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26 Dec '17

The antibacterial effect of topical ozone on the treatment of methicillin resistant Staphylococcus aureus skin infection

Posted by Marin Crangaci
               
   Skin can be infected by many types of microorganisms, most commonly by gram-positive strains of Staphylococcus and Streptococcus spp. Treatment of Staphylococcus aureus (S. aureus) infections, particularly that of methicillin resistant Staphylococcus aureus (MRSA), is a challenge in clinical practice.
  Ozone therapy has proven to be one of the strongest antiseptics against the majority of microorganisms involved in skin infections. The purpose of the present study was to evaluate the microbicidal effects of topical ozone therapy on S. aureus and MRSA, and determine the clinical efficacy of ozone therapy on patients with MRSA skin infection. Microbicidal effects of ozonated oil and ozonated water were determined by plating and Kirby Bauer methods.
  Clinical efficacy and safety of topical ozone were evaluated in two cases with skin MRSA infection. The killing rates of ozonated oil for S. aureus and MRSA were greater when compared with the control oil group. Almost 100% of S. aureus were eliminated by ozonated oil following 5 min. Almost 100% MRSA were eliminated by ozonated oil following 15 min. In addition, 100% S. aureus and 100% MRSA were eliminated by ozonated water in 1 min. The inhibition zone diameters of ozonated oil for S. aureus and MRSA were 17 and 13 mm, respectively, which were significantly larger than the control group. Both cases of skin MRSA infection were completely healed with ozone therapy.
  In conclusion, ozone therapy is a potential treatment for S. aureus and MRSA skin infection as it has great efficacy, few side effects and low-costs.
  Skin and soft tissue bacterial infections occur frequently in the general population. They are characterized by erythema, edema, and/or inflammation. and usually begin with an inflammatory process in epidermis, dermis, or subcutaneous tissues, they can spread to other parts of the body, leading to more serious symptoms. Antibiotic therapy is the option of choice for the treatment. However, most of antibiotics could lose their potency over time due to the antimicrobial resistance. Microbial resistance to Staphylococcus aureus (S. aureus), especially methicillin resistant Staphylococcus aureus (MRSA) and vancomycin resistant-MRSA, is a grand challenge in clinical practices globally.
  Ozone is naturally occurring gaseous molecule of triatomic allotrope of oxygen, formed recombination of oxygen atoms and represented as O3. The original application of Ozone was to sterilize microorganisms in drinking water. Now ozone has been used for treatment of open wounds, Herpes Zoster and Herpes Simple, because of its anti-microorganism effectiveness. Additionally, ozone has other advantages like such as improving wound healing, enhancing immune, no side effect, no‑toxic, environmental friendly and high efficacy. A few studies have shown that ozone therapy is efficient in killing many kinds of microorganisms, such as S. aureus, Streptococci spp, Escherichia coli, Enterococcus faecalis, and P. aeruginosa.
  Studies also have shown that ozone therapy can disinfect against S. aureus and MRSA strain in vitro. In vivo studies have suggested that ozone therapy is safe and exhibits antibacterial effects for the treatment of peritonitis. Ozone has shown its efficacy on healing MRSA skin infections when combined with other drugs. However, the effect of ozone therapy alone in the treatment of MRSA skin infections is not to be determined.
  This study (The antibacterial effect of topical ozone on the treatment of MRSA skin infection MINGSHENG SONG1*, QINGHAI ZENG2*, YAPING XIANG2 , LIHUA GAO2 , JIAN HUANG2 , JINHUA HUANG2 , KATHY WU2 and JIANYUN LU2 Departments of 1Laboratory Medicine and 2 Dermatology, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, P.R. China Received March 17, 2017; Accepted November 15, 2017) aims to evaluate the microbicidal effects of topical ozone therapy on S. aureus and MRSA and determine its clinical efficacy on MRSA skin infections.
  Kirby bauer method
  The bacteria samples prepared above were dropped on sterile cotton swabs. The surface was lightly and uniformly inoculated by cotton swab on agar plate. Then the scrips impregnated with ozonated oil or control oil were pasted into the agar plate, followed by incubation at 37˚C for 16-18 h. The inhibitory ring test was performed. If the inhibition zone diameter was bigger than 7 mm, it was considered effective; otherwise, it was not.
   Patients and ozone treatment
  The Ethnic Committee of Third Xiangya Hospital approved the study, and the informed consents of all the participants were obtained. Two patients with skin MRSA infection were recruited in this study. In addition to skin infections, no other diseases were present in the two patients. The skin lesions were washed or debrided by ozonated water in therapy room once a day, followed by application of ozonated oil twice per day at home. Antibiotics and other drugs were not administrated during the ozone therapy.
   Results
Killing rate of ozone on S. aureus and MRSA
   The killing rate of ozonated oil on S. aureus was much higher than the control. Almost 100% S. aureus were killed in 5 min. For MRSA, the killing rate of ozonated oil was also much higher than the control oil. Almost 100% MRSA were killed within 15 min (Fig. 1). The killing rates over time between ozonated oil and control for S. aureus and MRSA were presented in Tables I and II. The ozonated water (1 mg/l) can sterilize 100% S. aureus and 100% MRSA in one minute (Fig. 2). 
