MSN, GNP BC, CWOCN

Jenny Hurlow MSN, GNP‐BC, [email protected] Heal on Beale

October 28, 2016

This program will provide a review of what we know about wound biofilm and how this knowledge should be impacting clinical practice. This program will include a discussion of real wound cases that have been confirmed by advanced microscopy techniques to contain bacteria in biofilm. This discussion will include clinical information such as wound etiology, chronicity, infection history, and treatment strategies utilized. The question, ‘Can we see bacterial biofilm on a wound?’ will be answered.

Clinical Biofilms - Jenny Hurlow

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1. Reid G, Chan RCY, Bruce AW, Costerton JW. Prevention of urinary tract infections in rats with an indigenous Lactobacillus casei strain. Infect Immunity 1985;49:320‐4.2. James GA. Swogger E. Wolcott R. Biofilms in Chronic Wounds. Wound Repair Regen. 2008 Jan‐Feb;16(1):37‐443. Gurjala AN, Geringer MR, Seth AK, Hong SJ, Smeltzer MS, Galiano RD, et al. Development of a novel, highly quantitative in vivo model for the study of biofilm‐impaired cutaneous wound healing. Wound Repair Regen 2011;19:400‐10

1. Olsen, I. Biofilm‐specific antibiotic tolerance and resistance Eur J Clin Microbiol Infect Dis (2015) 34: 877. doi:10.1007/s10096‐015‐2323‐z2. Metcalf DG, Bowler PG. Biofilm delays wound healing: a review of the evidence. Burns Trauma. 2013;1:5–123. Seth AK, Geringer MR, Hong SJ, Leung KP, Mustoe TA, Galiano RD. In vivo modeling of biofilm‐infected wounds: a review. J Surg Res 2012;178:330–338

(15%) < 25mmHg

(77%) < 20mmHg addition of BBWC.

1. Wolcott RD, Rhoads DD. A study of biofilm‐based wound management in subjects with critical limb ischaemia. J Wound Care 2008;17:145–15


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• Biofilm was found to be involved in a deep sternal infection. 1

• Found in the tissue

• Found on the wires

• Potentially contributing billions to the global cost of chronic wounds! 2

1. Elgharably H, Mann E, AwadH, et al. First evidence of sternal wound biofilm following cardiac surgery. PLoS One 2013;8:e7032. Harding K, Posnett J, Vowden K. A new methodology for costing wound care. Int Wound J. 2013 Dec;10(6):623‐9.

1. . Wolcott RD, Rhoads DD. A study of biofilm‐based wound management in subjects with critical limb ischaemia. J Wound Care 2008;17:145–155

In the study by Wolcott and Rhoads 1

• All wound subjects;• chronic limb ischemia • treated with antibiofilm strategies.

• 77% of these subjects healed.

But only 69% of subjects with concominant diabetes and osteomyelitis healed ..despite same antibiofilm protocol.

Underscores the importance of host and wound environment variables, in addition to biofilm, in delaying healing

• Unlikely that wound chronicity Is simply due to the presence of biofilm

• Wound recalcitrance resulting from a complex, interdependent interaction between a myriad of factors.

Hurlow, J., Couch, K., Laforet, K., Bolton, L., Metcalf, D., Bowler, P. Clinical Biofilms: A Challenging Frontier in Wound Care. Advances in Wound Care. 2015. 4(5): 295‐301


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moisture

1. Hurlow J. Couch K. Laforet K. Bolton L. Metcalf D, Bowler P. Clinical Biofilms: A Challenging Frontier in Wound Care. Adv in Wnd Care. 2015. 4(5). 295‐301. 2. Branda SS, Vik A, Friedman L, Kolter R. Biofilms: The matrix revisited. Trends Microbiol 2005; 13:20‐63. Cunningham A. et al. (2011) Biofilms: The Hypertext. Version 4.5 Retrieved March 23, 2016. http://www.hypertextbookshop.com/biofilmbook/v004/r003/. 4. Metcalf D. Bowler P. Biofilm delays healing: A review o f the evidence. Burns&Trauma. 2013. 1(1). 5‐12.5. Wolcott RD, Rumbaugh KP, James G, Schultz G, Phillips P, Yang Q, et al. Biofilm maturity studies indicate sharp debridement opens a time‐dependent therapeutic window. J Wound Care 2010;19:320‐8.

