The Evolving Approach to Biofilm in Wound Care Settings

  Here’s some basic math: Antibiotic resistance + biofilm = a significant healthcare problem.

  Healthcare-acquired infections (HAIs) are a hot-button topic — media, medical professionals, and patients are well aware that they continue to be a serious burden and risk. A recent study by the Centers for Disease Control and Prevention that reported one in 25 hospitalized patients is living with an infection acquired within a hospital or other healthcare facility is reflective of how critical this issue is.

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  When considering HAIs, multidrug resistant organisms (MDROs), also known as antibiotic resistant “superbugs,” are a major element — with mounting concern over the increase of bacterial resistance to antibiotics over the last few decades. But what is often overlooked is that these MDROs, including community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), Clostridium difficile, Acinetobacter baumannii, and Pseudomonas aeruginosa, often exist within biofilm. Though medical researchers have begun to take the implication of biofilm in recurrent infections more seriously, the need for increased research and attention remains vital. Despite many patients living with HAIs, and still others living day to day with painful, nonhealing chronic wounds, the medical community does not take biofilm infections as seriously as it does other conditions such as cancer and diabetes, both of which have more of a legacy of research and reputation.

  Biofilm forms when microbial cells attach to a hard surface or living tissue and subsequently evolve into a microbial community encased within a self-produced protective slime. Biofilm can be found on both living tissues and nonliving surfaces, such as shower drains, rocks at the bottom of most streams, and on the surface and inside of plants. Though it’s passively encountered in nature and on household elements, biofilm can be quite harmful when it comes to healthcare. The Center for Integrative Biology and Infectious Diseases of the National Institutes of Health estimates that biofilm accounts for 80% of all human infections. When biofilm bacteria are allowed to mature within a wound, the bacteria become encased in a protective matrix, allowing the bacteria to become tolerant to systemic and many topical antimicrobial agents. While antimicrobial agents can provide temporary relief by eradicating planktonic bacteria, the recalcitrant biofilm community remains, which can result in a challenging perpetuating chronic situation.

  MDROs protected in biofilm are quite dangerous from an infectious disease perspective, especially when associated with comorbid conditions such as pneumonia in patients living with cystic fibrosis, implant- and catheter-associated infections, and chronic wounds, namely diabetic foot ulcers (DFUs). Biofilm’s protective nature means that MDROs that are already difficult to treat become exponentially more so because the bacteria are protected by the surrounding biofilm matrix. This protective nature and ability to quickly reform can lead to persistent infections that decrease quality of life and, in many cases, result in death.

  Treatment strategies for MDROs have included prevention tactics incorporated into all routine patient care, such as accurate and prompt diagnosis, prudent use of antimicrobials, and hand washing to prevent transmission from patient to patient. But even with the best preventative and tactical methods in place, we will need to create new tools and strategies to control spread of bacteria in our facilities and community.

Current Treatment Approach For Wound Care Patients

  Sharp debridement of a wound is the current standard treatment option for disrupting and removing biofilm, but the procedure can also damage healing tissue (granulation) and be painful for the patient. It can also become costly, both in terms of government reimbursement for debridement and the cost of debridement supplies. Further, debridement will not remove all biofilm in the wound bed; much remains intact and could be introduced into deeper, more vulnerable structures during sharp debridement. Conversely, there is no way to prevent biofilm from forming on a wound surface in the first place. A wound is the perfect environment for biofilm to form (warm, moist, nutritious) and is directly adjacent to any potentially colonized intact epidermis, which reinforces the need for a product that can actually disrupt bacterial biofilm.

  While they may provide temporary relief, antibiotic treatments are unable to provide permanent healing when bacteria are protected by biofilm. When mixed with biofilm, infection gains colony defenses that slow the penetration of antibiotics. The bottom line: In chronic wounds where blood flow is impaired and biofilm is prevalent, the likelihood of systemic antibiotics working is very low. Chronically inflamed, nonhealing wounds affect about 6.5 million people in the US. Chronic infection is not always thought of as a fatal disease because it progresses slowly and occurs over the long term, but bacteria in biofilm represent a potent force that creates physical, financial, and emotional challenges, and often result in death.

Future of Biofilm Treatment

  The paradigm of treating chronic biofilm-associated wound infections is somewhat of a moving target in that the biofilm community is living and evolving its own strategies for survival even as we attempt to subdue it with ours. The way we care for chronic wound infections today is a pattern of largely ignoring them until they flare up and then treating them episodically with antibiotics when they do. Still, antibiotics do not permanently resolve the infection and repeated use of antibiotics is a contributing factor to the development of MDROs. The alternative solution to a chronic infection is to simply remove the infected tissue, which in the case of, say, a DFU could involve amputation. Ultimately these protocols significantly diminish quality of life and often still do not permanently resolve the infection. Wound care providers must dedicate focus and funding toward the development of innovative treatment options that address the entire lifecycle of a chronic wound, instead of simply the acute events.

  The first step in redefining the treatment paradigm is for clinicians to focus more targeted efforts toward combating chronic, biofilm-related infections and paying more attention to their impact on individual patients and our collective health system. Facilities, especially wound clinics, must integrate new strategies and devices into treatment protocols and stay privy to new products that may be coming to market. Additionally, providers and patients will need to be educated to properly understand the implications of bacterial biofilm.

  Even still, the ultimate weapon to disrupt bacteria protected in biofilm is the development of diagnostic tools, implementation of personalized approaches, and creation of new devices and products. Devices that can penetrate and disrupt wound biofilm more effectively to facilitate destruction of exposed bacteria are needed. There are companies making significant strides in developing novel solutions to addressing bacteria in biofilm, such as silver impregnated wound dressings and nontoxic antiseptic solutions. As medical professionals, we must encourage our peers to work with companies to help develop protocols for better wound care and to include their products and methodology throughout all settings involved in healthcare delivery. With the right amount of education, research, and advocacy, the potential to bring innovations to the forefront and establish a new frontier in general healthcare delivery and specifically to our patients who are living with chronic wounds is there.

Jennifer Hurlow owns her own practice: Wound Practitioner LLC, Germantown, TN, and may be reached at jenny.hurlow@gmail.com.