Transcript

Hello, my name is Heidi Cross, and I am a wound and ostomy nurse in Syracuse, New York, and I've been asked by WoundSource to say a few words about biofilm, so thank you so much for inviting me to do that. 

Well, quite honestly, objectively, there really isn't a whole lot to go on when trying to definitively determine are we dealing with biofilm. I always like to say that wound assessment and detecting biofilm is a multisensory thing. You have to use your visual sense, your olfactory sense, your tactile sense, even. Signs generally can be subtle, especially in the initial stages, often presenting as poor or friable granulation tissue, maybe with increased moisture and exudate, there's a developing odor, there's perhaps a low-grade erythema, and we see really a slowly healing or seemingly not improving wound. The wound may be more prone to developing devitalized tissue, such as slough and yellow tissue. I think that if there is slough in the wound, we can pretty well safely presume the presence of a biofilm. 

Sometimes it can be difficult to distinguish a biofilm from an actual wound infection as in a chronic wound; the usual signs of a wound infection can be subtle, just like the biofilm, especially in immunocompromised patients or patients with multiple comorbidities. So just in general, what do we look for? We don't seem to have any improvement in the wound the way we would like. The wound just does not seem to be advancing the way we would hope and expect, usually within a 4-6 week time period that they tell us a wound should show some signs of improvement.

Slough is a form of necrotic tissue, contains ingredients such as fibrin, leukocytes, dead cells, microbes, and proteinaceous materials. Biofilm usually is seen as a slimy or gelatinous substance on the surface of the wound. However, they go hand in hand. A wound with biofilm is definitely more prone to developing devitalized tissue such as slough, as well as poor and friable granulation tissue. And then slough actually attracts bacteria to the wound, increasing inflammation. I think that if there is sluff in the wound, we can pretty well presume the presence of a biofilm. 

In terms of biofilm, we have to think of both prevention as well as treatment. Wound hygiene really is the buzzword, followed by debridement and then appropriate dressings that meet the needs of the wound. The International Wound Infection Institute out of London has some readily available papers. They're really great for free on its website, and I definitely suggest you head over there, the International Wound Infection Institute, and look at their stuff. Also, we have the work of Dr. Gregory Schultz, who in my mind is and forever will be the godfather of biofilm. He did a ton of research about biofilm and published quite extensively. He extensively added to our body of knowledge related to this topic. Sadly, he passed away in 2024. 

So, what does wound hygiene mean? That means that we sufficiently clean the wound and the skin around the wound or the periwound out at least 4 centimeters and perhaps even out further with each and every wound dressing change. We often talk about therapeutic cleansing. I can't stress too much how key this step is. We have been told over the years to clean wounds with normal saline, but given what we know about biofilm and how prevalent it is, especially when we are realizing a lack of progress in wound healing, I believe we need to incorporate antimicrobial cleansers into our routine. As far as technique goes, I like the statement, “Clean it like you mean it.” Just baptizing the wound does not do the trick. Get a little aggressive in attempting to remove the gunk in the wound, stopping short, of course, of disrupting developing granulation tissue. You might be surprised at what you find underneath that layer of yellow gunk. 

Irrigating wounds is a great idea, especially when we are dealing with deeper wounds, undermining, and tunneling, etc. Pulse lavage, a form of mechanical hydrotherapy, if it's available to you, is an excellent option for both biofilm removal as well as accomplishing some debridement. Also, there is negative pressure installation therapy, which can be very effective at flushing out wound biofilm and debris. So that's cleansing the wound.

What do we do then? Then debriding becomes an important part of the wound game plan, debridement of devitalized tissue, to break up the biofilm. A gentle scraping of the wound with a curate is sometimes all it takes done routinely with each dressing change and wound cleansing. Depending on the amount of devitalized tissue in the wound bed, more aggressive debridement may be necessary, and if you are qualified to do conservative sharp debridement, this may be a good time. In the process of debriding, though, be aware that you are breaking up the biofilm, that is our goal after all, but in the process potentially releasing fragments of biofilm and planktonic bacteria, which are then going to go forth, spread out throughout the wound, and create more biofilm, which can then rapidly reform. So that is why the next step is so important to apply an antimicrobial dressing that is going to help in the process of eliminating biofilm by inhibiting or killing the growth of microbes. And we know that the choices here are myriad, but it basically comes down to dressings such as silver, PHMB, honey, or any of those antiseptics. 

Well, as far as time constraints go, doing a good job at biofilm control incorporating all the steps we've talked about, admittedly does take some time. So sometimes it can be difficult to perform perfect wound care each time. But we have to realize that taking that extra little bit of time will ultimately result in faster and more effective wound healing, ultimately saving time by leading to faster wound healing, fewer infections, which of course would mean a decreased need for systemic antibiotics with all their potential side effects, such as antibiotic resistance and GI effects. Most importantly, however, is that it will lead to happier patients. So here's a suggestion. Be sure that all wound orders are explicitly spelled out, including the cleansing aspect of wound care, and how to effectively do that, including the skin around the wound. Make sure the orders include detailed instructions on how to appropriately clean the wound, apply the dressing, and use the wound products appropriately. Everyone has to be on board and educated about good and effective wound care. If despite all that, the wound is not progressing, make sure first that you have accounted for all causes of nonprogression, such as, is the wound appropriately offloaded with proper pressure relief? Has nutrition been addressed? Are diabetes and other underlying conditions appropriately managed and treated? That is why an interdisciplinary approach always is so necessary. Wound healing is a team effort, including making sure the patient is part of the team. Involve nutrition, involve PT and OT, involve the physicians, involve social work, and of course a wound specialist, if not already involved, or perhaps we might be at a time when referral to a wound care center or a specialist is called for.