Biofilm and Infected Wounds

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Biofilm: Colonies of multiphenotype, free-floating bacteria that secrete a polysaccharide matrix that protects the bacteria from immune response and antibiotics.

Chronic wounds: Wounds that stall in the inflammation phase and fail to progress toward healing within 3 months are considered chronic or hard to heal.

Continuous inflammation: When wound healing becomes stalled in the inflammatory phase because of the presence of bacteria and their endotoxins, the wound is unable to move out of the inflammatory phase and into the repair phase.

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As scientists and researchers have delved deeper into the causes of wounds and wound chronicity, matrix metalloproteinases, or MMPs, have come into sharper focus. MMPs are not just present in chronic wounds — they also play an essential role in acute wounds.

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An injury to the human body initiates a wound healing chain reaction that occurs in four sequential but overlapping phases: hemostasis, inflammatory, proliferative and maturation. This post focuses on the second (inflammatory) phase, which begins after blood flow stops (i.e., hemostasis) and defender white blood cells, or leukocytes, migrate to the site of the injury — a process known as chemotaxis.

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Vulnerable skin within the skin microclimate is caused by a multitude of factors that are often aggravated by one another. Urine and feces, for example, have a negative impact on the skin as a result of the microorganisms and enzymes they contain. These factors break down the skin barrier and cause inflammation through the release of cytokines that trigger an immune response leading to symptoms of dermatitis (i.e., moisture-associated skin damage [MASD]). Incontinence-associated dermatitis (IAD) is one type of MASD, and the external factors that contribute to IAD include microclimate (water, temperature, pH), mechanical forces (friction, pressure, shear), and biochemical factors (fungi, irritants, bacteria, enzymes).

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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.

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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.

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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.

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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.

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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.

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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.