S6 S6
Clinical comment
Biofilm in wound care
Abstract
Key words:
Biofilm
Wound debridement
Kumal Rajpaul
email: [email protected] Senior Tissue Viability Lead Nurse, King’s College Hospital NHS Foundation Trust
T
he management of chronic wounds can be challenging. It has been suggested that the presence of biofilm can significantly contribute to the chronicity of wounds (Wolcott, 2008), with a growing body of evidence suggesting that biofilm is present in the majority of chronic wounds (Harding et al, 2008; James et al, 2008; KirketerpMøller et al, 2008; Bjarnsholt et al, 2010; Han et al, 2011; Keast et al, 2014). Biofilms are complex structures consisting of microbialassociated cells embedded in an extra cellular matrix (ECM) of hydrated extra polymeric substance (EPS). These cells are irreversibly attached to a biological or non-biological surface (Davis et al, 2008). Biofilm can contain multiple species of bacteria that shield against the immune system and antimicrobial agents. At a basic level, a biofilm can be described as a bacteria embedded in a thick, slimy barrier of sugar and proteins (Keast et al, 2014). The biofilm barrier protects the microorganisms from external threats (Phillips et al, 2010).
healing and chronic wound infection resistant to antibiotics, leading to prolonged hospitalisation for some patients. There appears to be a correlation between biofilms and non-healing in chronic wounds. It is suggested that biofilms are a major player in the chronicity of wounds. They are a complex concept to diagnose and management needs to be multifactorial. Wound cleansing
Antimicrobial dressings
Biofilm in wounds can be resistant to environmental stresses that can overwhelm a lone bacterium. Furthermore, bacteria within biofilm communities are influenced by the pheromone system (quorum sensing), which can modulate the community’s activity and development by directing components to differentiate and develop into specific roles (Wolcott et al, 2008). Biofilms are bacteria in wounds that attach and colonise surfaces through a variety of different mechanisms and can form micro-colonies and complex communities. These are more common in chronic wounds (James et al, 2008).
Biofilm development The literature suggests that biofilm’s formation goes through several stages. n Initial reversible attachment of planktonic microorganisms n Permanent surface attachment—as the bacteria multiply, they become more firmly attached and differentiate, changing gene expression patterns in ways that promote survival (quorum sensing) n Early vertical development n Multiple towers with channels between maturing biofilms n Mature biofilm being dispersed to other areas.
Biofilm and its relationship with infection These stages can also be interpreted (Phillips et al, 2008) as the following actions (Figure 1): n I. Contamination n II. Colonisation n III. Biofilm development—inflammatory host response n IV. Spreading infection
© 2015 MA Healthcare Ltd
A biofilm can be described as a microbial colony encased in a polysaccharide matrix which can become attached to a wound surface. This can affect the healing potential of chronic wounds due to the production of destructive enzymes and toxins which can promote a chronic inflammatory state within the wound. Biofilms can be polymicrobial and can result in delayed wound
Community Wound Care March 2015 sh Journal of Community Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on August 21, 2015. For personal use only. No other uses without permission. . All rights rese
S8 S8
Clinical comment: Biofilm in wound care
II
III
n V. Spreading to systemic infection.
Implications for wound care Chronic wounds would appear to be more susceptible to biofilm formation, as indicated in a study carried out by James et al (2008), which suggests that 60% of chronic wounds have a biofilm following electron microscopy of tissue biopsies when compared with only 6% in acute wound specimens. Controlled in vivo acute wound studies have confirmed that biofilm negatively impacts on chronic wounds more by delaying healing through persistent inflammation (Nguyen et al, 2013), delayed granulation tissue formation and delayed epitheal migration (Gurjala et al, 2011), making biofilm the primary cause of wound chronicity (Wolcott, 2010). It is noted that individual bacterial species possess distinct levels
Figure 2. Host defence unable to clear infection due to biofilm
Impaired migration and proliferation of keratinocytes Bacteria protects from systemic antibiotics
James Lemon
Bacteria protected from tropical agents in biofilm
IV
V
of biofilm virulence (Seth et al, 2012a,b,c), while multispecies biofilm delays healing more than single species (Figure 2). Biofilm is associated with impaired migration and proliferation of keratinocytes (Brill and Bottrich, 2007) and provides a reservoir of infections for wounds.
