The Use of Dilute Dakin's Solution for the Treatment of Angioinvasive Fungal Infection in the Combat Wounded: A Case Series

Abstract

Disseminated fungal infections are normally opportunistic infections in the immunocompromised population. Current literature has documented a high mortality rate with these infections in civilian trauma or as complications of severe burns. There is only one published case of fungal infection in a combat-injured individual to date, which resulted in mortality despite aggressive debridement and appropriate antifungal agents. We present here three patients in whom aggressive debridement, antifungals, and the addition of dilute Dakin's solution with negative pressure wound therapy was used to treat angioinvasive mold. Angioinvasive fungal infection continue to be one of the most aggressive and devastating infections that our combat-injured patients face. With the addition of dilute Dakin's solution, we successfully managed three critically ill patients. Previous literature had shown close to 30% mortality associated with cutaneous mucormycosis and the mortality rate approaches 100% with disseminated angioinvasive fungal infections. These results provide hope not only for the combat-injured patients being treated for both local and disseminated angioinvasive fungal infections, but also for the civilian trauma and immunocompromised patients.

Early Complications and Outcomes in Combat Injury–Related Invasive Fungal Wound Infections

“…18 Treatment involves serial aggressive debridements, utilization of antifungal agents, and surgical amputation or revision of amputation levels when warranted. 1,5,6,15,17,20,21 Anecdotally, clinicians involved in the management of combat-related IFIs have noted that these infections generally lead to marked shortening of residual limbs, increased time and operative procedures prior to wound closure, and high rates of early complications. Nevertheless, as these factors have not yet been quantified, the impact of IFIs on those outcomes remains uncertain.…”

Periodontal effects of 0.25% sodium hypochlorite twice‐weekly oral rinse. A pilot study

“…It is used as a disinfectant in hospitals, animal facilities and in human drinking water supply, and serves as a bleaching agent and a food additive in industry. Sodium hypochlorite at 0.5% (Dakin's solution) was used with great success to control infections of combat wounded soldiers during World War I, before antibiotics , and was recently found effective in the treatment of wounded soldiers with potentially deadly angioinvasive fungal infections . The intermittent use of dilute sodium hypochlorite in “bleach baths” has shown efficacy as adjunctive therapy for atopic dermatitis .…”

Dakin solution alters macrophage viability and function

“…Interestingly, in one study wounds treated with DS also showed significantly increased neodermal thickness when compared with the controls, and greater numbers of proliferating fibroblasts [38]. Recently, in a small case series of military trauma patients, 0.025% DS was delivered with negative pressure wound therapy as an adjunct to aggressive debridement, and antifungals with clinical success [39]. The discrepancy between in vitro and in vivo studies is likely related to inactivation of sodium hypochlorite by the plasma components of the wound exudate, necessitating higher concentrations for in vivo efficacy, which was known by Carrel and Fleming [10,11].…”