discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/5356805
CITATIONS READS
111 2,678
2 authors, including:
Randall Wolcott
Medical Director of Southwest Reginal Wound Care Center
62 PUBLICATIONS 5,435 CITATIONS
SEE PROFILE
All content following this page was uploaded by Randall Wolcott on 02 April 2015.
T
biofilms; critical limb ischaemia; wound healing
here are many barriers to wound healing, planktonic bacteria are sensitive to antibiotics and R.D. Wolcott, MD, CWS,
and wound-care providers identify and biocides, so a prolonged surgical scrub should elimi- Director;
D.D. Rhoads,
manage a myriad of wound barriers every nate the increased bacteria. However, even if a more MT(ASCP)CM, Laboratory
day. For example, each patient with a aggressive surgical scrub is used on the wound, the Research Coordinator;
wound is evaluated each visit for poor per- results from primary closure after eight hours remain both at Southwest
fusion, acute infection, poor nutrition, repetitive poor. What is the explanation for the poor healing Regional Wound Care
Center, Lubbock, Texas
pressure, unmanaged medical disease, and so on. of chronic wounds?
US.
Unfortunately, even when these barriers are man- Email: randy@
aged well, patient outcomes do not seem to be sig- The possible role of biofilm in preventing randallwolcott.com
nificantly improved.1,2 chronic wound healing
Additionally, some nagging questions about Bacterial biofilms may be the unrecognised but
chronic wounds exist. For example, why does a important barrier that impairs the healing of chron-
chronic wound often persist longer than a neigh- ic wounds (Table 1). The concept of biofilm is not
bouring acute wound that arises during the course well known in medicine,4 and it is only beginning
of therapy (Fig 1)? Why does an acute traumatic to be understood in the basic scientific community.
wound that is closed with sutures after it has been Biofilm is created when a single-cell planktonic bac-
present for more than eight hours run a greater risk terium adheres to the surface of the wound by
of wound dehiscence than if it were closed after a attaching to the exposed extracellular matrix pro-
shorter period of time?3 In the traumatic wound, teins. The bacteria can rapidly begin expressing
current planktonic (single cell) concepts suggest extracellular polymeric substance (EPS) and up to
that more bacteria have accumulated in the older 800 new proteins to form a microcolony within
wound, which has led to colonisation. Fortunately, hours.5 Within 10 hours, each single-cell planktonic
s
j o u r n a l o f wo u n d c a r e v o l 1 7 , n o 4 , A P R I L 2 0 0 8 145
research
146 j o u r n a l o f wo u n d c a r e v o l 1 7 , n o 4 , A P R I L 2 0 0 8
research
Fig 2. The first wound (left) represents a traditional model of infection. In this traditional paradigm, the
bacteria progress from contaminants to colonisers to infectors. This traditional model focuses on the number
of bacterial cells that can be cultured from a wound, and it may be a good picture of the agents that cause
acute symptoms during an acute infection. However, we suggest that chronic wounds typically have an
underlying infection that does not yield a flamboyant, acute host response but which delays host healing. The
second wound (right) represents this chronic, underlying biofilm infection. These biofilms can develop from a
small number of contaminating bacteria, which can attach to the wound, develop into microcolonies and
mature into a robust biofilm community that interacts using chemical signalling. Mature biofilms often
comprise many genotypically distinct constituents, and each genotype can produce cells with various
phenotypes. This diversity and quantity of cells in a biofilm cannot be determined effectively using traditional
culturing techniques, so more sensitive diagnostic tools are needed to better identify the organisms causing
chronic biofilm infections.
j o u r n a l o f wo u n d c a r e v o l 1 7 , n o 4 , A P R I L 2 0 0 8 147
research
April, 2003.
148 j o u r n a l o f wo u n d c a r e v o l 1 7 , n o 4 , A P R I L 2 0 0 8
research
13 Serralta,V.W., Harrison- patients were followed for up to two years, and as defined as a TCpO2 below 20mmHg), for whom
Balestra, C., Cazzaniga, A.L.
Lifestyles of bacteria in
wounds healed or improved in only two out of 13 analysis showed 65% improved or completely re-
wounds: presence of biofilms? patients with CLI. Even though the standard of care epithelialised their wounds.
Wounds 2001; 13: 1, 29-34. was acceptable and included a multidisciplinary team, Despite the promising results reported in the lit-
14 Bello,Y.M., Falabella, A.F., individualised dressings and offloading, the care did erature, patients with CLI who develop wounds are
Cazzaniga, A.L. et al. Are
biofilms present in human not rise to the standard of current management. The being managed in very different ways, depending
chronic wounds? Paper limb salvage rate of only 15% is not surprising. solely on which physician they visit first. Some phy-
presented at Symposium on However, Fife et al.s large retrospective study of sicians choose immediate amputation in a wound-
Advanced Wound Care and
Medical Research Forum on the correlation of TCpO2 levels to outcomes of ed, critically ischaemic limb; other physicians pur-
Wound Repair, April, 2001. hyperbaric oxygen (HBO) management provides sue a trial of therapy. A major and sometimes painful
15 Clutterbuck, A.L.,Woods, more promising results.24 The standard of care for paradigm shift in medicine concerning limb salvage
E.J., Knottenbelt, D.C. et al.