Identifying a biofilm Biofilm characteristics indicate that it has a sticky multicellular structure. Clinically, they appear as a translucent, shiny, glazed slimy manifestation, often containing a sloughlike substance that reforms rapidly and responds poorly to traditional antimicrobial therapies (Percival and Bowler, 2004; Rhoads et al, 2008). Further evidence in the literature suggests that other classic clinical signs and symptoms may indicate the presence of a biofilm. These include excessive moisture, poor-quality granulation tissue formation, signs of local infection, history of antibiotic failure or recurring infection after therapy ceases, culture-negative swabs despite clinical suspicions or the wound remaining stagnant despite addressing all other factors, including comorbidities (Metcalf et al, 2014). Metcalf et al further describe a clinical algorithm for wound biofilm identification that guides clinicians in the recognition of biofilm and the subsequent wound management practices (Figure 3). The diagnosis of a biofilm is usually made through clinical assessment (Harding et al, 2008) and microscopic or molecular analysis (James et al, 2008). Standard clinical microbiology tests are optimised to culture planktonic bacteria and do not adequately measure biofilm bacteria (Bjarnsholt et al, 2008). However, it is suggested that the concept of critical colonisation/localised infection may describe the presence of a biofilm in a chronic wound (Phillips et al, 2010). In clinical practice it is unlikely that the option of microscopic or molecular analysis would be readily available to clinicians.
© 2015 MA Healthcare Ltd
I
James Lemon
Figure 1. Developmental stages of biofilm1
Community Wound Care March 2015 sh Journal of Community Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on August 21, 2015. For personal use only. No other uses without permission. . All rights rese
S10 S10
Clinical comment: Biofilm in wound care
Figure 3. A clinical algorithm for wound biofilm identification (Metcalf, 2014) Visual Signs 1. Does the surface substance detach easily and atraumatically from the underlying would bed using physical removed techniques such as swabs, pads or sharp debridement? No
Yes
2. Does the surface substance persist despite use of autolytic or enzymatic debridement? No
Yes
probably biofilm with increasing confidence
probably host devitalised tissue, e.g., slough, fibrin
3. Does the surface substance reform quickly (in 1-2 days) in the absence of frequent intervention (e.g. cleansing, cleaning, debridement)?
No
Yes
Non-Visual Signs 4. Does the wound respond poorly to topical or systemic antibiotics? Yes
5. Does the wound respond poorly or slowly to dressings than contain antiseptic agents (e.g. silver, iodine, PHMB), including products that may control biofilm in vitro (e.g., cadexorrer iodine, nanocrystalline silver or ionic silver containing carboxymethyl cellulose dressings)?
Yes
6. Does the wound respond favourably to multi-modal strategies such as physical debridement, cleansing, and topical antimicrobial agents and dressings? Yes
No probably planktonic bacteria No
No
Methods for managing biofilm There are no simple methods for managing biofilm; however, understanding how biofilm formation occurs within wounds will guide the clinician in optimising biofilm-based wound care. The literature suggests that biofilms are difficult to eradicate due to factors associated with quorum sensing and the speed of their development and redevelopment after their disruption (Walcott and Rhoads, 2008; Walcott et al, 2008). This makes the eradication of biofilm problematic. In clinical practice, it is suggested that a combination of biofilm-based wound care procedures should be implemented, including wound bed preparation. It is suggested that physical disruption such as sharp debridement or mechanical debridement (fibrous pads, curettage) has been shown to be critical in the healing of chronic wounds (Attinger and Wolcott, 2012) and is generally agreed to be the best method of removing biofilms (Leaper et al, 2012). Repeated or maintenance debridement makes the biofilm susceptible to outside agents and can be used as an ongoing strategy for suppressing microbial regrowth and biofilm reformation (Schultz, 2011).
