Special Contribution on Biofilm in Wounds from Leonard Schembri

The Wound Centre^© has received another wonderful contribution from Leonard Schembri in Malta.

I would like to thank Leonard for his dedication in writing this  - a significant contribution about Biofilm.

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BIOFILM/S AND WOUNDS

Leonard Schembri S.N., R.N. (Aust.), B.Nsg. (Aust.), B.A., T.E.F.L.

Phytotherapeutical Studies (Brazil).

A biofilm is a collection of microbial cells that are attached to a surface and embedded in a self-produced extrapolymeric substance. (Davis et. al. 2008). Bacterial biofilms cause or complicate numerous medical conditions, including chronic wounds. (Wolcott & Rhoads 2008).

The biofilm has become a common occurrence in wounds and this poses a big challenge to all the Nurses and Doctors. Unfortunately, many Health Professionals still do not know how to manage a biofilmed wound.

There are different schools of thought of how and why a biofilm is formed. Be that as it may, this short article is not about the how and why. It is about different methods of “how to remove” the biofilm from wounds whether they’d be acute or chronic.

All the information below is from the author’s experience.

First method A biofilm could easily be removed with sterile plastic forceps. The procedure itself is, many a time, painless. However, with certain types of wounds, for example, an arterial leg ulcer (below the knee), this simple procedure could be painful.

The problem of pain could be overcome by either one of the following two methods explained below.

1. a. The application of Emla Cream (a local anaesthetic) on top of and around the wound. Then the Health Practioner has to wait an hour for the cream to absorbed. Waiting for two hours is better.
2. b. If the pain is excessive, in addition to the Emla Cream, the Nurse (or other Health Practioner), can apply Lignocaine 1% solution. The vial’s transparent solution is placed onto two layers of gauze and then the wet gauze is applied over the wound and its immediate and surrounding healthy tissue. This is left in place for 2 minutes or slightly longer. Soon afterwards, the Nurse can start to remove the biofilm with a sterile scoop or the edge of a sharp blade.

Second method Another method which is liked by some Health Practioners is the application of Negative Therapy Pressure (NPT) or Vacuum Assisted Closure (VAC).

This, we have found, could be applied over a stubborn biofilm where the Nurse finds it extremely difficult to remove. After one or two applications of this therapy, the biofilm is removed.

Unfortunately, the biofilm has the tendency of returning (recalcitrance) once the therapy is stopped. Thus it is important to apply a suitable dressing or to continue with the use of NPT or VAC to prevent the biofilm from reforming.

Third method Prontosan is a new solution for biofilms. This solution is first placed on a couple of sterile gauze swabs and then applied over the wound and left in situ for 15 minutes.

This is meant to break up the biofilm or eat away, as it were, at the film and the bacteria underneath. It ought to be mentioned at this stage, that the first method (mentioned above) is first carried out and is then followed by using this method. To compliment the Prontosan solution, B. Braun has come up with Prontosan Gel.

This gel is to prevent the formation of a further biofilm or to continue the action of breaking the biofilm, that is, killing the bacteria underneath. Once the wound is free from the biofilm, the gel enhances granulating tissue.

If, on the other hand, the biofilm is thick and stubborn and  the Health Practioner can still see the biofilm present on the wound, then s/he can remove the biofilm with either a scoop or a sharp blade some 2 to 3 weeks after the application of the solution and gel. The combination of these two products seems to dislodge easier the film from the surface of the wound bed.

Fourth method A super-oxygenated environment is good for healthy tissue and bad for biofilms. (Wolcott 2008). Thus, hyperbaric oxygen is one method of combating biofilms. Even though this idea might be a good idea for diabetic ulcers with recurring biofilms, it has not as yet been accepted by our peers.

Nurses still need to promote “research marketing”, so to speak, with surgical and medical staff; research marketing which is based on anecdotal research and further up the ladder of research.

Fifth method The Cutimed Sorbact dressing – This dressing, which could be left in situ for up to one week, is applied over the biofilmed wound. However, the secondary dressing is changed regularly, that is, when there is too much discharge. The dressing captures the bacteria and inactivates their activity (sequestration).

It is an easy dressing to apply and does not require any special technique of application. It ought to be mentioned, that the first method (mentioned above) is first carried out and is then followed with the use of this dressing. It has been observed that this dressing is better used once there is no biofilm as it prevents the formation of the biofilm.

Sixth method Another simple and straightforward method is to obtain a brand new sterile toothbrush. The Health Practitioner can clean the biofilmed wound with the toothbrush under running water. S/he can refer to the guidelines of the first method, referred to above, if the patient is in pain or experiences pain during the procedure.

This method is partially successful but it aids at removing the thickness of the biofilm. To check the efficacy of the procedure, it might be a good idea to do half of the wound at first and compare this with the rest of the wound. Either one of the methods referred to above can then be applied.

Future wound dressings Presently, it is common practice not to use any other anti biofilm agents. This is because there are no specific commercial wound dressings on the market for biofilms.

However, there are potential anti biofilm agents which still need be explored and researched in the treatment for wound biofilms.

According to various authors, some of these chemical and natural agents are: Lactoferrin, Xylitol, Gallium, Dispersin B and Honey (Manuka)* (Percival et. al. 2010). In the author’s opinion, there are no anti biofilm wound dressings; at least, not in Malta.  We hope to witness, in the future, some new form of wound dressing with these agents.

This gives manufacturers the opportunity to explore and experiment with new products.

In the case of mouth biofilms, the author does not know whether there are any of the agents (mentioned above) which could be used against biofilms.

It would be interesting to find out what Dentists use when there is a biofilm in the mouth and the reason of using one agent over the other.

The methods and the chemical/natural agents used by Dentists could be adopted by Nurses and Doctors which might lead to a breakthrough in the treatment for wound biofilms.

* In some instances, Manuka Honey was used against MRSA in Mater Dei Hospital. This is not the case any longer as silver dressings have been introduced since then. There is a Honey dressing on the market but it does not specify that it is Manuka Honey. From the author’s experience, a commercial wound dressing is a sterile manufactured product where the Health Professional user opens the dressing and lays it over the wound to help/assist the wound to heal in the shortest time possible.

References: Davis S.C. et. al., Microscopic and physiologic evidence for biofilm-associated wound colonization in vivo. Wound Repair Regen. 2008 Jan-Feb; 16(1):23-9.

Percival S.L., Cutting K.F., Williams D., Biofilms: possible strategies for suppression in chronic wound. Nursing Standard Autumn 2010.

Wolcott R.D., Rhoads D.D., A study of biofilm-based wound management in subjects with critical limb ischaemia. J Wound Care. 2008 Apr;17(4):145-8, 150-2, 154-5. _______________________________________________________________________________________________

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