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Biofilms in wounds

Wound infection is defined by the presence of microorganisms in sufficient number or virulence to cause a host response locally and/or systemically1. Wound infection thus is a complex interplay between the infecting microorganism and the host immune response. Implementation of effective strategies to prevent, diagnose and manage wound infection, is important in reducing patient morbidity and mortality1.

Recent studies indicate that biofilms can be found in 60-100% of non-healing wounds. Biofilms are known to cause infection, inflammation and delayed wound healing4,27. The exact definition of a biofilm has been extensively debated within the scientific community for some time, but most scientists now agree that biofilms can be described as clusters of bacteria and fungi in a matrix, self-produced or of host origin4. Biofilms can be both surface attached and non-surface attached as for instance those found embedded in the wound environment.

Confocal laser scanning microscopy (CLSM) on biopsies from an infected porcine woundmodel (P. aeruginosa)

Pig tissue (eukaryotic cells) is stained with DAPI (blue) and the microorganisms/biofilms are stained with a specific PNA-FISH for bacteria only (red).

Figure 1

Biofilms are characterised by increased tolerance towards antimicrobials, antibiotics and the host immune cells compared to planktonic microorganisms. Planktonic and biofilms are two different microbial growth forms, each with different characteristics and susceptibility towards treatment. Planktonic microorganisms are free-floating, single cells that are generally easier to kill with antibiotics and antimicrobials and for the immune cells 28,29. In the past, most knowledge of microorganisms and treatment strategies were based on studies of these planktonic microorganisms grown in laboratory flask cultures. Recent studies and knowledge of the presence and importance of biofilms in non-healing wounds require the implementation of biofilm strategies into antimicrobial product development and evaluation.

Reference list

See full list of references

1. International Wound Infection Institute (IWII). Wound infection in clinical practice. Wounds International. 2016.

2. Coloplast A/S, ReD associates. Data on file. 2014.

3. Schultz G, Bjarnsholt T, James GA, Leaper DJ, McBain AJ, Malone M, et al. Consensus guidelines for the identification and treatment ofbiofilms in chronic nonhealing wounds. Wound Repair and Regeneration. 2017;25(5):744-57.

4. World Union of Wound Healing Societies (WUWHS). Florence Congress, Position Document. Management of biofilm. 2016.

5. Appropriate use of silver dressings in wounds. An expert working group consensus. International consensus. London; 2012.

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7. Rodriguez-Arguello J, Lienhard K, Patel P, Geransar R, Somayaji R, Parsons L, et al. A Scoping Review of the Use of Silver-impregnatedDressings for the Treatment of Chronic Wounds. Ostomy Wound Management. 2018;64(3):14-31.

8. Dissemond J, Bottrich JG, Braunwarth H, Hilt J, Wilken P, Munter KC. Evidence for silver in wound care - meta-analysis of clinical studiesfrom 2000-2015. Journal of the German Society of Dermatology. 2017;15(5):524-35.

9. Norman G, Westby MJ, Rithalia AD, Stubbs N, Soares MO, Dumville JC. Dressings and topical agents for treating venous leg ulcers.Cochrane Database of Systematic Reviews. 2018(6):1-289.

10. Münter KC, Beele H, Russell L, Crespi A, Grochenig E, Basse P, et al. Effect of a sustained silver-releasing dressing on ulcers with delayedhealing: the CONTOP study. Journal of wound care. 2006;15(5):199-206.

11. Jørgensen B, Price P, Andersen KE, Gottrup F, Bech-Thomsen N, Scanlon E, et al. The silver-releasing foam dressing, Contreet Foam,promotes faster healing of critically colonised venous leg ulcers: a randomised, controlled trial. International wound journal. 2005;2(1):64-73.

12. Rayman G, Rayman A, Baker NR, Jurgeviciene N, Dargis V, Sulcaite R, et al. Sustained silver-releasing dressing in the treatment of diabeticfoot ulcers British Journal of Nursing. 2004;14(2);109-14.

13. Humbert P, Zuccarelli F, Debure C, Vendeaud Busquet F, Bressieux J-M, Bedane C, et al. Leg Ulcers Presenting Local Signs of Infection:Interest of Biatain Argent Wound Dressing. Journal des Plaies et Cicatrisations. 2006;52(9):41-7.

14. Lázaro-Martínez JL, Álvaro-Afonso FJ, García-Álvarez Y, García-Morales E, Sanz-Corbalán I, Molines-Barroso RJ. Clinical and microbiologicaleffectiveness of a hydropolymer alveolar dressing with ionic silver complex and silicone adhesive. Poster, EWMA(EPP021); 2018.

15. Leaper D, Münter C, Meaume S, Scalise A, Mompó NB, Jakobsen BP, et al. The Use of Biatain Ag in Hard-to-Heal Venous Leg Ulcers:Meta-Analysis of Randomised Controlled Trials. PLoS ONE. 2013;8(7):e67083.

16. Jemec GB, Kerihuel JC, Ousey K, Lauemoller SL, Leaper DJ. Cost-Effective Use of Silver Dressings for the Treatment of Hard-to-HealChronic Venous Leg Ulcers. Plos One. 2014;9(6):e100582.