Debridement of wounds should be accompanied by cleansing of the wound with an antiseptic cleansing solution such as those containing betaine. Betaine (undecylenamidopropyl 0.1%) is classified as a surfactant which reduces surface tension and aids better cleaning and removal of debris and bacteria by irrigation. Polyhexamethylene biguanide (PHMB) is a useful wound cleansing agent in the management of biofilms. This is a broad-spectrum antimicrobial agent with a fast onset of effect that is well tolerated. Finally, it is important to choose an appropriate antimicrobial dressing following debridement based on the clinical characteristics of the wound (Wolcott, 2014). Topical antimicrobial dressings that provide broad-spectrum cover, such as such as silvers, iodine, honey and PHMB, are preferred (Percival et al, 2008; Phillips et al, 2010). Clinicians should consider patients’ sensitivities and allergies to dressings and this should form part of a holistic patient assessment.
Conclusion The literature suggests that biofilms are difficult to treat and remove. This is due to the protective state the biofilm adopts
© 2015 MA Healthcare Ltd
underlying comorbidity
Community Wound Care March 2015 sh Journal of Community Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on August 21, 2015. For personal use only. No other uses without permission. . All rights rese
Clinical comment: Biofilm in wound care
attributable to quorum sensing, which induces changes in the bacterial gene expression that aims to promote survival of the microorganism (Phillips et al, 2010). Debridement cannot completely eradicate biofilms from the wound bed and it can reform relatively quickly. A simple diagnostic point-of-care biofilm detection test has been suggested several times recently (Phillips et al, 2010; Hall-Stoodley et al, 2012; Metcalf and Bowler, 2014). In the future this may be useful for guiding effective wound bed preparation and dressing selection. However, in the absence of a point-of-care test, clinicians need to utilise the clinical signs associated with a wound biofilm and chose appropriate wound management strategies. CWC Attinger C, Wolcott R (2012) Clinically assessing biofilm in chronic wounds. Adv Wound Care 1(3): 127–32 Brill F, Bottrich JG (2007) Expert statement: treatment of wounds with Prontosan Wound Irrigation Solution for the removal of biofilms and other wound coatings. B. Braun Medical, Sempach Bjarnsholt T, Kirketerp-Møller K, Østrup Jensen P et al (2010) Why chronic wounds will not heal: a novel hypothesis. Wound Repair Regen 16: 2–10 Davis SC, Ricotti C, Cazzaniga A, Welsh E, Eaglstein WH, Mertz PM (2008) Microscopic and physiologic evidence for biofilm-associated wound colonization in vivo. Wound Repair Regen 16: 23–9. doi: 10.1111/j.1524-475X.2007.00303.x Gurjala AN, Geringer MR, Seth AK et al (2011) Development of a novel, highly quantitative in vivo model for the study of biofilm-impaired cutaneous wound healing. Wound Repair Regen 19: 400–10. doi: 10.1111/j.1524-475X.2011.00690.x Hall-Stoodley L, Stoodley P, Kathju S et al (2012) Towards diagnostic guidelines for biofilm-associated infections. FEMS Immunol Med Microbiol 65(2): 127–45 Han A, Zenilman JM, Melendez JH et al (2011) The importance of a multifaceted approach to characterizing the microbial flora of chronic wounds. Wound Repair Regen 19(5): 532–41 Harding KG, Carville K, Cuddigan J, Fletcher J, Fuchs P, Ishikawa O (2008) Wound infection in clinical practice. Int Wound J 5(Suppl. 3): iii–11. doi: 10.1111/j.1742481X.2008.00488.x James GA, Swogger E, Wolcott R et al (2008) Biofilms in chronic wounds. Wound Repair Regen 16: 37–44 Keast D, Swanson T, Carville K, Fletcher J, Schultz G, Black J (2014) Ten top tips: understanding and managing wound biofilm. Wounds International 5(2): 20–24 Kirketerp-Møller K, Jenson PO, Fazli M et al (2008) Distribution, organization, and ecology of bacteria in chronic wounds. J Clin Microbiol 46(8): 2712–22. doi: 10.1128/JCM.00501-08 Leaper DJ, Schultz G, Carville K, Fletcher J, Swanson T, Drake R (2012) Extending the TIME concept: what have we learned in the past 10 years? Int Wound J 9 (Suppl. 2):
S11
