Transcript

I'm Dr. James McGuire. I'm a podiatrist at Temple University in Philadelphia, where I serve at the School of Podiatric Medicine as a professor in the departments of medicine and biomechanics. I've been Wound Center Director since 1999. 

First of all, biofilms are present on every wound. I've seen studies, most of the studies show 70 to 80-some percent of wounds, some 90, have biofilm present. I think it's probably closer to 100. The way we label biofilm is not neobiofilms or baby biofilms. It's like you have to have a certain criteria, a certain number of bacteria, et cetera, a certain presence of multiple species and other things like that that are present in biofilms. But all wounds have had some degree of biofilm on them. No matter how you manage them, you're going to get a biofilm. Any dressing that just traps moisture in the wound, which we want to do to keep it moist over the time period that it's being dressed, will create an environment where bacteria can grow. If we make it anaerobic, more anaerobes will grow. If we make it more aerobic, more aerobes will grow. But they all start to communicate with each other, form EPS or polysaccharide coatings, which protect them from, you know, external destruction of the bacteria and keep them isolated from antibiotics if we try to take care of them only with antibiotics. So all wounds have them. It's our job to try to control them. There's a lot of research being done these days on kind of good biofilms. And we will see, you know, pretty soon we'll see some good bacteria being given to us in forms of gels and other things that we can enhance the environment with or create a biofilm that will help keep the sort of antihuman biofilms, the invasive biofilms, the difficult biofilms off the wounds.

Most wounds need to be, I would say, at least cleansed or mechanically debrided on a regular basis. One of our most effective ways to keep biofilm down is to disrupt the biofilm in some way. That disruption is usually in the form of some sort of debridement. Now, it isn't practical for a patient to come to your office every day so that you can do that. But you want to do it on, we have a sort of little motto at our clinic, which is every wound every week. So as long as you have a chronic wound that's having difficulty closing, we usually have you come in once a week for a really good wound debridement and cleansing, and that's either mechanical or surgical or a combination of both. We use autolytic debridement, using hydrogels. We can talk about that a little bit more about what kind of hydrogels, but then also enzymatic debridement, which we'll use for what a lot of people call macro- and microdebridement. Macrodebridement is the physical removal of things from the wound surface. Microdebridement is the use of an enzyme to slowly remove small particles that you can't see or you can't get with these other methods of debridement. 

If you're working diligently with a patient who has either help or has the flexibility to take care of lower extremity wounds or any wound, they can do some debriding activity at home, which is cleansing of the wound, either with saline or other solutions that they've been told to use. There's debate about whether you need sterile water or regular water will work, but we don't recommend either one of those. We recommend a hypochlorous solution of all the antimicrobials we've used so far. That one seems to be the most people-friendly. It doesn't harm human tissue. It is deadly to most bacteria, viruses, and yeasts, funguses, etc. And it is sort of innocuous with regards to its use.

As long as the patient is doing dressing changes appropriately, that you've set up a good program for them, you've taught them how to do it, or their family member how to do it, and you've ordered the proper dressings for home, they should easily be able to cleanse or replace dressings either every day or every other day. And that's another whole thing we have to decide based on wound drainage, and lots of drainage needs regular changing. Wounds that don't drain as much, you can leave them alone for a few days before you do that. But cleansing them, removing that biofilm, is the best way to keep them from becoming sort of a biofilm-populated. And that requires this disruption of the wound surface, ie, regular cleansing or removal of that developing biofilm. 

The phrase I usually use is, if you wouldn't put it in your eye, don't put it on a wound. So if you don't have something that you would clean your eye with or swish around in your mouth to get rid of gingivitis or like some of the biofilm we get on our teeth in the morning, you know, why would you put it on somebody's open wound, which is a direct portal to the inside of the body, especially big wounds? So we tend to use things that are, you know, very, very, you know, low harm, decreased harm for the patient. I want to use words that are, you know, everybody kind of understands and that are innocuous. The thing that we found for most of those, the only one that I would, the only exception to that is the use of an iodine solution or Betadine, povidone. And we can talk about that separately. 

