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Biofilm: Why it matters to wound care and treatment innovations to fight it

You know that fuzzy film you sometimes feel on your teeth first thing in the morning? That’s biofilm. Dentists refer to it as plaque and have long understood its negative effects on the health of your teeth. They encourage daily brushing and flossing to effectively manage biofilm growth.1

But what about biofilm in wounds?

Biofilm has only been a buzzword in wound care for the past two decades or so, but it has taken on vital importance in the war against challenging wounds.2

Biofilms are communities of bacteria that are covered in a polysaccharide matrix. That translates to a slimy barrier of sugars and proteins. Almost all hard-to-heal wounds have some amount of biofilm.3, 4

of non-healing wounds may contain biofilm 5

How does biofilm impact wound healing?

The frustrating part for your work on wounds is that biofilms are notoriously tolerant to antibiotics and seemingly protected from the patient’s natural immunities, which contributes to the wound’s chronic character.

In fact, studies show that biofilm bacteria can be up to a 1,000 times more resistant to antibiotics than free-floating bacteria of the same species.6

“We are just now seeing more and more research into how biofilm can affect a body’s ability to heal wounds and what treatments can most effectively create an optimal wound healing environment,” says Medline Clinician Katie James BA, RN, CWCN

Biofilm formation

There are three stages to biofilm formation:3, 7, 8

  1. Attachment: First, planktonic, or free-floating, bacteria attach themselves to the wound.
  2. Colonization: Given the time and opportunity, bacteria band together into a diverse community that changes to promote its own survival.
  3. Critical colonization: This is the mature state of biofilm when it secretes its slimy covering known as the extracellular polymeric substance (EPS), serving as powerful protection against the patient’s immune system and traditional antimicrobials.

Following that last step, a fourth step often occurs when free-floating bacteria may then detach from the structure to form new colonies. When that happens, the person’s immune system responds again, creating a “chronic relapsing infection.”9

Dr. Gregory Schultz provides details about biofilm formation in this webinar, available for download now.

Learn more

When to suspect biofilm

Biofilm is sneaky because routine lab tests can not differentiate between floating bacteria and attached biofilm even exist to detect it, and it’s often growing under the surface of the wound.10

“Trying to see biofilm with your naked eyes is like trying to see the wind. In reality, we only see the result of the wind.”
– John P. Kennedy, RPh, PhD, research professor, South University School of Pharmacy, and consultant to Medline Industries

What you see: stalled wound healing. The unique structure and EPS barrier of biofilm kills tissue in a slow, steady process that, if gone unchecked, can have devastating consequences. “The end result is typically some type of surgical removal of degraded tissues,” explains Dr. Kennedy. “In wound care, too often, that could mean amputation.” Before biofilm gets the upper hand, look out for qualities in the wound that might signal its existence.

Clues to biofilm formation

The International Wound Infection Institute’s Consensus Update 2016 on Wound Infection in Clinical Practice outlines some criteria that can help you identify potential biofilm formation on your patients’ wounds:4

  • Failure of appropriate antibiotic treatment
  • Resistance to appropriate antimicrobial treatment
  • Recurrence of delayed healing after antibiotic treatment
  • Delayed healing despite optimal wound management and health support
  • Increased exudate or moisture
  • Low-level chronic inflammation
  • Low-level erythema
  • Poor granulation or friable/hypergranulation
  • Secondary signs of infection

Tools to treat biofilm

Standardizing a treatment protocol may help manage biofilm on a wound to help wound healing. “Since biofilm is found in such a high population of chronic wounds, it has to be a part of any discussion regarding wound healing and treatment practices today,” James says. In addition to the negative effects for the patient, James notes, “The longer it takes to heal a wound, the increased cost to heal that wound.” The right treatment can speed your patient’s healing time and reduce expenses for your patients and the healthcare facility.

Treating biofilm can be situational. The three tactics below are not a linear timetable, but rather offer an interactive approach.

3 tools for the effective management of biofilm:4, 11, 12

Debridement – Sharps debridement helps disrupt biofilm in the wound and promotes wound healing.

Topical antibacterial - Keep biofilm at bay by creating a cleaner wound bed with a topical antibacterial like iodine, delivered through an iodophor foam dressing, such as IoPlex.
Disrupt biofilm - A concentrated surfactant such as PluroGel can help soften, loosen and lift debris away from the wound bed. You can use it in between and after debridement to help reduce the possibility of biofilm reformation. Read more about how surfactant-based wound dressings can help manage biofilm.

“With the ability to have a controlled release platform, IoPlex has become
an effective agent in managing the biofilm activity.”

– Katie James, BA, RN, CWCN, Medline clinician

The strength of iodine as an antibacterial

Iodine has been used in wound care since the American Civil War. Scientists believe that its value is related to its ability to penetrate the cell wall of micro-organisms.13 While silver has been a standard in hard-to-heal wound care, numerous in-vitro studies show that iodine is better at controlling biofilm than other antibacterial agents.14

“There are only a few true antibacterials on the market, and silver has been the number one go-to, even though iodine actually has a broader spectrum of effectiveness than silver,” James explains. “The problem with iodine is that, alone, it is also cytotoxic, meaning that it kills the good with the bad. Now, with the ability to have a controlled release platform, IoPlex has become an effective agent in managing the biofilm activity.”

Key takeway

Biofilm may be to blame for hard-to-heal wounds—and one of the reasons why your job is so important. Although treating biofilm is tricky because of its tolerance to typical antibiotics, if you know the signs to look for and the right products to use, you can help improve healing outcomes for your patients. Product innovations to manage biofilm, such as the effective use of iodine, could be your secret weapon.

More about advances in the use of iodine
Harnessing the antibacterial power of iodine has given nurses another tool to battle against biofilm. IoPlex works by releasing iodine over a sustained period of time. You can’t stop when you feel better; you have to finish the multi-day course, because the bacteria are still there, waiting to grow freely again. In its form as a polyvinyl alcohol foam dressing complexed with iodine, IoPlex releases iodine in a controlled way, reducing cytotoxicity. Pre-moistened, the dressing also changes color to alert you when the iodine has been depleted.
Target biofilm with iodine
Manage biofilm through slow-release iodine in IoPlex Iodophor Foam Dressing, based on in vitro studies.
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