1–19 Metcalf DG, Bowler PG (2014) Clinical perceptions of wound biofilm. Int Wound J doi: 10.1111/iwj.12358 Metcalf DG, Bowler PG, Hurlow J (2014) A clinical algorithm for wound biofilm identification. J Wound Care 23(3): 137–42 Nguyen KT, Seth AK, Hong SJ et al (2013) Deficient cytokine expression and neutrophil oxidative burst contribute to impaired cutaneous wound healing in diabetic, biofilm-containing chronic wounds. Wound Repair Regen 21(6): 833–4. doi: 10.1111/ wrr.12109 Percival LS, Bowler P (2004) Biofilms and their potential role in wound healing. Wounds 16: 234–40 Percival LS, Bowler P, Woods EJ (2008) Assessing the effects of an antimicrobial wound dressing on biofilms. Wound Repair Regen 16(1): 52–7. doi: 10.1111/j.1524475X.2007.00350.x Phillips P, Sampson E,Yang Q, Antonelli P, Progulske-Fox A, Schultz G (2008) Bacterial biofilms in wounds. Wound Healing Southern Africa 1(2): 10–12 Phillips PL, Wolcott RD, Fletcher J, Schultz GS (2010) Biofilms made easy. Wounds International 1(3): 1–6 Rhoads DD, Wolcott RD, Percival LS (2008) Biofilms in wounds: management strategies. J Wound Care 17(11): 502–8 Schultz G (2011) Understanding biofilm-based wound care: what you need to know. Wounds International Webcast, 2011 http://bit.ly/1FwzZeA (accessed 26 February 2015) Seth AK, Geringer MR, Hong SJ, Leung KP, Galiano RD, Mustoe TA (2012) Comparative analysis of single-species and polybacterial wound biofilms using a quantitative, in vivo, rabbit ear model. PLoS ONE 7(8): e42897. doi: 10.1371/ journal.pone.0042897 Seth AK, Geringer MR, Galiano RD, Leung KP, Mustoe TA, Hong SJ (2012) Quantitative comparison and analysis of species-specific wound biofilm virulence using an in vivo, rabbit ear model. J Am Coll Surg 215(3): 388–99. doi: 10.1016/j. jamcollsurg.2012.05.028 Seth AK, Geringer MR, Gurjala AN (2012) Treatment of Pseudomonas aeruginosa biofilm-infected wounds with clinical wound care strategies: a quantitative study using an in vivo rabbit ear model. Plast Reconstr Surg 129(2): 262–74 Wolcott R (2014) Understanding biofilm formation and biofilm-based wound care. Wound Middle East (Wounds International) 1(1): 24–6 Wolcott RD, Rhoads DD (2008) A study of biofilm-based wound management in subjects with critical limb ischaemia. J Wound Care 17(4): 145–55 Wolcott R D, Rhoads DD, Dowd SE (2008) Biofilms and chronic wound inflammation. J Wound Care 17(8): 333–41 Wolcott RD, Rhoads DD, Bennett ME (2010) Chronic wounds and the medical biofilm paradigm. J Wound Care 19(2): 45–53
BREAKING NEWS:
© 2015 MA Healthcare Ltd
Community nurses, join in the conversation online ‘Like’ us on Facebook (www.facebook.com/communitynursing)
Follow us on Twitter (@BJCommunityNurs)
Join our community nurses group on LinkedIn (www.linkedin.com, then search British Journal of Community Nursing)
and stay in contact with us with your views or ideas ([email protected])
www.magonlinelibrary.com/toc/bjcn/current
Community Wound Care March 2015 sh Journal of Community Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on August 21, 2015. For personal use only. No other uses without permission. . All rights rese
Clinical comment
Biofilm in wound care
Abstract
Key words:
Biofilm
Wound debridement
Kumal Rajpaul
email: [email protected] Senior Tissue Viability Lead Nurse, King’s College Hospital NHS Foundation Trust
T
he management of chronic wounds can be challenging. It has been suggested that the presence of biofilm can significantly contribute to the chronicity of wounds (Wolcott, 2008), with a growing body of evidence suggesting that biofilm is present in the majority of chronic wounds (Harding et al, 2008; James et al, 2008; KirketerpMøller et al, 2008; Bjarnsholt et al, 2010; Han et al, 2011; Keast et al, 2014). Biofilms are complex structures consisting of microbialassociated cells embedded in an extra cellular matrix (ECM) of hydrated extra polymeric substance (EPS). These cells are irreversibly attached to a biological or non-biological surface (Davis et al, 2008). Biofilm can contain multiple species of bacteria that shield against the immune system and antimicrobial agents. At a basic level, a biofilm can be described as a bacteria embedded in a thick, slimy barrier of sugar and proteins (Keast et al, 2014). The biofilm barrier protects the microorganisms from external threats (Phillips et al, 2010).
