Chronic Non-Healing Wounds: Biofilm-Based Management Strategies for Faster Healing

Chronic Non-Healing Wounds: Biofilm-Based Management Strategies for Faster Healing

Introduction

A chronic non-healing wound is one that has not progressed through the normal stages of healing in a timely and organized manner, showing little to no improvement within 30 days. All wounds have the potential to become chronic wounds, which may include venous ulcers, diabetic ulcers, and pressure ulcers.

Wound healing phases-Stalled at inflammatory phase

Chronic non-healing wounds are a significant challenge in healthcare, requiring ongoing care and often failing to heal properly despite multiple treatments. One of the main factors contributing to non-healing wounds is the presence of BIOFILM—a protective layer that bacteria create to shield themselves from treatments. It has been reported that 80% to 100% of non-healing wounds have biofilm. Effective biofilm-based wound management is, therefore, crucial for promoting wound healing. This article will explore biofilm’s role in chronic non-healing wounds and strategies for effectively implementing biofilm-based wound care.

What Is Biofilm in Chronic Non- Healing Wounds and Why It Prevents Healing

Biofilm is a community of bacteria that attaches to the surface of a wound, creating a protective matrix that shields the bacteria from the body’s immune system and treatments like antibiotics. In chronic wounds, biofilm forms quickly, often within just a few days, and becomes a major barrier to healing. This protective layer makes the bacteria highly resistant—up to 1,000 times more resistant than free-floating bacteria—to antibiotics and antiseptics, which prevents infections from being properly treated. Biofilm also keeps wounds in a state of constant inflammation due to chronic infection, preventing them from progressing through the natural stages of healing, such as tissue regeneration and wound closure. Consequently, chronic wounds remain stuck in the inflammatory phase and over time, this can lead to complications like spreading cellulitis to the peri-wound skin, systemic infection, or sepsis. Without effective biofilm management, these wounds are unlikely to heal.

Diagram of a biofilm showing bacteria encased within a protective matrix

 Biofilm commonly causes local wound infection, presenting with the following signs and symptoms

• Sloughy tissue
• Necrotic tissue
• Increased levels of exudate
• Friable hypergranulation tissue
• Malodour
• Peri-wound skin redness and swelling’
• pain

How do you detect biofilm?

Biofilms are microscopic structures that are invisible to the naked eye, requiring a high-powered microscope for detection.

Scanning electron micrograph of a bacterial biofilm on a chronic wound

In a clinical setting, tissue biopsy is the most effective method for detecting biofilm. However, biofilm is often tiny and unevenly distributed across the wound bed. A wound may contain different species of biofilm, usually scattered in small, isolated clusters, making them easy to miss during wound biopsy.

A Chronic and sloughy foot wound

The Importance of Biofilm-Based Management in Chronic Non-Healing Wounds

To effectively treat chronic non-healing wounds, wound specialists must focus on addressing biofilm. This requires specialized techniques and treatments that directly target the biofilm by breaking down its matrix layer and making bacteria more susceptible to treatment. Focusing on biofilm-based management can result in improved healing outcomes and reduced infections. The following sections will discuss the best practices for managing biofilm in chronic wounds. The strategies for biofilm-based wound management can essentially be categorised in the following four steps:

Step 1: Cleansing the Wound and Surrounding Skin

Cleansing is crucial for keeping wounds clean. It involves thoroughly cleaning the wound and the surrounding skin to remove debris, bacteria, and residual biofilm. Using an appropriate cleanser is essential; wound specialists often recommend gentle yet effective solutions with antimicrobial properties. Regular cleansing of the wound bed helps maintain a clean wound environment, reduces the risk of infection, and prepares the wound for further treatment. It’s important to clean the surrounding skin as well to prevent the spread of bacteria into the wound.

Step 2: Debridement for Biofilm Removal

Debridement is the process of removing dead, damaged, infected tissue, and biofilm from the wound bed. This step is vital because it exposes healthy tissue, allowing it to regenerate and promotes faster healing. In chronic wounds, regular debridement is essential as it disrupts biofilm and prevents it from re-forming, thus allowing the wound to move beyond the inflammatory phase and begin healing.

There are different types of debridement, including surgical, autolytic, enzymatic, and mechanical methods. The best choice depends on the wound’s condition and the patient’s comfort level.

Addressing Wound Bed Fragility and Pain

Wound specialists need to take into account the delicate nature of the wound and the patient’s pain when performing debridement. Employing the correct technique reduces discomfort and protects the healthy tissue. Managing pain through the use of topical analgesics or carrying out the procedure in phases is crucial to guarantee patient comfort and compliance.

Step 3: Refashioning the Wound Edges

After removing any slough and dead tissue from the wound bed (debridement), it’s often necessary to refashion the edges to help the wound heal properly. This may involve trimming the edges to ensure they are in continuation with the wound bed. The goal is to encourage new skin tissue to grow into the wound and to promote natural wound contraction. Properly managed wound edges help prevent the wound from becoming stagnant and support the healing process. Paying attention to this step is crucial, as well-defined edges can significantly affect how long it takes for the wound to heal.

The refashioning of wound edges

Step 4: Dressing the Wound for Optimal Healing

The proper dressing is important for protecting the wound, keeping it moist, and reducing the risk of infection. Advanced wound dressings are designed to help manage biofilm by maintaining a moist environment and delivering antimicrobial agents. Keeping the right balance of moisture is crucial for healing and prevents biofilm from reforming. Antimicrobial dressings are particularly useful for managing chronic wounds as they can kill bacteria and prevent biofilm from forming again. Many of these dressings contain agents like silver or iodine, which provide continuous protection against biofilm. Selecting the appropriate dressing depends on the size, depth, and exudate level of the wound. Wound specialists often use a step-up or step-down approach, adjusting the dressing type based on the condition of the wound and its healing progress.

Optimizing Skin Surrounding the Wound

Remember that caring for the skin around a wound is as important as caring for the wound itself. Keeping the area moisturized and free of irritants is crucial for promoting healing and preventing the wound from getting worse or new wounds from forming.

Adjunctive Therapies for Biofilm Disruption

Adjunctive therapies, such as negative pressure wound therapy (NPWT) and ultrasound therapy, can help improve biofilm disruption and promote wound healing. NPWT uses suction to remove wound fluid and stimulate tissue growth, while ultrasound therapy employs sound waves to break up biofilm and support healing. These therapies are usually used in combination with debridement, antimicrobials, and dressings to enhance their effectiveness. In cases where biofilm persists despite standard treatment, adjunctive therapies can offer additional support.

Negative Pressure Therapy of Foot Wound

Foot Wound with Healthy Granulation Tissue Following NPWT

Personalized Wound Care Plans

The approach to managing biofilm in chronic wounds should be tailored to each patient. Factors such as the patient’s overall health, the size and location of the wound, and the extent of biofilm should be considered when developing a treatment plan.

Conclusion: The Importance of Biofilm-Based Management in Chronic Wounds

Biofilm is a significant obstacle in healing chronic wounds. Its protective structure allows bacteria to thrive and resist treatment, leading to prolonged wound healing and an increased risk of infection. However, with the right biofilm-based management techniques, healthcare providers can break down biofilm, reduce infections, and promote faster healing.