Progress in molecular microbiology, microscopy technology, and methodologies for studying bacteria have improved our ability to detect the presence of biofilms, but there is still plenty that we don’t know about them. Chronic non-healing wounds host bacterias that can be found in all types of wounds, regardless of their cause. The development of biofilms follows a predictable pattern: attachment, microcolony formation, maturation, and dispersion are all stages of the process. Initially, the connection is reversible; however, the attachment becomes stronger as cells expand and modify the expression of their genes over time. This mechanism of cell communication is referred to as quorum sensing, and it is what allows cells to survive.
Wounds should be evaluated thoroughly by the clinician, including the clinical history, any signs, and symptoms, as well as a microscopic culture and tissue sample, to assist in identifying any potentially pathogenic bacteria. Conventional culturing methods are insensitive, and studies have shown that they consistently fail to distinguish between the many types of organisms found in biofilms. When it comes to recognizing biofilm colonies, DNA-based technology or molecular approaches perform far better than conventional culturing methods. Better healing outcomes will be achieved through the use of a multidisciplinary strategy that incorporates good wound cleansing and well-established wound care concepts. According to research, microbes rarely infiltrate healthy tissue until the wound bed has become damaged due to drying out.
Suppression of biofilm activity in a wound can be accomplished by a variety of tactics and treatments. Specifically, the goal is to attack only the biofilm and not the body’s defensive and healing mechanisms. A biofilm-based wound treatment method includes aggressive debridement, topical antiseptics, systemic antibiotics, DNA identification of bacteria, and management of the host factor. It is necessary to prepare the wound bed for healing by employing the same debridement techniques that are used to assist with biofilm removal. It is critical to keep the wound bed free of devitalized tissue and biofilm in order to maximize the wound healing process. When biofilm colonies infect the wound bed, the transition from an open wound to a closed wound becomes more difficult. Biofilms that have been developed contain both physical and metabolic protections. These defenses allow the biofilm to withstand antimicrobials that would normally alienate planktonic cells, and they include resistance to host defenses, biocides, antibiotics, and UV light, among other things. Sharp debridement of wounds in a sequential manner interrupts biofilm formation and inhibitory factors, which can result in faster wound healing. It is impossible to forecast the outcome because we do not yet know how deep the biofilm colony must be penetrated in order to be completely removed.
BEAMS is a common acronym in remembering the various debridement methods.
The use of maggots, Lucilia sericata, for debridement is referred to as biological debridement (green bottle fly). The flies are raised in a sterile environment and are used to digest dead tissue and pathogens in the laboratory setting. The sterile maggots are put to the wound bed, and a cover dressing is applied over the maggots to “constrict” them to the wound bed. There are pre-assembled dressings and custom dressings available, as well as the possibility to design your own from scratch.
Enzymatic debridement is accomplished through the administration of a topical substance that has been prescribed and that chemically liquefies necrotic tissues with enzymes. They disintegrate and engulf devitalized tissue within the wound matrix, causing it to become infected. When some antimicrobial drugs are used in concert with collagenase, the efficiency of enzymatic debridement can be reduced significantly. In conjunction with surgical and sharp debridement, this approach can be employed to achieve the best results. However, depending on the insurance payer source, this method can be prohibitively expensive; however, discount programs are available. Enzymatic debridement is frequently used in the long-term care setting because it is less painful and can be performed on a daily basis by nurses.
Autolytic debridement is the most time-consuming approach, and it is the one that is most generally employed in long-term care facilities. There is no discomfort associated with this approach. This procedure makes use of the body’s own enzymes and moisture beneath a dressing, resulting in the liquefaction of non-viable tissue. It is critical to maintaining a healthy balance of moisture. Dressing frequency and absorbency are important considerations. Hydrocolloids, hydrogels, and transparent films are three types of dressings that are routinely utilized.
Mechanical debridement can be accomplished using irrigation, hydrotherapy, wet-to-dry dressings, and an abraded approach, among other methods. Although this procedure is cost-effective, it has the potential to harm healthy tissue and create pain. As a result of the alternatives available with advanced wound care dressings, state surveyors are wary of using wet-to-dry dressings in the long-term care context, particularly in nursing homes. When dressing wounds, this style of dressing is utilized to eliminate excess drainage and dead tissue. Another approach that is widely recognized in long-term care is a wet-to-moist dressing. Drainage and dead tissue are removed from wounds with the application of this form of dressing, which helps to promote moist wound healing while removing drainage. Deep wounds with undermining and tunneling must be packed loosely to prevent infection. Without packing, the area may seal off and form a pocket, which may not heal properly, resulting in infection or an abscess in the wound. When compared to the wet-to-dry dressing, which needs to be changed every 4 to 6 hours, this form of dressing needs to be changed every day.
Surgical Sharp and Conservative Sharp
Sharp debridement, both surgical and conservative, is performed by a qualified practitioner utilizing surgical instruments such as a scalpel, curette, scissors, rongeur, and forceps. This sort of debridement helps to enhance wound healing by eliminating biofilm and devitalized tissue from the wound site. The level of debridement is assessed by the amount of devitalized tissue that is removed from the wound. Debridement performed in a surgical operating theatre is the most vigorous form of debridement available. Sharp and cautious debridement can be carried out at a clinic or at the patient’s bedside using sterile instruments and techniques.
Finding the pieces of the puzzle to biofilms has been ongoing. However, we know more now than a decade ago. Biofilms are known for their considerable defense protection from host immunities and utmost tolerance to antimicrobial agents. There are no normal standard signs and symptoms, or precise methods to identify biofilms. Key essentials to preventing, disrupting, and suppressing biofilm regrowth are aggressive debridement, topical antibiofilm strategies, and host factor management strategies.
The views and opinions stated in this blog are exclusively those of the author and do not reflect iWound, its affiliates, or partner companies.
Future Reading and References
Leaper D. Sharp technique for wound debridement. World Wide Wounds. 2002. Available at: http://www.worldwidewounds.com/2002/december/Leaper/Sharp-Debridement.html.
Sherman RA. A new dressing design for use with maggot therapy. Plast Reconstr Surg. 1997;100(2):451–6.
Wound Evaluation for Biofilm Reduction – WoundSource. https://www.woundsource.com/blog/breaking-biofilm-cycle-strategies-evaluating-and-managing-wound-bioburden
Liu WL, Jiang YL, Wang YQ, Li YX, Liu YX. Combined debridement in chronic wounds: a literature review. Chin Nurs Res. 2017;4(1):5–8. Available at: https://www.sciencedirect.com/science/article/pii/S2095771817300063.
Wolcott RD, Hanson JD, Rees EJ, et al. Analysis of the chronic wound microbiota of 2,963 patients by 16S rDNA pyrosequencing [published online ahead of print December 10, 2015]. Wound Repair Regen. 2016;24(1):163–174.
Hoffman LR, Déziel E, D’Argenio DA, et al. Selection for Staphylococcus aureus small colony variants due to growth in the presence of Pseudomonas aeruginosa [published online ahead of print December 15, 2006]. Proc Natl Acad Sci U S A. 2006; 103(52):19890–19895.
Fux CA, Costerton JW, Stewart PS, Stoodley P. Survival strategies of infectious biofilms. Trends Microbiol. 2005;13(1):34–40.
WoundSource Debridement Devices https://www.woundsource.com/product-category/debridement/debridement-devices