healing and chronic wound infection resistant to antibiotics, leading to prolonged hospitalisation for some patients. There appears to be a correlation between biofilms and non-healing in chronic wounds. It is suggested that biofilms are a major player in the chronicity of wounds. They are a complex concept to diagnose and management needs to be multifactorial. Wound cleansing
Antimicrobial dressings
Biofilm in wounds can be resistant to environmental stresses that can overwhelm a lone bacterium. Furthermore, bacteria within biofilm communities are influenced by the pheromone system (quorum sensing), which can modulate the community’s activity and development by directing components to differentiate and develop into specific roles (Wolcott et al, 2008). Biofilms are bacteria in wounds that attach and colonise surfaces through a variety of different mechanisms and can form micro-colonies and complex communities. These are more common in chronic wounds (James et al, 2008).
Biofilm development The literature suggests that biofilm’s formation goes through several stages. n Initial reversible attachment of planktonic microorganisms n Permanent surface attachment—as the bacteria multiply, they become more firmly attached and differentiate, changing gene expression patterns in ways that promote survival (quorum sensing) n Early vertical development n Multiple towers with channels between maturing biofilms n Mature biofilm being dispersed to other areas.
Biofilm and its relationship with infection These stages can also be interpreted (Phillips et al, 2008) as the following actions (Figure 1): n I. Contamination n II. Colonisation n III. Biofilm development—inflammatory host response n IV. Spreading infection
© 2015 MA Healthcare Ltd
A biofilm can be described as a microbial colony encased in a polysaccharide matrix which can become attached to a wound surface. This can affect the healing potential of chronic wounds due to the production of destructive enzymes and toxins which can promote a chronic inflammatory state within the wound. Biofilms can be polymicrobial and can result in delayed wound
Community Wound Care March 2015 sh Journal of Community Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on August 21, 2015. For personal use only. No other uses without permission. . All rights rese
S8 S8
Clinical comment: Biofilm in wound care
II
III
n V. Spreading to systemic infection.
Implications for wound care Chronic wounds would appear to be more susceptible to biofilm formation, as indicated in a study carried out by James et al (2008), which suggests that 60% of chronic wounds have a biofilm following electron microscopy of tissue biopsies when compared with only 6% in acute wound specimens. Controlled in vivo acute wound studies have confirmed that biofilm negatively impacts on chronic wounds more by delaying healing through persistent inflammation (Nguyen et al, 2013), delayed granulation tissue formation and delayed epitheal migration (Gurjala et al, 2011), making biofilm the primary cause of wound chronicity (Wolcott, 2010). It is noted that individual bacterial species possess distinct levels
Figure 2. Host defence unable to clear infection due to biofilm
Impaired migration and proliferation of keratinocytes Bacteria protects from systemic antibiotics
James Lemon
Bacteria protected from tropical agents in biofilm
IV
V
of biofilm virulence (Seth et al, 2012a,b,c), while multispecies biofilm delays healing more than single species (Figure 2). Biofilm is associated with impaired migration and proliferation of keratinocytes (Brill and Bottrich, 2007) and provides a reservoir of infections for wounds.