1. Song T, DuperthuyM, Wai SN. Sub‐Optimal Treatment of Bacterial Biofilms. RamageG, ed. Antibiotics. 2016;5(2):23. doi:10.3390/antibiotics5020023.) 2. Mulcahy H, Charron‐MazenodL, Lewenza S. Extracellular DNA Chelates Cations and Induces Antibiotic Resistance in Pseudomonas aeruginosa Biofilms. PLoS Pathog 2008. 4(11): e1000213. doi: 10.1371/journal.ppat.10002133. Hurlow, J., Couch, K., Laforet, K., Bolton, L., Metcalf, D., Bowler, P. Clinical Biofilms: A Challenging Frontier in Wound Care. Advances in Wound Care. 2015. 4(5): 295‐3014. In vitro observations of biofilm formation beneath a range of antimicrobial wound dressings. Scully R, Hobot J, Walker M, Metcalf D, 2014. Poster presentation at EWMA

Planktonic

24 hours

48 hours

Dispersal

1. Bacteria in biofilm are more TOLERANT of antimicrobials, not RESISTANT to

2. Inflammation: A localized protective response of the body to irritation, injury or destruction of tissue 1

3. Infection: The deposition and multiplication of bacteria in tissue with an associated host immune response 2

1. http://aawconline.org/wp‐content/uploads/2015/10/AAWC‐Quality‐of‐Care‐with‐I‐CVIswebsite‐v3.pdf2. http://www.worldwidewounds.com/2004/january/Collier/Management‐of‐Wound‐infections.htm

In vitro observations of biofilm formation beneath a range of antimicrobial wound dressings. Scully R, Hobot J, Walker M, Metcalf D, 2015. Poster presentation at EWMA

Biofilm will cover surface. It may also penetrate into the tissue. This is then when application of just topical antimicrobials may not work. Hence the need to eradicate the biofilm before this can happen


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1. Jennifer A. Gaddy PhD. Veterans Affairs Tennessee Valley Healthcare Services, Nashville, Tennessee, United States of America & Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA

1. http://aawconline.org/wp‐content/uploads/2015/10/AAWC‐Quality‐of‐Care‐with‐I‐CVIswebsite‐v3.pdf2. Metcalf D. Bowler P. Biofilm delays wound healing: A review of the evidence. Burns&Trauma. 2013. 1(1). 5‐12

1.http://aawconline.org/wp‐content/uploads/2015/10/AAWC‐Quality‐of‐Care‐with‐I‐CVIswebsite‐v3.pdf2. Metcalf D. Bowler P. Biofilm delays wound healing: A review of the evidence. Burns&Trauma. 2013. 1(1). 5‐12


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Biofilm or Slough?

48 yr old diabetic female R med calf infected wound

Opaque film, atraumatically debrided but reformed daily under proteolytic enzyme.

With regular biofilm debridment, antiseptic cleanser, absorptive silver dressing, and IV antibiotics this wound eventually healed 1

1. Hurlow J. Bowler P. Clinical Experience with Wound Biofilm and Management: A Case Series ‐Ostomy Wound Manage. 2009 Apr;55(4):38‐49

Commonly used for tissue examination analyze architecture, cell

proliferation, and immune cell infiltrate.

However, can also stain DNA or RNA, to identify potential microbes infecting tissues.

