Identifying and managing biofilms have become two of the most important aspects of wound care. Biofilms can have a significant impact on wound healing, by contributing to bacterial infection, inflammation, and delayed wound healing.¹ These issues make reducing biofilm presence a critical component of effective wound care. Although over 60% of chronic wounds contain a biofilm, many health care professionals are not able to identify biofilm formation in their patients.² To manage this challenge effectively, health care professionals must understand what biofilms are, how to identify them, and how to take steps to reduce their impact on wound healing.

What are Biofilms Made of?

Biofilms are microbial communities, generally composed of bacteria, fungi, and other microorganisms. Although the organisms themselves are microscopic, once biofilms mature they often form a visible protective matrix that attaches the community to the surface. Small, underdeveloped biofilms may be difficult to identify, but as they grow larger, they are much more easily visible, often taking the appearance of a viscous, shiny film. This film protects the microorganisms living within it and prevents antibodies from reaching them.^1-3

Wound Care Effects

Biofims can delay wound healing and increase the risk of infection for the patient. Because the film protects the microorganisms from the body's natural immune response, it can be difficult for patients to heal on their own. As the body tries to fight the biofilm through an inflammatory response, the body may actually help the biofilm by providing nutrition in the form of exudate. This creates a situation in which the body is ineffectively fighting biofilms while damaging healing tissue and delaying wound healing.^1,3

Why Proactive Wound Management is Critical

Biofilms generally develop in three distinct stages. Initially, they are composed of a small community of bacteria and other microorganisms that have attached themselves to the surface. At this stage, health care practitioners can relatively easily reverse the development of the biofilm through cleaning and debridement. After a period of time, the community will have formed a more permanent attachment to the surface and created a more cohesive symbiotic community.

Finally, the community will begin producing extracellular polymeric substance, which is the viscous substance that forms the foundation of the biofilm. It creates a protective barrier that can make it significantly more difficult to sanitize the wound and remove the bacteria.¹ This process takes a total of two to four days, with initial attachment occurring in a matter of hours. As the biofilm progresses through these stages, it becomes increasingly difficult for health care practitioners to remove it and for the patient's immune system to fight it effectively. Even after debriding a well-established biofilm, it can form again in as little as 24 hours, significantly more quickly than the initial formation.²

How to Prevent and Reverse Biofilm Formation

To combat the growth and reformation of biofilms, health care professionals must understand best practices in biofilm management. Debridement and cleansing are currently thought to be the most effective means of removing and preventing biofilms. However, it is critical that health care professionals recognize biofilms early and clean the area effectively.

• Inspect wounds for biofilms – To treat biofilms, it is important to recognize them early. Although the first stages of biofilm formation are difficult to see, there may be indications that a biofilm is forming. There are generally no obvious signs of infections with biofilms. However, if wound progress is stagnant for multiple weeks, this may be an indication that a colony has formed and is impeding the natural healing process. It is also important to look for the more obvious shiny film of a well-established colony.²
• Regularly cleanse and debride wound area – The most important components of biofilm management are frequent cleansing and debriding of the wound area. These are the best-known means of removing the biofilm material and preventing mature biofilm formation. The best methods of debridement for biofilms have not yet been clinically tested, so the health care professional should choose whichever is suitable for the patient's conditions and the practitioner's experience.^1,2
• Increase frequency of debridement for mature formations – Unless extensive debridement is performed, cleansing and debridement cannot completely remove the biofilm; however, these management methods can prevent it from reestablishing itself. Without consistent care, biofilms can reestablish themselves within as little as 24 hours. This makes it extremely important that health care professionals increase the frequency of cleansing and debridement when a biofilm is suspected. A barrier dressing and topical antimicrobials can also help reduce the risk of recontamination of the area.^1,2

Research on the effects and treatment of biofilms is an extremely active area, and health care professionals should monitor the most recent literature to ensure that they are giving patients the best possible care. Because biofilms can form so quickly and have such a significant effect on wound healing, it is critical that they be addressed promptly and consistently. By following current best practices, health care professionals can help reduce the risk of delayed wound healing and improve patients' outcomes.

References:

1. Phillips PL, Wolcott RD, Fletcher J, Schultz GS. Biofilms made easy. Wounds Int. 2010;1(3).

2. Carver C. How to identify biofilm in a wound. WoundSource. http://www.woundsource.com/blog/how-identify-biofilm-in-wound. Published August 18, 2015. Accessed December 20, 2017.

3. Donlan RM. Biofilms: microbial life on surfaces. Emerg Infect Dis. 2002;8(9):881-90.