Identifying a biofilm Biofilm characteristics indicate that it has a sticky multicellular structure. Clinically, they appear as a translucent, shiny, glazed slimy manifestation, often containing a sloughlike substance that reforms rapidly and responds poorly to traditional antimicrobial therapies (Percival and Bowler, 2004; Rhoads et al, 2008). Further evidence in the literature suggests that other classic clinical signs and symptoms may indicate the presence of a biofilm. These include excessive moisture, poor-quality granulation tissue formation, signs of local infection, history of antibiotic failure or recurring infection after therapy ceases, culture-negative swabs despite clinical suspicions or the wound remaining stagnant despite addressing all other factors, including comorbidities (Metcalf et al, 2014). Metcalf et al further describe a clinical algorithm for wound biofilm identification that guides clinicians in the recognition of biofilm and the subsequent wound management practices (Figure 3). The diagnosis of a biofilm is usually made through clinical assessment (Harding et al, 2008) and microscopic or molecular analysis (James et al, 2008). Standard clinical microbiology tests are optimised to culture planktonic bacteria and do not adequately measure biofilm bacteria (Bjarnsholt et al, 2008). However, it is suggested that the concept of critical colonisation/localised infection may describe the presence of a biofilm in a chronic wound (Phillips et al, 2010). In clinical practice it is unlikely that the option of microscopic or molecular analysis would be readily available to clinicians.
© 2015 MA Healthcare Ltd
I
James Lemon
Figure 1. Developmental stages of biofilm1
Community Wound Care March 2015 sh Journal of Community Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on August 21, 2015. For personal use only. No other uses without permission. . All rights rese
S10 S10
Clinical comment: Biofilm in wound care
Figure 3. A clinical algorithm for wound biofilm identification (Metcalf, 2014) Visual Signs 1. Does the surface substance detach easily and atraumatically from the underlying would bed using physical removed techniques such as swabs, pads or sharp debridement? No
Yes
2. Does the surface substance persist despite use of autolytic or enzymatic debridement? No
Yes
probably biofilm with increasing confidence
probably host devitalised tissue, e.g., slough, fibrin
3. Does the surface substance reform quickly (in 1-2 days) in the absence of frequent intervention (e.g. cleansing, cleaning, debridement)?
No
Yes
Non-Visual Signs 4. Does the wound respond poorly to topical or systemic antibiotics? Yes
5. Does the wound respond poorly or slowly to dressings than contain antiseptic agents (e.g. silver, iodine, PHMB), including products that may control biofilm in vitro (e.g., cadexorrer iodine, nanocrystalline silver or ionic silver containing carboxymethyl cellulose dressings)?
Yes
6. Does the wound respond favourably to multi-modal strategies such as physical debridement, cleansing, and topical antimicrobial agents and dressings? Yes
No probably planktonic bacteria No
No
Methods for managing biofilm There are no simple methods for managing biofilm; however, understanding how biofilm formation occurs within wounds will guide the clinician in optimising biofilm-based wound care. The literature suggests that biofilms are difficult to eradicate due to factors associated with quorum sensing and the speed of their development and redevelopment after their disruption (Walcott and Rhoads, 2008; Walcott et al, 2008). This makes the eradication of biofilm problematic. In clinical practice, it is suggested that a combination of biofilm-based wound care procedures should be implemented, including wound bed preparation. It is suggested that physical disruption such as sharp debridement or mechanical debridement (fibrous pads, curettage) has been shown to be critical in the healing of chronic wounds (Attinger and Wolcott, 2012) and is generally agreed to be the best method of removing biofilms (Leaper et al, 2012). Repeated or maintenance debridement makes the biofilm susceptible to outside agents and can be used as an ongoing strategy for suppressing microbial regrowth and biofilm reformation (Schultz, 2011).