17. Mouës C, Heule F, Legerstee R, Hovius S. Five Millennia of Wound Care Products - What is New? A Literature Review. Ostomy WoundManagement. 2009;55(3):16-8.

18. Sibbald R, Williamson D, Orsted H, Campbell K, Keast D, Krasner D, et al. Preparing the Wound Bed - Debridement, Bacterial Balance, andMoisture Balance. Ostomy Wound Management. 2000;46(11):14-35.

19. Adderley UJ. Managing wound exudate and promoting healing. British Journal of Community Nursing. 2010;15(3):15-20.

20. Christiansen C, Huniche GB, Allesen-Holm M. In vitro evaluation of a silver foam dressing with and without silicone adhesive againstbiofilms and a broad range of microorganisms. Poster, EWMA(EPP025); 2018.

21. Lansdown AB. Silver in health care: antimicrobial effects and safety in use. Current Problems in Dermatology. 2006;33:17-34.

22. Percival SL, Thomas J, Linton S, Okel T, Corum L, Slone W. The antimicrobial efficacy of silver on antibiotic-resistant bacteria isolated fromburn wounds. International wound journal. 2012;9(5):488-93.

23. Böttrich JG, Brill FHH, Dissemond J, Steinmann J, Münter KC, Schümmelfeder F, et al. A Systematic Review of the Risk of BacterialResistance to Silver. Poster, EWMA; 2018.

24. Percival SL, Woods E, Nutekpor M, Bowler P, Radford A, Cochrane C. Prevalence of Silver Resistance in Bacteria Isolated from DiabeticFoot Ulcers and Efficacy of Silver-Containing Wound Dressings. Ostomy Wound Management. 2008;54(3):30-40.

25. Kostenko V, Lyczak J, Turner K, Martinuzzi RJ. Impact of Silver-Containing Wound Dressings on Bacterial Biofilm Viability and Susceptibilityto Antibiotics during Prolonged Treatment. Antimicrobial Agents and Chemotherapy. 2010;54(12):5120-31.

26. Burger C, Lemoult S, Andersen MB. Silver release profile and antibacterial effect of a new silver foam dressing with silicone adhesive.Poster, EWMA(EPP025); 2018.

27. Malone M, Bjarnsholt T, McBain AJ, James GA, Stoodley P, Leaper D, et al. The prevalence of biofilms in chronic wounds: a systematicreview and meta-analysis of published data. Journal of wound care. 2017;26(1):20-5.

28. Bjarnsholt T. The Role of Bacterial Biofilms in Chronic Infections. Acta pathologica, microbiologica, et immunologica Scandinavica.2013;121(s136):1-58.

29. Costerton JW. Bacterial Biofilms: A Common Cause of Persistent Infections. Science. 1999;284(5418):1318-22.

30. Crone S, Garde C, Bjarnsholt T, Alhede M. A novel in vitro wound biofilm model used to evaluate low-frequency ultrasonic-assisted wounddebridement. Journal of wound care. 2015;24(2):64-72.

31. Bessa LJ, Fazii P, Di Giulio M, Cellini L. Bacterial isolates from infected wounds and their antibiotic susceptibility pattern: some remarksabout wound infection. International wound journal. 2013;12(1):47-52.

32. Yin HQ, Langford R, Burrell RE. Comparative Evaluation of the Antimicrobial Activity of ACTICOAT Antimicrobial Barrier Dressing. Journalof Burn Care & Rehabilitation. 1999;20(3):195-200.

33. ASTM E2149-13a, Standard Test Method for Determining the Antimicrobial Activity of Antimicrobial Agents Under Dynamic ContactConditions. ASTM International. 2013.

34. prEN16756 (draft). Antimicrobial wound dressings – Requirements and test methods. 2014.

35. Howell-Jones RS, Wilson MJ, Hill KE, Howard AJ, Price PE, Thomas DW. A review of the microbiology, antibiotic usage and resistance inchronic skin wounds. Journal of Antimicrobial Chemotherapy. 2005;55(2):143-9.

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38. Thomas S. Laboratory findings on the exudate-handling capabilities of cavity foam and foam-film dressings. Journal of wound care.2010;19(5):192-9.

39. White R, Cutting KF. Modern exudate management: a review of wound treatments. Poster, EWMA(EPP025); 2018.

40. Romanelli M, Vowden K, Weir D. Exudate management made easy. Wounds International. 2010;1(2):1-6.

41. Andersen MB. Comparison of 24 hours fluid handling and absorption under pressure between four wound dressings with Ag and siliconeadhesive. EWMA(EP296); 2016.

42. Baños AM, Nogueras FI, Palomar LF. Clinical evaluation of a silver dressing in the treatment of infected and colonized ulcers. Revista deenfermería. 2008;31(3):42-8.

43. Senet P, Bause R, Jorgensen B, Fogh K. Clinical efficacy of a silver-releasing foam dressing in venous leg ulcer healing: a randomisedcontrolled trial. International wound journal. 2014;11(6):649-55.

44. Flanagan M. Wound measurement: can it help us to monitor progression to healing? Journal of wound care. 2003;12(5):189-94.

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