Clinical Update TEN TOP TIPS Understanding and managing wound biofilm


investigation into the efficacy of antiseptics for anti-biofilm management is warranted, however, some commonly used antiseptic solutions are: polyhexanide (PHMB) with betaine (a surfactant); povidone-iodine; octenidine with ethylhexyl glycerine (a surfactant). As previously stated, each clinician should be aware of the cytotoxicity of each solution, appropriate concentrations and the individual wound requirements when choosing the most appropriate solution.


5


DEBRIDEMENT: MECHANICAL REMOVAL OF BIOFILM IS


OFTEN REQUIRED


Debridement can be defined as the removal of nonviable tissue and foreign matter (including residual dressing product) from a wound. Wound bed preparation and TIME (management of Tissue, Infection and Inflammation, Moisture Balance and Edges of wound) have been considered the standard for appropriate wound management for over a decade[30]


and biofilm-


based wound care incorporates these same principles [FIGURE 2].


Table 1. Clinical indicators of biofilm in chronic wounds and supporting evidence. Excessive moisture / exudate


Sharp debridement is considered the most


significant method in the prevention and control of biofilm. Wolcott and colleagues[22]


have


demonstrated that post-debridement biofilm is more susceptible to antimicrobial treatments for 24–48 hours. They suggest serial debridement to remove mature biofilm, followed by the application of a topical antimicrobial to address the remaining immature, more susceptible biofilm.


of topical antimicrobials against biofilm Figure 2. Principles of wound biofilm management.[5]


6


TOPICAL ANTIMICROBIALS The action and bactericidal efficacy


REFERENCES 1. James GA et al (2008) Wound


Repair Regen 16(1): 37–44


2. Kirketerp-Møller K et al (2008) J Clin Microbiol 46(8): 2712–22


3. Bjarnsholt T et al (2008) Wound Repair Regen 16(1): 2–10


4. Han A et al (2011) Wound Repair Regen 19(5): 532-41


5. Phillipps PL et al (2010) Biofilms Made Easy. Available at: http://bit. ly/1l638VX (accessed 23.04.2014)


6. Schultz G et al (2008) J Wound Care 17(11): 502–8


7. Attinger C, Wolcott R (2012) Adv Wound Care (New Rochelle) 1(3): 127–32


8. Fazli M et al (2009) J Clin Microbiol 47(12): 4084–9


Evidence that excessive moisture encourages biofilm development[12]


Poor-quality granulation tissue High bioburden may present as friable granulation tissue[13] (e.g. friable, hypergranulation) Signs and symptoms of


local infection Antibiotic failure or recurring infection following antibiotic cessation


Negative wound culture


Nonhealing in spite of optimal wound management and host support


Infection lasting >30 days Secondary signs of infection are more typical of biofilm infection[14]


Antibiotic failure is the hallmark of biofilm infection. The use of antibiotics is still controversial regarding biofilm management; it has


been suggested that – without the use of concurrent strategies for biofilm management – efficacy may be as low as 25%–30%[15,16]


Routine cultures will only pick up the free-floating (i.e. planktonic) bacteria, not those within a biofilm[17,18]


Biofilm defences include resistance to: ultraviolet light, biocides, antibiotics and host defences. Biofilm can quickly reconstitute but strategically does not kill its host[19]


Infections of <30 days’ duration may also contain biofilm, planktonic infection would not persist >30 days[15]


Responds to corticosteroids and Inflammation is a by-product of biofilm, thus a good response to these TNF- alpha inhibitors


treatments suggests presence of biofilm. Decreasing inflammation removes the primary source of nutrition[15]


Gelatinous material easily Clinicians and researchers are trying to determine if the by-product of


removed from the wound surface biofilm formation can be clinically seen. Case studies demonstrate differences in wound material that can be easily removed but quickly reform, either on the wound or under a dressing. Some authors believe that slough equals biofilm, but this has not been conclusively proven. A build-up of self-secreting polymers and host components is suggestive of biofilm[20,21]


Surface substance reform quickly Research suggests that biofilm can reform within 24–72 hours[22]


9. Fazli M et al (2011) Wound Repair Regen 19(3): 387–91


10. Metcalf DG et al ( 2014) J Wound Care 23(3): 137–42


11. Yang Q et al (2013) Wound Repair Regen 21(5): 704–14


12. Hurlow J, Bowler PG (2012) J Wound Care 21(3): 109–14


13. Cutting KF, Harding KG (1994) J Wound Care 3(4): 198–201


14. Wolcott RD et al (2008) J Wound Care 17(8): 333–41


15. Wolcott RD et al (2010) J Wound Care 19(2): 45–53


16. Rhoads DD et al (2008) J Wound Care 17(11): 502–8


17. Fonseca A (2011) EWMA Journal 11(2):10–2


18. Wolcott RD, Ehrlich GH (2008) JAMA 299(22): 2682–4


19. Dalton T et al (2011) PLoS ONE 6(11): e27317


20. Cutting K et al (2010) Biofilms and significance to wound healing. In Percival S, Cutting K (eds) Microbiology of Wounds. CRC Press, Boca Raton, FL: 233–47


21. Hurlow J, Bowler PG (2009) Ostomy Wound Manage 55(4): 38–49


22. Wolcott RD et al (2010) J Wound Care 19(8): 320–8


23. Zhao G et al (2013) Adv Wound Care (New Rochelle) 2(7): 389–99


24. Malik et al (2013) Diabetes Metab Syndr 7(2): 101–7


“Sharp debridement is considered the most significant method in the prevention and control of biofilm.”


Wounds International Vol 5 | Issue 2 | ©Wounds International 2014 | www.woundsinternational.com


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