Debridement of wounds should be accompanied by cleansing of the wound with an antiseptic cleansing solution such as those containing betaine. Betaine (undecylenamidopropyl 0.1%) is classified as a surfactant which reduces surface tension and aids better cleaning and removal of debris and bacteria by irrigation. Polyhexamethylene biguanide (PHMB) is a useful wound cleansing agent in the management of biofilms. This is a broad-spectrum antimicrobial agent with a fast onset of effect that is well tolerated. Finally, it is important to choose an appropriate antimicrobial dressing following debridement based on the clinical characteristics of the wound (Wolcott, 2014). Topical antimicrobial dressings that provide broad-spectrum cover, such as such as silvers, iodine, honey and PHMB, are preferred (Percival et al, 2008; Phillips et al, 2010). Clinicians should consider patients’ sensitivities and allergies to dressings and this should form part of a holistic patient assessment.
Conclusion The literature suggests that biofilms are difficult to treat and remove. This is due to the protective state the biofilm adopts
© 2015 MA Healthcare Ltd
underlying comorbidity
Community Wound Care March 2015 sh Journal of Community Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on August 21, 2015. For personal use only. No other uses without permission. . All rights rese
Clinical comment: Biofilm in wound care
attributable to quorum sensing, which induces changes in the bacterial gene expression that aims to promote survival of the microorganism (Phillips et al, 2010). Debridement cannot completely eradicate biofilms from the wound bed and it can reform relatively quickly. A simple diagnostic point-of-care biofilm detection test has been suggested several times recently (Phillips et al, 2010; Hall-Stoodley et al, 2012; Metcalf and Bowler, 2014). In the future this may be useful for guiding effective wound bed preparation and dressing selection. However, in the absence of a point-of-care test, clinicians need to utilise the clinical signs associated with a wound biofilm and chose appropriate wound management strategies. CWC Attinger C, Wolcott R (2012) Clinically assessing biofilm in chronic wounds. Adv Wound Care 1(3): 127–32 Brill F, Bottrich JG (2007) Expert statement: treatment of wounds with Prontosan Wound Irrigation Solution for the removal of biofilms and other wound coatings. B. Braun Medical, Sempach Bjarnsholt T, Kirketerp-Møller K, Østrup Jensen P et al (2010) Why chronic wounds will not heal: a novel hypothesis. Wound Repair Regen 16: 2–10 Davis SC, Ricotti C, Cazzaniga A, Welsh E, Eaglstein WH, Mertz PM (2008) Microscopic and physiologic evidence for biofilm-associated wound colonization in vivo. Wound Repair Regen 16: 23–9. doi: 10.1111/j.1524-475X.2007.00303.x Gurjala AN, Geringer MR, Seth AK et al (2011) Development of a novel, highly quantitative in vivo model for the study of biofilm-impaired cutaneous wound healing. Wound Repair Regen 19: 400–10. doi: 10.1111/j.1524-475X.2011.00690.x Hall-Stoodley L, Stoodley P, Kathju S et al (2012) Towards diagnostic guidelines for biofilm-associated infections. FEMS Immunol Med Microbiol 65(2): 127–45 Han A, Zenilman JM, Melendez JH et al (2011) The importance of a multifaceted approach to characterizing the microbial flora of chronic wounds. Wound Repair Regen 19(5): 532–41 Harding KG, Carville K, Cuddigan J, Fletcher J, Fuchs P, Ishikawa O (2008) Wound infection in clinical practice. Int Wound J 5(Suppl. 3): iii–11. doi: 10.1111/j.1742481X.2008.00488.x James GA, Swogger E, Wolcott R et al (2008) Biofilms in chronic wounds. Wound Repair Regen 16: 37–44 Keast D, Swanson T, Carville K, Fletcher J, Schultz G, Black J (2014) Ten top tips: understanding and managing wound biofilm. Wounds International 5(2): 20–24 Kirketerp-Møller K, Jenson PO, Fazli M et al (2008) Distribution, organization, and ecology of bacteria in chronic wounds. J Clin Microbiol 46(8): 2712–22. doi: 10.1128/JCM.00501-08 Leaper DJ, Schultz G, Carville K, Fletcher J, Swanson T, Drake R (2012) Extending the TIME concept: what have we learned in the past 10 years? Int Wound J 9 (Suppl. 2):
