Perceptions of Wound Biofilm by Wound Care Clinicians

Objective. The aim of this study was to gain a greater understanding of the perceptions of wound biofilm held by wound care clinicians. Methods. Independent market research was conducted in the United States and Europe via an online questionnaire to understand the knowledge levels of wound biofilm among clinicians. Results. Clinicians from the United States appeared most knowledgeable on the subject of wound biofilm, though there was a wider consensus that biofilm contributes to delayed wound healing. A number of visual and indirect clinical signs for the presence of wound biofilm were commonly listed by all clinicians. In this study, and others, widespread calls for further education on wound biofilm, in addition to anti-biofilm and diagnostic technologies, were made. Conclusions. This study has contributed to the global call to focus on tackling biofilm for the benefit of wound care patients, caregivers, and health care systems.

There is increasing evidence and awareness that biofilm exists in a majority of nonhealing wounds¹ and is linked to both wound recalcitrance and infection.² Together with the presence of devitalized host tissue, biofilm is recognized as a local component of the wound environment that requires removal to enable wound progression.^3,4 However, uncertainty exists among wound care clinicians regarding confirmation of the presence of biofilm and its subsequent management,⁵ a challenge exacerbated by a lack of proven biofilm management tools available today. 

Although recent efforts have been made to assist in recognizing signs and symptoms of wound biofilm,^2,6,7 continuing research is required to confirm and characterize the presence and effects of wound biofilm. The objective of this study was to gain a greater understanding of the perceptions of wound biofilm held by clinicians in a number of countries.

Independent market research was conducted by Waggle Dance Marketing Research, LLC (Scottsdale, AZ) in the United States and Europe to better understand the knowledge levels, awareness, experiences, and impact of biofilm among wound care clinicians. The study conducted was an online 20- to 25-minute, self-administered survey of 81 clinicians from the United States, United Kingdom, Germany, and Italy. There were 6 questions relating to perceptions of biofilm posed, of which 5 were prescriptive (Table).

Knowledge levels and experiences of wound biofilm varied from country to country, with US clinicians appearing more confident in their knowledge base, and Italian clinicians the least confident (Figure 1). The theme that biofilm delays healing, needs removal, and can be tolerant to standard antimicrobial therapies was evident in verbatim quotes, independent of clinician knowledge level of biofilm (Figure 2). 

Certain wound characteristics consistently were described as being associated with the presence of biofilm. Visual signs included surface slime and shiny or colored substances (Figure 3A), while indirect signs were poor responses to standard wound care, including antimicrobial dressings or antibiotics, delayed wound healing, and signs of infection (exudate, odor, inflammation, etc) (Figure 3B). 

Overall, 74% of clinicians surveyed believed wound biofilm delays healing, with 100% of US clinicians believing this to be the case, compared with only 60% of UK clinicians questioned in this survey (Figure 4). 

Finally, when asked about actions required to ensure clinicians are more aware of the effect of biofilm on wound healing, most suggested more education was required. Examples of more education would be in the form of visits from sales representatives, internal training, and evidence of scientific, clinical, and cost-effectiveness (Figure 5).

This study highlighted knowledge gaps for wound care clinicians on the subject of wound biofilm, particularly in the United Kingdom compared with the United States, while a Canadian study⁸ recently reported that knowledge levels are generally low for wound biofilm-related topics. The need for further scientific and clinical research and more widespread educational opportunities in this emerging field was highlighted in the present survey. In agreement, a larger survey⁹ of Australian and US clinicians recently concluded there is a need to better educate clinicians on the identification and management of wound biofilm. Recent consensus panels^10,11 also have called for biofilm diagnostic technologies, while the role of advanced antimicrobial dressings in the management of wound biofilm is becoming clear.¹²

Limitations of this study include the small sample size of 81 clinicians. Although the survey data were collected independently, it was subsequently analyzed and reported by employees of ConvaTec Ltd. (Deeside, Flintshire, UK).¹³

This study, along with more recent surveys around the world, highlights the need for biofilm education alongside new, effective anti-biofilm technologies and wound management strategies to help heal wounds more quickly and benefit patients, caregivers, and health care systems. 

Authors: Daniel Metcalf, PhD; and Philip G. Bowler, MPhil

Affiliation: ConvaTec Ltd. (Deeside, Flintshire, UK)

Correspondence: Daniel Metcalf, PhD, ConvaTec Global Development Centre, First Avenue, Deeside Industrial Park, Deeside CH5 2NU, UK; daniel.metcalf@convatec.com

Disclosure: The authors are full-time employees of ConvaTec Ltd. Waggle Dance was paid by ConvaTec to conduct this study. Waggle Dance compensated all participants for their time engaged in providing opinions. The results of this article were presented as a poster at the 2018 Symposium on Advanced Wound Care Fall in Las Vegas, NV.