Cold plasma technology as a novel antimicrobial platform - mechanisms, efficacy, and clinical translation: a systematic literature review

Background The global antimicrobial resistance (AMR) crisis necessitates innovative therapeutic approaches beyond traditional antibiotics. Cold atmospheric plasma (CAP), an ionized gas containing reactive species, has emerged as a potent physical antimicrobial technology with broad-spectrum activity. This systematic review critically evaluates current evidence on CAP's antimicrobial mechanisms, efficacy against diverse pathogens, and clinical translation potential. Methods We conducted a systematic literature search following PRISMA guidelines across PubMed, Scopus, and Web of Science databases (January 2018-December 2025). Included studies investigated CAP's antimicrobial properties in vitro, in vivo, or clinically. Results Analysis of 64 included studies revealed that CAP's antimicrobial effects primarily stem from reactive oxygen and nitrogen species (RONS) generation, causing oxidative damage to microbial membranes, proteins, and DNA. CAP demonstrates significant efficacy against multidrug-resistant bacteria, viruses, fungi, and biofilms. Clinical studies show particular promise in chronic wound management, with randomized controlled trials demonstrating accelerated healing and reduced microbial load. Conclusion CAP represents a promising multi-target approach to antimicrobial therapy, offering a multi-target mechanism that circumvents conventional resistance pathways. While standardization and dosimetry challenges remain, CAP holds immense potential for integration into clinical practice against AMR.