USE OF DIALKYL CARBAMOYL CHLORIDE IN THE PREVENTION AND TREATMENT OF BIOFILM IN WOUNDS

Objectives: The aim was to identify the benefits of using Dialkyl Carbamoyl Chloride for the treatment of biofilms in wounds. Methods: This is an integrative literature review that aimed to answer the guiding question: “What are the benefits of using Dialkyl Carbamoyl Chloride in the healing of skin lesions?”. The article selection stages resulted in 13 articles included. Results: The selected articles were grouped into two groups, namely: prevention and treatment of infection in wounds and prevention of surgical site infection, with nine productions in the first group and four in the second. Studies have shown that Dialkyl Carbamoyl Chloride attenuates colonization symptoms, such as odor, pain complaints and oozing, in addition to aiding in the prophylactic management of wound biofilm. Evidence indicates that dressings with Dialkyl Carbamoyl Chloride have no adverse effects, making them viable and safe options for chronic, acute and, mainly, infected injuries. Conclusion: It was identified that Dialkyl Carbamoyl Chloride was able to promote beneficial actions in the treatment of wounds, especially those of greater complexity. The proper choice of dressings and coverings can contribute to the rational use of existing technologies and antimicrobials, culminating in cost reduction and promotion of quality of life for individuals with chronic wounds. agudas y principalmente infectadas. Conclusión: Se identificó que la Cloruro de dialquil carbamoil fue capaz de promover acciones beneficiosas para el tratamiento de heridas, especialmente las de mayor complejidad. La elección adecuada de cubiertas y apósitos puede contribuir al uso racional de las tecnologías y los antimicrobianos existentes, culminando en la reducción de costos y la promoción de la calidad de vida de las personas con heridas crónicas.


INTRODUCTION
Difficult healing wounds are a global public health problem. It is known that several factors interfere in the healing process, and the intrinsic and extrinsic aspects of the patient should be considered in their assessment. However, it is recognized that most lesions with delayed or impaired healing are associated with the presence of biofilm 1,2 .
Microbial biofilms are defined as a group of microorganisms (MO) surrounded by a protective polymeric matrix and adhered to a surface, which can be either biotic or abiotic, formed from one or multiple species of MO 3 . Biofilm commonly presents in the wound bed with devitalized tissue and present in white cell protein exudate. Among the main clinical indicators of lesions with biofilm, there are lesions with induration, erythema and increase in exudate, in addition to pain complaints related to the wound. Biofilms are able to reconstitute themselves in the short term, due to the secretion of polymers and host components, indicating the need for regular cleaning of the lesion 4 .
The fact that biofilm is able to quickly reconstitute itself in the wound bed becomes a limiting factor for its management exclusively through mechanical debridement 2 . Thus, the adoption of structured care is recommended, aimed at removing the biofilm already installed in the bed, as well as the use of strategies that prevent further formation of this microbial conglomerate 4 .
In this context, several technologies have been developed with a focus on the management of biofilm and wound infection, among them we have Dialkyl Carbamoyl Chloride, also known as DACC, which is considered a local antimicrobial, as its pharmacological mechanism is the sequestration of microorganisms into the dressing through simple chemical bonds 5 . artículos seleccionados se agruparon en dos grupos, a saber: Prevención y tratamiento de la infección en heridas y Prevención de la infección del sitio quirúrgico, con 9 producciones en el primer grupo y 4 en el segundo. Los estudios demostraron que Cloruro de dialquil carbamoil atenúa los síntomas de la colonización, como el olor, el dolor y la exudación, además, ayuda en el manejo profiláctico de la biopelícula de la herida. La evidencia apunta a que la cobertura Cloruro de dialquil carbamoil no tiene efectos adversos, lo que la convierte en opciones viables y seguras para lesiones crónicas, agudas y principalmente infectadas. Conclusión: Se identificó que la Cloruro de dialquil carbamoil fue capaz de promover acciones beneficiosas para el tratamiento de heridas, especialmente las de mayor complejidad. La elección adecuada de cubiertas y apósitos puede contribuir al uso racional de las tecnologías y los antimicrobianos existentes, culminando en la reducción de costos y la promoción de la calidad de vida de las personas con heridas crónicas.
Use of Dialkyl Carbamoyl Chloride in the prevention and treatment of biofilm in wounds

OBJECTIVES
The objective was to identify the benefits of using D ACC to treat biofilms in wounds.

