No abstract

Recognition of the existence of biofilm in chronic wounds is increasing among wound care practitioners, and a growing body of evidence indicates that biofilm contributes significantly to wound recalcitrance. While clinical guidelines regarding the involvement of biofilm in human bacterial infections have been proposed, there remains uncertainty and lack of guidance towards biofilm presence in wounds. The intention of this report is to collate knowledge and evidence of the visual and indirect clinical indicators of wound biofilm, and propose an algorithm designed to facilitate clinical recognition of biofilm and subsequent wound management practices.

Biofilm has been implicated as a barrier to wound healing and it is widely accepted that the majority of wounds not following a normal healing trajectory contain biofilm. Therefore, strategies that inform and engage clinicians to reduce biofilm and optimise the wound tissue environment to enable wound progression are of interest to wound care providers. In March 2019, an advisory board was convened where experts considered the barriers and opportunities to drive a broader adoption of a biofilm-based approach to wound care. Poor clarity and articulation of wound terminology were identified as likely barriers to clinical adoption of rigorous and proactive microbial decontamination that is supportive of wound healing advancement. A transition to an intuitive term such as ‘wound hygiene’ was proposed to communicate a comprehensive wound decontamination plan with an associated message of expected habitual routine. ‘Wound hygiene’, is a relatable concept that supports meticulous wound practice that addresses barriers to wound healing, such as biofilm, while aligning with antimicrobial stewardship programmes.

The number of people in the world with diabetes has nearly quadrupled in the past 40 years. Current data show that 25% of these diabetics will develop a foot ulcer in their lifetime and that the cost of care for a diabetic foot ulcer (DFU) is over twice that of any other chronic ulcer aetiology. Microbial biofilm has been linked to both wound chronicity and infection. Close to 1 in 2 diabetics with a DFU are predicted to go on to develop a diabetic foot infection (DFI). The majority of these DFIs have been found to evolve even before the diabetic individual has received an initial referral for expert DFU management. Of these infected DFUs, less than half have been shown to heal over the next year; many of these individuals will require costly hospitalisation, and current data show that far too many DFIs will require extremity amputation to achieve infection resolution. The development of an infection in a DFU is critical at least in part because paradigms of infection prevention and management are evolving. The effectiveness of our current practice standards is being challenged by a growing body of research related to the prevalence and recalcitrance of the microbes in biofilm to topical and systemic antimicrobials. This article will review the magnitude of current challenges related to DFI prevention and management along with what is currently considered to be standard of care. These ideas will be compared and contrasted with what is known about the biofilm phenotype; then, considerations to support progress towards the development of more cost-effective protocols of care are highlighted.

Objective The aim of this study was to analyse wound biofilm from a clinical perspective. Research has shown that biofilm is the preferred microbial phenotype in health and disease and is present in a majority of chronic wounds. Biofilm has been linked to chronic wound inflammation, impairment in granulation tissue and epithelial migration, yet there lacks the ability to confirm the clinical presence of biofilm. This study links the clinical setting with microscopic laboratory confirmation of the presence of biofilm in carefully selected wound debridement samples. Method Human wound debridement samples were collected from adult patients with chronic non-healing wounds who presented at the wound care centre. Sample choice was guided by an algorithm that was developed based on what is known about the characteristics of wound biofilm. The samples were then evaluated by light microscopy and scanning electron microscopy for the presence of biofilm. Details about subject history and treatment were recorded. Adherence to biofilm-based wound care (BBWC) strategies was inconsistent. Other standard antimicrobial dressings were used and no modern antiseptic wound dressings with the addition of proven antibiofilm agents were available for use. Results Of the patients recruited, 75% of the macroscopic samples contained biofilm despite the prior use of modern antiseptic wound dressings and in some cases, systemic antibiotics. Wounds found to contain biofilm were not all acutely infected but biofilm was present when infection was noted. The clinical histories associated with positive samples were consistent with ideas presented in the algorithm used to guide sample selection. Conclusion Visual cues can be used by the clinician to guide suspicion of the presence of wound biofilm. This suspicion can be further enhanced with the use of a clinical algorithm. Standard antiseptic wound dressings used in this study demonstrated limited antibiofilm efficacy. This study also highlighted a need for the clinical team to focus on expiration of dressing action and consistent practice of BBWC strategies which includes the use of proven antibiofilm agents. Declaration of interest This work was supported by the Department of Veterans Affairs Career Development Award CDA-2 1IK2BX001701 to J.A.G. Microscopical experiments were performed in part through the use of the VUMC Cell Imaging Shared Resource (supported by NIH grants CA68485, DK20593, DK58404, DK59637 and EY08126).