  Bacterial inhibitory: Inhibition zone diameter
  The inhibition zone diameters of ozonated oil for S. aureus and MRSA were 17 and 13 mm respectively, which were significantly much larger than the control (Fig. 3).
  Practicing treatment
   A 21-year-old male patient presented to the Dermatology Department of our hospital complaining of a painful abscess on his left calf muscle for approximately 20 days. Denied any systemic diseases or health issues. Skin examination revealed induration, bleeding and surrounding erythema in the left upper Achilles tendon (Fig. 4A).
  The overlying skin had become thin and felt fluctuant with spontaneous pus secretion. Previous treatments included systemic antibiotics, cleaning and dressing changes for more than 20 days without any visible effect. Tests for diabetes and immune-suppression syndrome were negative. Bacteria culture, drug sensitive test and PCR test confirmed skin MRSA infection. The strain was resistant to clindamycin, erythromycin, cefoxitin, oxacillin, penicillin-G, piperacillin, and azithromycin. After diagnosis of MRSA infection, the patient voluntarily was put on topical application of ozone therapy. Ozonated water was used to wash the lesion for 10 min immediately, followed by soak the lesion for 20 min after debridement if necessary in our therapy room every day. The application of topical ozonated oil twice per day was carried out at home by the patient. Four days after treatment, the lesion was cleaned to remove necrotic tissue and pus secretion (Fig. 4B).      Affected areas were reduced by more than 70% during the first month (Fig. 4C) and was almost healed by the end of second month (Fig. 4D). Bacteria culture test revealed that tissues from the lesion did not develop bacteria one month after the topical ozone treatment. 
  In this study, has been demonstrated that ozonated oil and ozonated water have strong in vitro antibacterial effects against S. aureus and MRSA. This is the first study to prove that the topical application of ozone alone can be a powerful treatment option for MRSA skin infections.
  Data in this study have shown that ozonated oil can sterilize up to 98% of S. aureus in 5 min and up to 98% of MRSA in 15 min while ozonated water (1 mg/l) can sterilize 100% of S. aureus and 100% of MRSA in one minute. This results indicate that ozone therapy has very powerful anti-microbial properties against gram positive microorganisms, which was confirmed by the bacterial inhibitory experiment of ozonated oil.
  Results are consistent with reports regarding bacterial elimination in S. aureus or MRSA by ozone therapy. Notably ozone can sterilize both gram positive bacteria and gram negative bacteria. Ozone is an unstable molecule that rapidly decays to O2 and releases a single oxygen atom. The single oxygen atom reacts with the cell membrane of the bacteria, attacks the cellular components, interrupts the normal cell activity and then destroys bacteria. Ozone therapy has been used for infectious diseases such as conjunctivitis and keratitis, peritonitis, and surgical sepsis.
  In clinical practice, topical application of ozone therapy is very effective for healing MRSA induced skin ulceration. The two cases got remarkable therapeutic effects after ozone treatment alone. Besides the high efficiency for sterilization, ozone therapy exhibits a potential effect in wound healing. The possible mechanisms include: i) Increasing oxygen levels, glucose and ATP transporter molecules in ischemic tissues; ii) increasing the activity of bone marrow stem cells, so as to promote angiogenesis and tissue regeneration; iii) the upregulation of the expression of antioxidant enzymes in blood; iv) Promoting the neuronal medium rise; and v)Inducing growth factors. Ozone therapy was also reported to reduce pain and swelling. Patients in this study also presented significant decrease in pain and swelling. 
  Diabetic foot ulcers are a challenging clinical problem, characterized by neuropathy, peripheral arterial diseases, foot deformities, and infection. S. aureus was the most common pathogen identified in Diabetic foot ulcers, representing 46% of culture-positive patients. And 15% were  classified as MRSA.
  Ozone application was not only to kill S. aureus or MRSA, but also reported to significantly reduce the lesion area in patient with diabetic foot. Ozone also can improve glycemic control by controlling hyperglycemia and insulin sensitivity and preventing oxidative stress associated with diabetes mellitus and its complications. Because of the low-cost, ozone therapy can also reduce the medical bills for patients with diabetes mellitus and its complications. Ozonated water can keep the bactericidal effect for approximately 30 min, while ozonated oil can maintain its sterilization ability persistently.       Although ozone therapy can kill microbes, improve wound healing, reduce pain and swelling at minimal cost with almost no side effect, it is contraindicated in several diseases such as Blood Coagulation Failure, Bleeding Organs, Thrombocytopenia, Ozone Alergia, Hemorrhagic or Apoplectic Stroke, Ozone Intolerance.
   In summary, ozone therapy is potential treatment for S. aureus and MRSA skin infections with great efficacy, low side effects, and low-cost.
The antibacterial effect of topical ozone on the treatment of MRSA skin infection MINGSHENG SONG1*, QINGHAI ZENG2*, YAPING XIANG2 , LIHUA GAO2 , JIAN HUANG2 , JINHUA HUANG2 , KATHY WU2 and JIANYUN LU2 Departments of 1Laboratory Medicine and 2 Dermatology, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, P.R. China Received March 17, 2017; Accepted November 15, 2017 

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