Clinical Experience with Wound Biofilm and Management: A Case Series
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Abstract: Biofilm is a relatively new concept in the fields of infectious disease, wound infection, and healing. Although scientific research and “noise” regarding wound biofilm is increasing, little is known about the presentation, diagnosis, potential implications, and management strategies regarding wound biofilms. A series of four clinical cases is utilized to demonstrate the existence of wound biofilm. All patients presented with or developed a film on the wound bed that appeared to be distinct from slough; wounds also were failing to progress. Although the slough in some of the wounds was easily removed with traditional debridement methods, removal of the film required physical disruption with a curette or dry gauze. All wounds eventually progressed to healing. Considering the biofilm concept and available preclinical research, it is evident from this small case series that the appearance of biofilm in wounds is quite different from slough and requires different management strategies for its control. The evolving biofilm paradigm could profoundly change approaches to wound management. Additional research is needed in this evolving aspect of wound management.
The need to consider wound biofilm is likely to be new to a majority of wound care practitioners. However, they all may have encountered wound biofilm without being aware of its potential implications. Biofilm is found everywhere — in the slime growing on the inside of a flower vase, as plaque growing on the surface of unclean teeth, and as the gunk that clogs household drainpipes. Biofilm can form on virtually any natural or man-made surface; in medicine, infections such as periodontal disease, endocarditis, and otitis media all involve biofilm, as do infections associated with foreign bodies such as contact lenses, sutures, and catheters.1 All of these infections involve bacteria sticking to a tissue surface and the subsequent formation of a complex polymicrobial community within a micro-environment that provides protection from the outside world. This is biofilm, an entity most likely to form where substrate, moisture, nutrition, and stasis combine. A skin ulcer potentially provides an ideal environment for biofilm development.
The concept of biofilm was first described in detail in 1978.2 Although bacteria are perhaps most widely thought of as free-living (planktonic) or floating single cells that exist within the air or in aqueous environments, the most natural environment for a bacterium involves attaching to a surface and existing within a community of bacterial cells. It is now recognized that the physical and behavioral (phenotypic) characteristics of bacteria within a surface-attached biofilm community are very different from those exhibited by free-living bacterial cells. Where free-living bacteria are metabolically active and often highly susceptible to antimicrobial agents (including antibiotics and biocides) and immune cells, biofilm bacteria often adopt a sessile behavior with a significantly reduced growth rate that has been found in in vitro studies3 to result in a slower uptake of antimicrobial agents.3 Additionally, scientific studies have shown that once attached to a surface, biofilm bacteria produce an outer protective matrix (exopolymeric substance [EPS]) that acts as a physical barrier to permeation and action of antimicrobial agents.
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