METHOD
This is an integrative literature review, following the six main steps for its preparation, namely: synthesis of the topic to be studied, implementation of the inclusion and exclusion criteria, identification of selected studies for review, categorization and analysis of studies, interpretation of results and summary of the review 6 .
To delimit the guiding question, the PICO strategy was used, which is summarized as: In order to minimize probable errors or biases, the selection was carried out by two reviewers, independently and organized in two stages. In the first stage, the title and abstract were read, and in the second, the full text was read. In cases where there were disagreements, there was a discussion with the research supervisor about the inclusion or exclusion of the publication in the review (third reviewer).
After a complete reading of the publications included in this review, they were summarized in a Microsoft Word Office 365 document, containing: year of publication, name(s) of author(s), publication title, type of research, language , number of study participants, classification and brief summary about the content of the article, with step number 4.

RESULTS
The synthesis of the findings was organized and divided according to the etiological types of the lesions studied in the articles, being the surgical site, wounds with no defined etiology and wounds in pediatric patients, shown sequentially in Table 1, Table 2 and Table 3.

English
It showed improvement in the surgical site and there was no improvement in pain rates.
Use of Dialkyl Carbamoyl Chloride in the prevention and treatment of biofilm in wounds

DISCUSSION
Careful assessment of the wound, considering not only the injury, but also the patient's general condition and aspects related to the environment and access to health services, are essential for the success of the instituted treatment.
The microbial load of wounds has been a topic of discussion for many years. Nowadays, this theme has been advancing as microorganisms are more resistant to therapies with topical and/or systemic antibiotics. Given the overuse of antibiotics and the lack of evidence to support their clinical effectiveness in chronic wounds that do not heal, there is a need to develop therapies to overcome current barriers to healing in treating wounds caused by the ineffectiveness of antibiotics in infections of antimicrobial resistant lesions [8][9][10][11] . The use of systemic antibiotics, however, is recommended for deep or systemic infections, and may improve wound healing when appropriately indicated [8][9][10] .
With regard to classic topical antimicrobial therapy with the use of antibiotic products such as ointments, sprays and alikes, despite having some direct action on wound bacteria, there is also the possibility of bacterial resistance, in addition to inducing hypersensitivity reactions and superinfections 8,9 .
Considering therapies with low risk of generating microbial resistance, new products have been developed for the topical treatment of wounds, with the objective of promoting the interruption of the initial adhesion process of microorganisms to the wound bed, among these, the DACC stands out, a fatty acid derivative that acts as a passive antibacterial, in order to sequester the bacteria into the dressing through hydrophobic bonds on the microorganism's extracellular surface, promoting irreversible adherence to the DACC substrate [12][13][14] .
From the analysis of the results, there is a consensus regarding the benefits of using DACC for the management of biofilms in wounds. Furthermore, its use can accelerate the healing process when compared to the use of alginate, and it can be used as a prophylactic coverage for the development of infection 14 .
The DACC demonstrated, in vitro, the ability to bind to several pathological microorganisms, including Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA), having a bactericidal and bacteriostatic effect 5 .In addition, evidence demonstrates that the product provides bacteriostatic activity, however, without generating cytotoxicity, being considered an alternative and accessible route for the healing of infected lesions or contaminated with large amounts of biofilm 12,15 .