H & E stained sections landmarks for possible areas of microbial colonization

H & E: Hematoxylin and Eosin Stain


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Hurlow J. Blanz E. Gaddy J. Clinical Investigation of Biofilm in Non‐healing Wounds by High Resolution Microscopy Techniques. J Wound Care. 2016. 26. In Press

1. http://www.hypertextbookshop.com/biofilmbook/v004/r003/ Last accessed August 2016. 2. Leaper DJ, et al. Extending the TIME concept: what have we learned in the past 10 yrs. Int Wound J. 2012;9 Suppl 2:1‐19. doi: 10.1111/j.1742‐481 2.

Bacterial biofilms:

• Sugar coated bacteria. Not dead protein.

• To form a biofilm, microorganisms must "glue" themselves to a surface 1

• Autolysis: Moistens necrotic tissue,allowing degradation by host enzymes 2

• Moisture can ADD integrity to a biofilm.1


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Hurlow J. Blanz E. Gaddy J. Clinical Investigation of Biofilm in Non‐healing Wounds by High Resolution Microscopy Techniques. J Wound Care. 2016. 26. In Press

Will more systemic antibiotics aid healing?

Patchy yeast biofilm

Challenged with moisture management, expired dressing efficacy, PAD, recurrent antibiotics, debridement


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Large gram‐negative rod (Acinetobacterbaumannii) biofilm

Large streptococcal/staphylococcal biofilmLarge

mixed‐speciesbiofilm

Challenged with moisture management, expired dressing efficacy, debridement

Clinical Investigation of Biofilm in Non‐healing Wounds by High Resolution Microscopy Techniques

• Venous stasis ulcer L leg. 5 yrs chronicity.

• H/o osteomalacia, Lupus, arterial flow WNL.

• On IV antibx by her PCP for PA wound infection

• Treatment: silver gelling fiber dressing covered by hydroconductive, non gelling fiber dressing, then an absorptive cotton padding, secure with 4 layer elastic compression.

• Inconsistent sharp debridment but used antiseptic wound cleanser.


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Pseudomonas biofilm

• Recalcitrant infection despite guided IV antibiotics!

• Amputation

Challenged with moisture management, expired dressing efficacy, debridment

• Paraplegic with unstable crusted lesions over L shin of edematous L leg which reportedly started as blisters.

• Poorly managed diabetic, ABI WNL.

• Wound culture revealed MRSA.

• Confessed to inconsistent adherence to treatment strategy; cadexomer iodine gel, wrap compression and elevation.


• Staph biofilm tightly embedded in a thick matrix that is both fibrous, and sheet‐like.

• 1.5‐3.4 mm in thickness

• Consistent with culture results indicating patient is chronically colonized with MRSA


Challenged with moisture management, dry wound healing


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Scab

1. Association for Advanced Wound Care (AAWC) Wound Glossary. Released to membership April. 2012. http://aawconline.org/wp-content/uploads/2012/01/AAWC-Quality-of-Care-with-I-CVIswebsite-v3.pdf. Accessed April 20162. Park, E., Long, S.A., Seth, A.K., Geringer, M., et al. The use of desiccation to treat Staphylococcus aureus biofilm infected wounds. Wound Repair Regen. 2015. doi: 10.1111/wrr.12379. 3. Zhao G, et al. Biofilms and Inflammation in Chronic Wounds. 2013. ADVANCES IN WOUND CARE, VOLUME 2, NUMBER 7. pg 389-399

1. Hurlow J. Blanz E. Gaddy J. Clinical Investigation of Biofilm in Non‐healing Wounds by High Resolution Microscopy Techniques. J Wound Care. 2016. 26. In Press

Challenged with moisture management, expired dressing efficacy, debridement

Macroscopic staphylococcal biofilm (thickness, 1‐2.8 mm) reformed weekly under CTP

Wall ofstaph!