Biofilms and their relevance
wound management provided to patients was not is under way.
to veterinary medicine.Vet described in detail in the paper, but a description of In this study, chronic wounds in limbs with CLI
Microbiol 2007; 121: 1-2, 1-17. the advanced wound care was provided. Aggressive were chosen to evaluate the efficacy of BBWC to
16 Kalani, M., Brismar, K., and frequent debridement, appropriate antibiotics, determine if it can increase the frequency of healing.
Fagrell, B. et al.
Transcutaneous oxygen offloading, advanced dressings, non-invasive vascu-
tension and toe blood lar assessment, revascularisation as necessary, cell Method
pressure as predictors for therapies, and HBO were provided in a coordinated The Southwest Regional Wound Care Center in Lub-
outcome of diabetic foot
ulcers. Diabetes Care 1999; multidisciplinary fashion. Fife et al. identified 629 bock, Texas, US performed this retrospective study
22: 1, 147-51. diabetic patients (302 [48%] with critical ischaemia with institutional review board (IRB) approval
if the wound is
then
then
Healing
Alter the anatomy (open Aggressively manage surface Remove all necrotic tissue Gently manage surface Healed
tunnels and undermining) (sharp debridement) (sharp debridement) (ultrasonic debridement)
Block attachment Kill bacteria Quorum-sensing inhibitors Interfere with EPS False metabolites
(lactoferrin, EDTA) (Antiibiotics, silver, iodine) (farnesol) (farnesol, xylitol) (gallium, xylitol)
The biofilm-based wound-care algorithm was used as a guideline for managing the 190 critically ischaemic wounds reported in this study
150 j o u r n a l o f wo u n d c a r e v o l 1 7 , n o 4 , A P R I L 2 0 0 8
research
32: 5, 484-490.
j o u r n a l o f wo u n d c a r e v o l 1 7 , n o 4 , A P R I L 2 0 0 8 151
research
Case 2.This 56-year-old had a history of
diabetes for more than two decades.
24 Fife, C.E., Buyukcakir, Progressive necrosis of the forefoot
C., Otto, G.H. et al. developed, beginning with a small
The predictive value of
transcutaneous oxygen traumatic wound of the second toe. By
tension measurement in a b August 2004 major limb amputation was
diabetic lower extremity recommended because of the extensive
ulcers treated with
hyperbaric oxygen therapy: a tissue loss of the forefoot.The patient
retrospective analysis of refused amputation. Lactoferrin and
1,144 patients.Wound Repair RNA-III inhibiting peptide were used as
Regen 2002; 10: 4, 198-207.
25 Psaltis, A.J., Ha, K.R.,
complementary therapies.The change in
Beule, A.G. et al. Confocal the wound during the month of August
scanning laser microscopy c d 2004 was dramatic (insets b and c).The
evidence of biofilms in
patients with chronic change correlates with the addition of
Case 1. The patient is an 84-year-old
rhinosinusitis. Laryngoscope anti-biofilm agents to the patients
2007; 117: 7, 1302-1306. Hispanic male who presented with
standard wound-care regimen
26 Tapiainen, T., Sormunen, progressive necrosis of his right foot. The
R., Kaijalainen, T. et al. patient had severe critical limb
Ultrastructure of
Streptococcus pneumoniae ischaemia (TCpO2 of 1mmHg). He
after exposure to xylitol. J presented with multiple medical
Antimicrob Chemother problems including poor glycaemic
2004; 54: 1, 225-228.
27 Ward, P.P., Uribe-Luna, S., control, hypoalbuminaemia, anaemia and
Conneely, O.M. Lactoferrin concordance issues. The patient was a
and host defense. Biochem patriarch of a very large family and a b
Cell Biol 2002; 80: 1, 95-102.
28 Ward, P.P., Paz, E.,
decided that he would salvage his foot.