First thing I think you have to keep in mind is that most dressings do not elute or give anything to the wound surface. It's like they don't apply or release particles into the wound surface. Some of the newer ones, there's a new nitric oxide one and some other things that do release active substances in the wound. But most of the dressings, the antimicrobials in the dressings, pigments and silvers and other additives, are there to kill bacteria that get drawn up into the dressing by the dressing itself. As they remove moisture from the wound, the fluid that comes up into the dressing is sort of deactivated, like the bacteria are killed, so that you don't have a large biofilm and bacterial collection developing in the dressing over the top of what we're trying to maintain as a clean wound. It doesn't put active ingredients into the wound; it's not giving things to the wound. So for the most part, I don't worry too much about an antimicrobial dressing. If you have a lot of problems with a lot of bacteria developing, a lot of biofilm developing, a lot of odor, then we would use various, we've used the pigmented dressings a lot. We've used silver dressings. We have the copper dressing out now. There's a number of them, an antimicrobial gauze. But all these things come with extra expense. And if you're trying to keep the expense down, sometimes if you're doing a regular cleansing routine with the wound, you're not getting bacteria that have to be managed effectively by the dressing. We have had an iodine dressing in here that released iodine gas into the wound. That was a fairly effective dressing. There are other dressings that kind of melt onto the wound surface like the hydrogels and the alginates that contain honey and other things, which are antimicrobial. But most of the antimicrobials we use are not particularly effective against biofilms. Even hypochlorous gel, which stays on the wound a little longer, is not necessarily more effective against biofilms than anything else out there. The only one that seems to have really good data on penetrating biofilms is iodine, povidone iodine, Betadine, those iodine solutions. And there was no data done with the one that gives you, gives iodine gas out. 

How do you convince a patient that they need to take a very active role in helping to manage their problem? That you're not just going to take care of them, and they don't also just lean back and let family members take care of them, that they actually jump in and try and do this? And I really don't know. After many years of trying to explain to people that they have to offload their foot, and if they don't, they're going to get an ulcer back, and they get an ulcer back anyway. You need to be doing these dressing changes and then getting a lot of pushback about how hard it is or how difficult it is to do it on schedule or how expensive it is and trying to explain to them that it's a lot more expensive to have an amputation or to have a wound that doesn't heal quickly than it is to let these things go on. And that is to work out very diligently up front and trying to heal it quickly. I really don't know. 

The team effort part is it's been fairly easy to get medical professionals on board with trying to do the things that we suggest. The home care nurses have been great. The only problem is if I ask them to use something that they don't use regularly or is expensive that will take away from their bottom line, we do get pushback. I think trying to convince patients is really, you know, looking them in the eye and telling them that. The responsibility to heal this is theirs and really theirs alone. And if they don't take this on as a real life project and make it, get serious about it, they're just going to have all kinds of problems. And sometimes those problems happen and sometimes they'll blame you for the problems and you just have to suck it up and take it, because you did your best. 

Right up front, we try to send everybody in for a good vascular assessment or make sure that they have good vascular efficiency, that both they have both arterial venous and lymphatic flow in the limb, that they're going to be able to mount a good immune response. They're going to be able to mount a good healing response, and they're going to be able to get those waste products out of the area so that the wound can heal. So the first thing is to make sure they get a good vascular referral or at least vascular testing to see whether they need a referral right away. It's not a bad idea to refer. 

Secondly, every wound, we look for possibility that it's been open a little too long before they get to us and maybe the patient didn't notice or some other problem happened at home and they have osteomyelitis underneath there. We get a baseline x-ray, even when it doesn't look like there might be osteo, just so we have something to look at if later there is osteomyelitis. Then you go and make sure that they have adequate access to dressings, and you’ve got to work on that. You’ve got to find the right good home care agency that you work with, one that the patient is comfortable with, but also one that you're comfortable with. And then be in communication with the nurses, and they always have my personal cell phone number. They can call me 24/7 anytime they want. They're very good about not doing that, even patients. I mean, I hear doctors all the time. They're scared to death of giving patients their phone number. I work in the inner city. And if you were really worried about people calling you all the time, it might be in the environment that we have. They don't call. They're very respectful. They're very helpful. Crazy people call. But sometimes that's actually what they need. You need to help them. 

So they have good communication with me. I can talk to them anytime something happens. They all have good vascular access. When you have a pyoderma or something that you can't manage, get them to a dermatologist or a specialist as soon as possible. When you're concerned about their general health, what about their diabetes? What's their sugar management like? What is their nutrition like? You have to try to assemble a team of people you can refer patients to to get the necessary help that you need. There's only so much nutrition that I know as a podiatrist that I can recommend to patients. And everything after that, I've got to get them to somebody that knows something about nutrition. If I need more support in the area, I don't know what this disease is. I mean, I can't figure this out. I mean, as much as I go to AI and I ask it, I'm not getting good. I'm not getting good information. Man, I hate to say that. I'm not getting good information and I need some help with somebody that's had experience with this. I need to send that patient out and the sooner the better. Don't wait. Don't wait on something and just say, well, maybe it's going to get better in the next week or 2 or 3 or 4. And if you're doing anything too long and nothing's happening, don't keep doing it. You know, you want to be really stupid and just keep doing stupid things over and over again. I think Einstein said that or somebody like that. As I'm getting older, I'm getting a little wiser and a little more likely to use all the help I can get.