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Silver nanoparticle polyurethane foam dressing

saturated with wound exudate

Biofilm Algorithm

Metcalf D, et al. A clinical algorithm for wound biofilm identification. J Wound Care. 2014. 23(3). 137-142

Biofilm Algorithm

Metcalf D, et al. A clinical algorithm for wound biofilm identification. J Wound Care. 2014. 23(3). 137-142


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1. Rhoads D, et al. Biofilms in wounds: management strategies. JOURNAL OF WOUND CARE 20008, 17( 1 1), 502‐5082. Tam, A. et al. Effect of different iodine formulations on the expression and activity of Streptococcus mutans glucosyltransferase and fructosyltransferase in biofilm and planktonic environments. Journal of Antimicrobial Chemotherapy (2006) 57, 865–871.3. Chaw KC, et al. Role of Silver Ions in Destabilization of Intermolecular Adhesion Forces Measured by Atomic Force Microscopy in Staphylococcus epidermidis Biofilms. ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Dec. 2005, p. 4853–4859.

AutolyticDebridment

MechanicalDebridment

SharpDebridment

. Urish KL. DeMuth PW. Craft DW. Haider H. Davis CM. Pulsed lavage is inadequate at removal of biofilm from the surface of total knee arthroplasty materials J Arthroplasty. 2014

• Differs from management of host ‘slough’.

• Frequency?

• Regular debridment, doesn’t remove all of biofilm


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• Antiseptic dressings are effective against planktonic bacteria

• In vitro studies have shown that both silver and iodine wound dressings have some ability to kill bacteria in biofilm, the body of evidence is inconsistent 1‐5

• Are topical antibiotics ok?

1. Oduwole, K.O., Glynn, A.A., Molony, D.C., Murray, D., Rowe, S., Holland, L.M., McCormack, D.J., O'Gara, J.P. Anti‐biofilm activity of sub‐inhibitory povidone‐iodine concentrations against Staphylococcus epidermidis and Staphylococcus aureus. J Orthop Res. 2010. 28(9):1252‐6.2. Kalishwaralal, K., BarathMani Kanth, S., Pandian, S.R., Deepak, V., Gurunathan, S. Silver nanoparticles impede the biofilm formation by Pseudomonas aeruginosa and Staphylococcus epidermidis. Colloids Surf Biointerfaces. 2010. 79(2):340‐4.3. Kostenko, V., et al. Impact of Silver‐Containing Wound Dressings on Bacterial Biofilm Viability and Susceptibility to Antibiotics during Prolonged Treatment. Antimicrob. Agents Chemother. 2010. 54:125120‐5131

4. Percival, S., McCarty, S. Silver and alginates: Role in wound healing and biofilm control. Adv Wound Care. 2015. 4(7): 407‐414 5. Bourdillon, K. Dressings and biofilms: interpreting evidence from in vitro biofilm models. Wounds International. 2016. 7(1): 9‐14

Silver nanoparticle polyurethane foam dressing saturated with wound exudate

Significantly ischemic L lateral leg traumatic ulcer. After removal of polyurethane foam dressing


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Iodoflex – 24 hours (x500 mag.) Spheres = cadexomer beads; biofilm growing on them

Iodoflex – 24 hours (x5,000 mag.) Sphere = cadexomer bead; biofilm growing on it


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1. Rhoads D, et al. Biofilms in wounds: management strategies. JOURNAL OF WOUND CARE 20008, 17( 1 1), 502‐5082. Tam, A. et al. Effect of different iodine formulations on the expression and activity of Streptococcus mutans glucosyltransferase and fructosyltransferase in biofilm and planktonic environments. Journal of Antimicrobial Chemotherapy (2006) 57, 865–871.3. Chaw KC, et al. Role of Silver Ions in Destabilization of Intermolecular Adhesion Forces Measured by Atomic Force Microscopy in Staphylococcus epidermidis Biofilms. ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, Dec. 2005, p. 4853–4859.

Questions?

Thank you!


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MSN, GNP BC, CWOCN

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