Conneely, O.M. He was started on standard wound
Multifunctional roles of management along with biofilm-based
lactoferrin: a critical
overview. Cell Mol Life Sci wound-care strategies in December
2005; 62: 22, 2540-2548. 2005. The patient received advanced
29 Weinberg, E.D. Human dressings, aggressive and frequent
lactoferrin: a novel 5-6-05
therapeutic with broad
debridement, revascularisation in mid- c d
spectrum potential. J Pharm January 2006, and topical anti-biofilm
Pharmacol 2001; 53: 10, agents including lactoferrin (20mg/cm3)
1303-1310.
and xylitol (50mg/cm3). The patient took Case 3.This 63-year-old diabetic patient was
30 Weinberg, E.D. Antibiotic eight years post-renal transplant when he
properties and applications over one year to heal, but was able to
of lactoferrin. Curr Pharm ambulate on his foot throughout the developed a wound from a brace applied to
Des 2007; 13: 8, 801-811.
entire course of healing. Inset d was his right foot to manage severe Charcot
31 Katsuyama, M., deformity.The wound had eroded into the
Kobayashi,Y., Ichikawa, H. taken in December 2006, and complete
et al. A novel method to healing was reported in February 2007 tarsals of the foot.The patients TCpO2 was
control the balance of skin 4mmHg. Lactoferrin (20mg/cm3) was begun
microflora Part 2. A study in July 2004, which produced immediate
to assess the effect of a
cream containing farnesol silver, seem to have important synergies when used improvements in the wound, including
and xylitol on atopic dry to topically manage wounds. Selective biocides, decreased drainage, less devitalised tissue,
skin. J Dermatol Sci 2005; such as silver-impregnated dressings or cadexomer
38: 3, 207-213.
less slough and improved colour and
32 Katsuyama, M., Ichikawa, iodine, were used in combination with lactoferrin texture in the granulating wound bed.The
H., Ogawa, S., Ikezawa, Z. A and xylitol. Non-selective biocides and other agents wound healed in six months
novel method to control the toxic to host cells were avoided.
balance of skin microflora.
Part 1. Attack on biofilm of Antibiotics were considered an adjunct, being
Staphylococcus aureus without used in combination with the above agents.
antibiotics. J Dermatol Sci Advanced technologies such as platelet-derived
2005; 38: 3, 197-205.
33 Singh, P.K., Parsek, M.R.,
growth factor-beta, cell therapy (Dermagraft,
Greenberg, E.P.,Welsh, M.J. Advanced Biohealing and Apligraf, Organogenesis),
A component of innate and hyperbaric oxygen (HBO) were used as deemed
immunity prevents bacterial a b
biofilm development. Nature necessary by the treating clinician.
2002; 417: 6888, 552-555.
34 Model Guidelines for Results
the Use of Complementary
and Alternative Therapies in
Of the 190 patients included for evaluation in the
Medical Practice. Federation study, 146 (77%) showed complete healing and 44
of State Medical Boards. (23%) were categorised as non-healing. The healed
www.fsmb.org/pdf/2002_
grpol_Complementary_ group included 47% (68/146) of patients with
c d
osteomyelitis and 69% (101/146) with diabetes
s
Alternative_Therapies.pdf
152 j o u r n a l o f wo u n d c a r e v o l 1 7 , n o 4 , A P R I L 2 0 0 8
research
35 Balaban, N., Giacometti, mellitus, whereas the non-healed group had 75% care 65% of the time. For comparison with the cur-
A., Cirioni, O. et al. Use of
the quorum-sensing
(33/44) of patients with osteomyelitis and 77% rent study, we will consider those 65% of subjects to
inhibitor RNAIII-inhibiting (34/44) with diabetes mellitus (Table 3). Photo- be healed. The patients evaluated in the current
peptide to prevent biofilm graphs of the 190 cases are provided for verification study numbered 190 (53% diabetic, 100% with CLI).
formation in vivo by drug-
resistant Staphylococcus at www.woundcarehospital.com. Only patients with complete healing were included
epidermidis. J Infect Dis 2003; The mean age for the healed group was 70.1 years in the healed contingent, which is a more strin-
187: 4, 625-630. (13.2) (range 1795) and 72.4 years (12.7) (range gent criterion than the not failed category described
36 Balaban, N., Stoodley, P.,
Fux, C.A. et al. Prevention of 4395) for the non-healed group. The group show- in Fife et al.s study.
staphylococcal biofilm- ing complete healing had 56% males, whereas the Although Fifes patient populations are incom-
associated infections by the non-healing group had 48% males. TCpO2 findings pletely defined, they are similar enough to investi-
quorum sensing inhibitor
RIP. Clin Orthop Relat Res for the successful cohort were 9.3 6.4mmHg (range gate statistical comparison, and they received simi-
2005; 437: 48-54. 019) and 6.8 5.7mmHg (range 019) for the failed lar wound care to the subjects in the present study,
37 Percival, S.L., Kite, P., cohort. Thirty-eight patients had wounds that with the exception of BBWC being employed only
Eastwood, K. et al.
