Biofilm and Infected Wounds

Antibiotic resistance is a growing health threat, not just in the United States, but throughout the world. Health care professionals are facing problems with antibiotic resistance, as well as with resistance to other antimicrobial agents. The Centers for Disease Control and Prevention (CDC) noted in 2019 that “more than 2.8 million antibiotic-resistant infections occur in the United States (US) each year, and more than 35,000 people die as a result.” The CDC lists 18 current threats, with three on the watch list as emerging causes of antibiotic resistance. Many of the bacteria on this threat list are found in chronically stalled wounds. Therefore, wound clinicians must be good stewards of antimicrobial treatments to prevent contributing to an already worsening problem.

Treatment of chronic and complex wounds complicated by biofilm formed by pathogens remains a tremendous challenge for the health care industry. Recent increases in infections mediated by drug-resistant bacterial and fungal pathogens highlight the need for new antimicrobial therapies. The application of topical agents with antimicrobial and antiseptic properties is gaining traction as an alternative to antibiotic prescriptions.

Antibiosis: The biological relationship between two organisms in which one living organism kills another to ensure its existence.

Antimicrobial resistance: The process that occurs when bacteria, fungi, and parasites (microorganisms) change over time and no longer respond to antimicrobial medications. This resistance makes it more difficult to treat infections and increases the risk of spreading diseases that result in severe illness and death.

Antimicrobial stewardship plan: An antimicrobial stewardship plan should seek to prevent wound infection in the first place and should promote ideal antibiotic use in clinically infected patients while also preventing use of antibiotics in non-infected patients.

Antibiotic resistance is considered a significant public health concern by multiple international organizations. The US Centers for Disease Control and Prevention estimate that approximately 35,000 deaths occur in the United States each year related to antibiotic resistance. Moreover, the agency predicts that millions more deaths will occur in the coming decades. By 2050, it is estimated that the number of deaths resulting from drug-resistant infections will surpass 10 million, which equates to one person dying every three seconds. The total global cost to economic output related to these deaths is estimated at US $100 trillion.

Wound healing is often accompanied by bacterial infection. Many clinicians use antibiotics to treat wound infections. However, the overreliance on antibiotics is becoming an increasing concern for many global health organizations because it contributes to widespread antibiotic resistance. Excessive use of synthetic antibiotics leads to drug resistance, which poses a substantial threat to human health.

When assessing and documenting a wound, it is important to note the amount and type of wound exudate (drainage). Using our senses is a large part of the initial wound assessment, followed by accurate documentation. Wound exudate or drainage gives us significant information about what is going on with the wound, all the way down to a cellular level, and it is one of the wound components that guide our topical treatments. As mentioned in prior blogs, a dry cell is a dead cell, but a wound with too much moisture will also have delayed healing. Additionally, infection, poor nutrition, impaired mobility, impaired sensory perception, and even malignancy in the wound can impair the healing process.
In acute wounds, drainage typically decreases over several days while the wound heals, whereas in chronic wounds, a large amount of drainage is suggestive of prolonged inflammation with failure to move into the proliferative phase of wound healing. An increase in drainage with malodor can be an indication of infection and should be treated appropriately based on the overall picture and goals of wound care.
There are many different types, consistencies, colors, and characteristics of wound drainage. In this blog, we discuss the most common types and what they could mean.

By Temple University School of Podiatric Medicine Journal Review Club

The treatment of wounds has advanced significantly over the years and has involved a variety of therapy options, but the percentage of wounds that heal after 12 weeks remains at a mere 40%. One idea to improve wound healing is to improve diagnostic imaging of wounds, similar to the technological advances seen in many other specialties. Wound healing is costly, especially given that many wounds are hard to heal or there is difficulty in identifying the best course of treatment for the wound. If the current wound healing treatments show minimal improvement in four weeks and there are still thousands of bacteria-forming units on the wound, the clinician should re-evaluate the therapies being utilized and consider a change in treatment.

Prevention and management of biofilm and infection in wounds can be supported by using antimicrobial and antibiofilm dressings. Internationally, there has been a rising prevalence of antibiotic-resistant organisms; this has resulted in increased incorporation of antimicrobial dressings in wound management. These dressings offer many advantages because they are easy to use, are readily available, have a decreased risk of resistance, and deliver sustained release of antimicrobial agents to the wound bed. This mode of action allows for a lower concentration of the agent and thereby lowers the possibility of toxicity to host cells.

Bioburden: Bioburden is the number of microorganisms in a wound, and a high bioburden can cause delayed wound healing.

Biofilm: Biofilms are usually composed of mixed strains of bacteria, fungi, yeasts, algae, microbes, and other cellular debris that adhere to the wound surface.

Epibole: Epibole refers to rolled or curled-under closed wound edges. These rolled edges are thickened epidermis that may be callused, dry, scaly, and/or hyperkeratotic. When epibole is present in a wound, it signals to the body that the wound has healed, even though the wound remains open. Epibole must be resolved to allow the wound to close.

Delayed wound healing occurs in various wound types and in patients with significant comorbidities. Hard-to-heal wounds have proven to be a challenging and worldwide crisis resulting in high financial burdens.