S11
1–19 Metcalf DG, Bowler PG (2014) Clinical perceptions of wound biofilm. Int Wound J doi: 10.1111/iwj.12358 Metcalf DG, Bowler PG, Hurlow J (2014) A clinical algorithm for wound biofilm identification. J Wound Care 23(3): 137–42 Nguyen KT, Seth AK, Hong SJ et al (2013) Deficient cytokine expression and neutrophil oxidative burst contribute to impaired cutaneous wound healing in diabetic, biofilm-containing chronic wounds. Wound Repair Regen 21(6): 833–4. doi: 10.1111/ wrr.12109 Percival LS, Bowler P (2004) Biofilms and their potential role in wound healing. Wounds 16: 234–40 Percival LS, Bowler P, Woods EJ (2008) Assessing the effects of an antimicrobial wound dressing on biofilms. Wound Repair Regen 16(1): 52–7. doi: 10.1111/j.1524475X.2007.00350.x Phillips P, Sampson E,Yang Q, Antonelli P, Progulske-Fox A, Schultz G (2008) Bacterial biofilms in wounds. Wound Healing Southern Africa 1(2): 10–12 Phillips PL, Wolcott RD, Fletcher J, Schultz GS (2010) Biofilms made easy. Wounds International 1(3): 1–6 Rhoads DD, Wolcott RD, Percival LS (2008) Biofilms in wounds: management strategies. J Wound Care 17(11): 502–8 Schultz G (2011) Understanding biofilm-based wound care: what you need to know. Wounds International Webcast, 2011 http://bit.ly/1FwzZeA (accessed 26 February 2015) Seth AK, Geringer MR, Hong SJ, Leung KP, Galiano RD, Mustoe TA (2012) Comparative analysis of single-species and polybacterial wound biofilms using a quantitative, in vivo, rabbit ear model. PLoS ONE 7(8): e42897. doi: 10.1371/ journal.pone.0042897 Seth AK, Geringer MR, Galiano RD, Leung KP, Mustoe TA, Hong SJ (2012) Quantitative comparison and analysis of species-specific wound biofilm virulence using an in vivo, rabbit ear model. J Am Coll Surg 215(3): 388–99. doi: 10.1016/j. jamcollsurg.2012.05.028 Seth AK, Geringer MR, Gurjala AN (2012) Treatment of Pseudomonas aeruginosa biofilm-infected wounds with clinical wound care strategies: a quantitative study using an in vivo rabbit ear model. Plast Reconstr Surg 129(2): 262–74 Wolcott R (2014) Understanding biofilm formation and biofilm-based wound care. Wound Middle East (Wounds International) 1(1): 24–6 Wolcott RD, Rhoads DD (2008) A study of biofilm-based wound management in subjects with critical limb ischaemia. J Wound Care 17(4): 145–55 Wolcott R D, Rhoads DD, Dowd SE (2008) Biofilms and chronic wound inflammation. J Wound Care 17(8): 333–41 Wolcott RD, Rhoads DD, Bennett ME (2010) Chronic wounds and the medical biofilm paradigm. J Wound Care 19(2): 45–53
BREAKING NEWS:
© 2015 MA Healthcare Ltd
Community nurses, join in the conversation online ‘Like’ us on Facebook (www.facebook.com/communitynursing)
Follow us on Twitter (@BJCommunityNurs)
Join our community nurses group on LinkedIn (www.linkedin.com, then search British Journal of Community Nursing)
and stay in contact with us with your views or ideas ([email protected])
www.magonlinelibrary.com/toc/bjcn/current
Community Wound Care March 2015 sh Journal of Community Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on August 21, 2015. For personal use only. No other uses without permission. . All rights rese
