Wound care Microbe destruction
Researchers are exploring more comfortable and less invasive ways for effectively tackling biofilms in chronic wounds. Using ultrasound is one potential option. Clinical studies have shown that debridement tools designed to blast off dead tissue and microbes with low-frequency ultrasonic waves can increase the effectiveness of antibiotics and promote wound healing in patients with diabetic foot ulcers. But trials directly comparing patients treated with ultrasound debridement to the standard scalpel procedure are needed. Even once an effective debridement process has been established, Ousey points out that the choice of dressing is important too. “You want to maintain a nice warm healing environment,” she says. Healthcare professionals need to assess the wound carefully to determine the best course of action – checking, for instance, whether it’s too wet or too dry. “You don’t want to just slap a piece of gauze on there and put a plaster over the top of it.” Some dressings are better than others for dealing with biofilm. Alginate or polymeric foam dressings have been shown to prevent the reformation of biofilms. These are often impregnated with silver, iodine and methylene blue. Researchers at the University of Bradford, working in conjunction with Unilever and 5D Health Protection Group, are focusing on developing new ways to break up the biofilm in chronic wounds. The team has received a £25,000 grant from the National Biofilms Innovation Centre to develop a low-cost wound dressing hydrogel prototype that will destroy biofilm as it forms. “Our work will focus on looking at ways to break up that biofilm, essentially to make them more exposed so they are then more susceptible to drugs used to kill them,” said Stephen Rimmer, head of chemistry and biosciences at the university in a statement. “Our job will be to create a delivery system for drugs using polymers or hydrogels.” The aim is to produce a prototype by December 2021. Similarly, at the Indiana Centre for Regenerative Medicine and Engineering, researchers have developed a wound dressing with a difference. Their prototype uses an electrical field to zap the sticky layer of microorganisms. The dressing electrochemically self- generates 1V of electricity upon contact with body fluids such as wound fluid or blood, which is not enough to hurt or electrocute the patient but is sufficient to disrupt the biofilm and kill the microbes. The team discovered the dressing is not only successful in fighting the bacteria on its own but can be combined with other medications to boost its effectiveness. The dressing was even shown to help prevent new biofilm infections from forming, according to a paper published in the journal Annals of Surgery.
As well as advances in treatment and diagnostics, Ousey thinks there needs to be a focus on education. Healthcare professionals should be more aware of
Practical Patient Care /
www.practical-patient-care.com 41 The ‘step-up, step-down’ biofilm care pathway
1. From around day one to day four, implement multimodal therapies, including: aggressive debridement (if indicated), biofilm-directed topical antimicrobials and systemic antibiotics. The use of systemic antibiotics should be backed up with microbiological data.
2. In the next stage, lasting up to approximately a week, assess the wound response while debriding as appropriate and continuing with personalised antimicrobial therapy.
3. As the wound improves, treatment should be de-escalated for up to approximately four weeks. In the de-escalation phase, assess inflammation and healing, implement maintenance debridement, reassess the antimicrobial strategy and manage host factors.
4. Depending on clinical response, the pathway may follow different paths at four weeks until full closure, if that is the stated aim of the care plan. a. Where the wound shows potential for closure, then step down and continue with standard care.
b. Where the wound does not show promise of closure through a reduction in size, step up treatment with the introduction of advanced products and continue with the standard of care.
c. Otherwise, the full multidisciplinary team needs to be involved with any decision to shift to maintenance or palliative care.
Start multiple therapies
Personalise therapy
De-escalate treatment
Debridement; antimicrobials; identity bacteria; manage risk factors
Evaluate and decide
Assess healing; personalise antimicrobials; manage risk factors
Days 1–4 Days 5–7
Assess healing; maintenance debridement; assess need for antimicrobials; manage risk factors
Weeks 1–4
Advanced therapies; combination products
Standard care Continue until healed Source: ‘Implementing TIMERS: the race against hard-to-heal wounds’, Journal of Wound Care
biofilms and the damage they cause, as well as the fact that they may not immediately be obvious in chronic wounds. “Many people think they can see a biofilm if the wound is a bit shiny, but you can’t see a biofilm with the naked eye,” she says. “Biofilms are invisible, just like the virus that causes Covid-19. If we could just see it in front of us, we’d be able to manage it so much better.”
Step up treatment
Next-generation sequencing could help identify proteins associated with biofilm formation.
motorolka/
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