Another interesting aspect is the versatility of coverings with DACC. Studies show its use in several situations, one of them in the post-surgical excision of the pilonidal sinus, which is considered a common condition that affects young adults, being characterized by the appearance of hair follicles in the natal cleft of the sacrococcygeal area, generating infection, discomfort and pain complaints, in which treatment options are limited to surgical excision with healing by second intention 16 . Studies such as the SOKYSA study (2020) demonstrate the effectiveness of using D ACC in infected lesions, especially after pilonidal sinus excision. In the aforementioned study, DACC was compared to the use of alginate after excision. During dermatological follow-up, alginate-coated lesions showed a greater amount of slough compared to lesions coated with DACC. In relation to healing, the group with DACC had greater success, evolving to healing in up to 75 days 14 .
Another use of DACC is as a prophylactic coverage. A prospective, non-randomized and comparative study, in a vascular surgery center, with 200 participants who received dressings coated with DACC, showed a clear improvement in the number of patients with an infected surgical site using dressings with DACC when compared to conventional therapy 17 .
Another indication described was in cases of epidermolysis bullosa, being compared to the treatment of saline solution and 2% mupirocin correlates, demonstrating an improvement equivalent to traditional antimicrobial therapy, possibly being considered an alternative for patients who have adverse reactions to the use of mupirocin a 2%, as DACC has no known secondary reactions 18 .
Corroborating the study by Dwiyana (2019), a group of researchers, in 2012, evaluated the quantitative profile of bacterial bioburden in patients with lesions caused by epidermolysis bullosa, in which they presented a permissive narrative of the use of DACC for a long period, stating that there is attenuation of symptoms of intense colonization, such as odor, pain complaints and exudation, in addition, benefiting the prophylactic management of the wound biofilm 19 .
Use of Dialkyl Carbamoyl Chloride in the prevention and treatment of biofilm in wounds Furthermore, the use of DACC in complex lesions has been advised, since the pathogens are not destroyed, but stored, with no risk of accumulation of cellular debris in the lesion, which could lead to an exacerbation of the local inflammatory response, leading to tissue repair pain and dysfunction 5,18,19 ,and given the evidence described that coverages with DACC do not have adverse effects, they become viable options for chronic, acute and, mainly, infected injuries 12 .
In a multicenter study conducted in England and Ireland, they sought to assess the evolution of skin lesions in areas of erythema, edema, pain, odor and exudate, being used in a variety of patients with dichotomous lesions, such as venous ulcers, traumatic lesions and mixed ulcers. Its outcome showed a decrease in the number of lesions with signs of inflammation (79% to 29%), in addition to an increase in the number of lesions with epithelial tissues and granulation tissues in patients using dressings with DACC 20 .
The use of DACC with paraffin gauze soaked with chlorhexidine acetate in skin graft donation sites showed contributing characteristics to healing, reducing healing time, being effective and recommended in the treatment of infected wounds 21 .
In Brazil, dressings impregnated with DACC are available in the form of swabs, indicated for mechanical debridement and removal of biofilm, in the form of a compress and impregnated in multilayer dressings with silicone edges 3 .
With technological advances and the increase in the arsenal of technologies for wound treatment, it is essential that health professionals, especially nurses, have knowledge about the applicability of the various dressings and the possible expected results, so that the management of skin injuries, especially those of greater complexity, can be done assertively and considering cost-effectiveness.

CONCLUSION
It was identified that the DACC was able to promote beneficial actions regarding the treatment of wounds, especially those of greater complexity. Its role in microbial management stands out, whether for the prevention of surgical site infection, or for the treatment of infected wounds or with biofilm.
The proper choice of coverings and dressings can contribute to a more rational use of existing technologies and antibiotics (so controversial in clinical practice), culminating in cost reduction for the health system and promoting better quality of life for individuals who suffer from chronic wounds.
The limitation in the amount of research published on the subject is highlighted, with studies with a limited number of participants. Thus, it is extremely important to carry out further investigations that expand the use of this technology to other types of wounds and consider its cost-benefit and applicability.

DATA STATEMENT AVAILABILITY
Data will be made available on request.