Biofilm pathways: assessment and management

It has been reported that between 80–100% of ‘hard-to-heal’ wounds are associated with the presence of a biofilm (Bjarnsholt et al, 2008; Malone et al, 2017). Biofilms in wounds impede healing and increase the risk of repeated infection (Bjarnsholt et al, 2008; Metcalf et al, 2013).

This article outlines the definition, main components and examples of a biofilm pathway, and discusses the clinical assessment and management of a biofilm in hard-to-heal wounds.

What is a biofilm?

According to the World Union of Wound Healing Societies (WUWHS, 2016):

It has been suggested that biofilms consist of a complex community of microorganisms, which attach to surfaces and are encased within

There is a debate around whether biofilms, which are microscopic in nature, can be seen with the naked eye. In biofilm formation associated with hard-to-heal wounds, visual cues may indicate the presence of a biofilm, such as a shiny, translucent, slimy layer on the wound surface and the presence of slough or fibrin and gelatinous material which reforms quickly after removal (Lenselink and Andriessen, 2011; Hurlow and Bowler, 2012). Nonetheless, there is currently no ‘gold standard’ diagnostic test to define the presence of a wound biofilm or any identified quantifiable biomarkers (WUWHS, 2016; International Wound Infection Institute (IWII), 2022).

Various methods to visualise biofilm from tissue samples have been reported, such as the use of high-powered microscopes (scanning electron microscopy, fluorescence microscopy) alone or in combination with molecular DNA sequencing techniques, which use fluorescent probes to determine the presence or absence and location of bacteria (WUWHS, 2016; IWII, 2022).

As

Identifying non-healing, chronic or hard-to-heal wounds

Stagnant, chronic or hard-to-heal wounds are wounds that do not heal as anticipated or that show only minor improvements with appropriate standard care – including the use of prescribed antibiotics. These wounds often do not heal as a result of complications such as dehydration, increased bacterial burden, infection or the presence of comorbidities that could be adversely affecting the healing process (Collier, 2023).

Suspected biofilm

• Refer to local guidance on wound cleansing, debridement and the use of antimicrobials
• Manage with regular debridement and vigorous cleansing, 2–3 times a week or as clinically dictated
• Cleanse the wound, ideally with a product that has an antimicrobial effect and contains a surfactant, for example Prontosan (referring to manufacturer’s instructions for use) (Collier and Hofer, 2017)
• Debride further with monofilament fibre debridement technology, for example Debrisoft (refer to manufacturer’s instructions for use) (National Institute for Health and Care

Potential risks and complications associated with a biofilm pathway include:

• Patient reactions to wound cleansing solutions and topical antimicrobial dressing products – check manufacturer’s instructions and the patient’s previous wound history before use
• Surgical debridement – bleeding, involvement of other anatomical tissues or structures, delayed healing (a hard-to-heal wound), complications associated with anaesthesia
• Sharp debridement – bleeding, removal of healthy tissue, pain, increased risk of infection
• Mechanical debridement – non-selective, removes both viable and non-viable tissue

Nurses can use the information outlined in this article to evaluate the biofilm pathway in their healthcare setting – is it evidence-based? Is it up to date? If a pathway is not established, nurses should consider speaking to their manager and colleagues about the need for prompt development of a biofilm pathway.

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 1: Procedures for assessing people’s needs for person-centred care

1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages

Part 2: Procedures for the planning, provision and management of person-centred nursing care

4. Use evidence-based, best practice approaches for meeting the needs for care and support with hygiene and the maintenance of skin integrity, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions and

9. Use evidence-based, best practice approaches for meeting needs for care and support with the prevention and management of infection, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions

European Wound Management Association (EWMA)
International Wound Infection Institute (IWII)
World Union of Wound Healing Societies (WUWHS)

References

Bjarnsholt T, Kirketerp-Møller K, Østrup Jensen P et al. Why chronic wounds will not heal: a novel hypothesis. Wound Repair Regen. 2008;16(1):2–10. https://doi.org/10.1111/j.1524-475x.2007.00283.x

Choudhury M, Dowie F. A biofilm based wound care pathway based in community settings: a review. Wounds. 2022;18(4):14-20

Collier M, Hofer P. Taking wound cleansing seriously to minimise risk. Wounds UK. 2017;13(1):58-64

Collier M. Wounds. 2023. https://www.bjninform.com/clinical-a-z/wounds/ (accessed 17 August 2023)

Crouzet M, Le Senechal C, Brözel VS, et al. Exploring early steps in biofilm formation: set-up of an experimental system for molecular studies. BMC Microbiol. 2014;14:253. https://doi.org/10.1186/s12866-014-0253-z

Hurlow J, Bowler PG. Potential implications of biofilm in chronic wounds: a case series. J Wound Care. 2012;21(3). https://doi.org/10.12968/jowc.2012.21.3.109

International Wound Infection Institute (IWII). Wound infection in clinical practice. 2022. https://woundsinternational.com/wp-content/uploads/sites/8/2023/05/IWII-CD-2022-web.pdf (accessed 17 August 2023)

Koo H, Allan RN, Howlin RP, Stoodley P, Hall-Stoodley L. Targeting microbial biofilms: current and prospective therapeutic strategies. Nat Rev Microbiol. 2017;15(12):740-755.