science and Higher Education of the Russian Federation grant for the creation and development of world-class research centers No. 075-15-2020-912-“Photonics Center”.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of I.M. Sechenov First Moscow State Medical University (Sechenov University) (protocol code 13-22 from 20 January 2022).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data presented in this study are available on request from the corresponding author (accurately indicate status).

Conflicts of Interest

Arina Voitova was employed by the BIOSPEC Ltd. company. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Photonics 11 00594 g001
Figure 1. Revealed antibiotic-resistant microflora.
Figure 1. Revealed antibiotic-resistant microflora.
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Figure 2. Structure of photodynamic nanocomposite in ethosomal form for AlPc, MB, and Ce6.
Figure 2. Structure of photodynamic nanocomposite in ethosomal form for AlPc, MB, and Ce6.
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Figure 3. (a,b) 660/680 nm LED light source, (c) 660 nm and 675 nm laser source, (d) optical diffuser for intra-channel irradiation.
Figure 3. (a,b) 660/680 nm LED light source, (c) 660 nm and 675 nm laser source, (d) optical diffuser for intra-channel irradiation.
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Figure 4. Schematic diagram of the laser electron spectral analyzer LESA-01-BIOSPEC.
Figure 4. Schematic diagram of the laser electron spectral analyzer LESA-01-BIOSPEC.
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Figure 5. Results of spectral fluorescence diagnosis of wound lesions: (a) spectral data of tissue fluorescence; (b) distribution of fluorescence indices. (1) MB ethosomes; (2) AlPc ethosomes; (3) AlPc molecular solution; (4) diagnosis of deep wound lesions (channel) using AlPc molecular solution; (5) diagnosis of deep wound lesions (channel) using AlPc ethosomes.
Figure 5. Results of spectral fluorescence diagnosis of wound lesions: (a) spectral data of tissue fluorescence; (b) distribution of fluorescence indices. (1) MB ethosomes; (2) AlPc ethosomes; (3) AlPc molecular solution; (4) diagnosis of deep wound lesions (channel) using AlPc molecular solution; (5) diagnosis of deep wound lesions (channel) using AlPc ethosomes.
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Figure 6. Inactivation of antibiotic-resistant wound microflora by PDT (averaged data for all patients).
Figure 6. Inactivation of antibiotic-resistant wound microflora by PDT (averaged data for all patients).
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Figure 7. Left foot wound with traumatic amputation of four toes and arch. Pseudomonas aeruginosa 108. Four courses of PDT (Ce6). LED source with a wavelength of 660 nm, power density of 350 mW/cm2, energy dose of 190 J/cm2. (a–d) Dynamic of the wound healing.
Figure 7. Left foot wound with traumatic amputation of four toes and arch. Pseudomonas aeruginosa 108. Four courses of PDT (Ce6). LED source with a wavelength of 660 nm, power density of 350 mW/cm2, energy dose of 190 J/cm2. (a–d) Dynamic of the wound healing.
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Figure 8. Purulent necrotic wound on the plantar surface of the right foot from the heel area to the base of the toes. Four courses of PDT (nanoCe6). LED source with a wavelength of 660 nm, power density—350 mW/cm2, energy dose—230 J/cm2. (a–f) Dynamic of the wound healing.
Figure 8. Purulent necrotic wound on the plantar surface of the right foot from the heel area to the base of the toes. Four courses of PDT (nanoCe6). LED source with a wavelength of 660 nm, power density—350 mW/cm2, energy dose—230 J/cm2. (a–f) Dynamic of the wound healing.
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Figure 9. Drug penetration into tissues (biopsy) in (a) ethosomal form and in (b) molecular form, Ce6 as an example.
Figure 9. Drug penetration into tissues (biopsy) in (a) ethosomal form and in (b) molecular form, Ce6 as an example.
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Table 1. Distribution of patients according to photosensitizer used.
Table 1. Distribution of patients according to photosensitizer used.
Methylene Blue
(MB)		Photosens
(AlPc)		Fotoran e6 (Ce6)nanoMBnanoAlPcnanoCe6Total
n = 11n = 9n = 9n = 10n = 33n = 18n = 90
Table 2. PUSH-based Scale for Evaluation of Antibiotic Resistant Wound Healing after Phototherapy with modification.
Table 2. PUSH-based Scale for Evaluation of Antibiotic Resistant Wound Healing after Phototherapy with modification.
Length × Width (cm2)01
<0.3		2
0.3–0.6		3
0.7–1.0		4
1.1–2.0		5
2.1–3.0
6
3.1–4.0		7
4.1–8.0		8
8.1–12.0		9
12.1–24.0		10
>24.0
Exudate Amount0
None		1
Light		2
Moderate		3
Heavy
Tissue Type0
Closed		1
Epithelial Tissue		2
Granulation Tissue		3
Slough		4
Necrotic Tissue
Cytological Result01
Weak inflammatory reaction: decrease in neutrophils, increase in granulation tissue, fibroblasts		2
Moderate inflammatory reaction: decrease in neutrophils, mucus, microflora		3
Severe inflammatory reaction: a large number of neutrophils, mucus, microflora
Pain0
None		1
Light		2
Moderate		3
Severe
Table 3. Mean score of the modified PUSH scale depending on the drug used.
Table 3. Mean score of the modified PUSH scale depending on the drug used.
PSMean Points
Before Treatment (sd)3rd Day (sd)5th Day (sd)7th Day (sd)11th Day (sd)
MB21 (1.095)19 (1.221)17 (0.774)14 (0.831)10 (1.572)
Fotoran e6 (Ce6)20 (0.972)18 (1.093)13 (1.509)10 (1.81)9 (1.986)
Photosens (PcAl)21 (1.458)19 (1.641)16 (1.488)13 (1.908)10 (1.917)
nanoMB20 (1.075)17 (0.843)15 (0.876)11 (0.949)7 (0.843)
nanoCe620 (0.984)17 (0.959)14 (1.149)10 (1.423)6 (1.199)
nano PcAl20 (1.202)18 (1.139)13 (0.939)10 (1.295)7 (1.119)
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Shiryaev, A.; Ivankov, M.; Voitova, A.; Kalyagina, N.; Efendiev, K.; Pisareva, T.; Zavodnov, S.; Reshetov, I.; Loschenov, V. Photodynamic Therapy under Diagnostic Control of Wounds with Antibiotic-Resistant Microflora. Photonics 2024, 11, 594. https://doi.org/10.3390/photonics11070594

AMA Style

Shiryaev A, Ivankov M, Voitova A, Kalyagina N, Efendiev K, Pisareva T, Zavodnov S, Reshetov I, Loschenov V. Photodynamic Therapy under Diagnostic Control of Wounds with Antibiotic-Resistant Microflora. Photonics. 2024; 11(7):594. https://doi.org/10.3390/photonics11070594

Chicago/Turabian Style

Shiryaev, Artem, Mikhail Ivankov, Arina Voitova, Nina Kalyagina, Kanamat Efendiev, Tatiana Pisareva, Sergey Zavodnov, Igor Reshetov, and Victor Loschenov. 2024. "Photodynamic Therapy under Diagnostic Control of Wounds with Antibiotic-Resistant Microflora" Photonics 11, no. 7: 594. https://doi.org/10.3390/photonics11070594

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