Tetrasodium EDTA as a appeared to be moving towards healing but discon- in the present study.
novel central venous tinued follow-up (for unknown reasons) before pic- The null hypothesis used was as follows: the cur-
catheter lock solution tures documented complete epithelialisation; 36 of rent study populations healing frequency is the
against biofilm. Infect
Control Hosp Epidemiol these patients reported healing via telephone. Two same as the study population reported by Fife
2005; 26: 6; 515-519. patients could not be contacted by telephone and (P1=P2). Using Fishers exact test (p<0.05) and the z-
38 Kaneko,Y., Thoendel, M., were included in the non-healed category. No treat- test (p<0.05), the null hypothesis must be rejected.
Olakanmi, O. et al. The
transition metal gallium ment complications were reported. Patients healed significantly more frequently using
disrupts Pseudomonas When considering the 216 patients in the inten- BBWC than using traditional wound care alone
aeruginosa iron metabolism
and has antimicrobial and
tion-to-treat group, the healing rate dropped to 68% (98% confidence).
antibiofilm activity. J Clin (146/216); 20% (44/216) did not heal, and 12% Biofilm-based wound care also improved the per-
Invest 2007; 117: 4, 877-888. (26/216) did not enter this treatment programme. formance of other treatments. For example, we
39 Chaignon, P., Sadovskaya,
Three case histories are provided to illustrate the observed an improved clinical response to allograft
I., Ragunah, C. et al.
Susceptibility of efficacy of BBWC (cases 13, see boxes). All three and xenograft skin, growth factors, and cell therapy.
staphylococcal biofilms to responded to the use of topical lactoferrin and xyl- We observed much less degradation of the graft
enzymatic treatments
depends on their chemical itol in conjunction with other methods, as material or the applied growth factors. The normal
composition. Appl Microbiol described in the methodology. One patient required appearance of graft material at three to five days
Biotechnol 2007; 75: 1, 125- the compassionate use of RNA-III inhibiting pep- with a BBWC approach is a much more intact graft
132.
40 Donelli, G., Francolini, I.,
tide (RIP).35,36 RIP is a quorum-sensing inhibitor instead of the degraded, slimy material that used to
Romoli, D. et al. Synergistic that interferes with important biofilm pathways in be seen (Fig 6). Suppressing wound biofilm may
activity of dispersin B and staphylococci. This patient had meticillin-resistant increase the efficacy of advanced technologies, such
cefamandole nafate in
inhibition of staphylococcal Staphylococcus aureus that was recalcitrant to all as purified keratinocytes and/or fibroblasts. With
biofilm growth on conventional therapies, requiring innovative bio- less enzymatic degradation and fewer bacterial viru-
polyurethanes. Antimicrob film strategies. lence factors, the applied cells and small proteins
Agents Chemother 2007;
51: 8, 2733-2740. seem to work much better.
41 Jabra-Rizk, M.A., Meiller, Discussion We deduce that part of the improvement in clini-
T.F., James, C.E., Shirtliff, M.E. The 77% healing rate of all the patients with CLI cal outcomes when using BBWC is due to a decrease
Effect of farnesol on
Staphylococcus aureus biofilm managed in the biofilm-based treatment group is in matrix metalloproteinase activity, decreased
formation and antimicrobial better than the healing rate obtained in patients elastase activity, and decreased exudate in the
susceptibility. Antimicrob
Agents Chemother 2006;
treated aggressively at other modern wound-care wound environment. These characteristics are much
50: 4, 1463-1469. treatment facilities. Even in patients with the com- more conducive to the effects of growth factors,
42 Hentzer, M., Wu, H., bined comorbidities of diabetes and osteomyelitis, other applied proteins, and living cells.
Andersen, J.B. et al. healing rates were 67%. Seventy-five per cent of Because of this improved clinical efficacy of these
Attenuation of Pseudomonas
aeruginosa virulence by patients with diabetes and CLI healed completely. proactive healing agents, we have turned to them
quorum sensing inhibitors. It is proposed that the improvement in outcomes in earlier and in more patients, significantly increasing
EMBO J 2003; 22: 15,
3803-3815.
these patients over those reported in the literature their use.
43 Wu, H., Song, Z., correlates directly with the use of anti-biofilm Finally, targeting biofilm with anti-biofilm agents
Hentzer, M. et al. Synthetic agents and methods that were used to manage the can markedly improve the efficacy of antibiotics
furanones inhibit quorum-
sensing and enhance
wounds. These findings provide indirect evidence and HBO therapy. This has led to significant reduc-
bacterial clearance in that biofilm is indeed an important barrier to tions in our use of these interventions, which seems
Pseudomonas aeruginosa lung wound healing. counterintuitive. However, since antibiotics and
infection in mice. J
Antimicrob Chemother The closest match for the patients included in this HBO are operating against disrupted biofilm colony
2004; 53: 6, 1054-1061. study with patient populations reported in the lit- defences, they can achieve their goals in a shorter
erature are those reported in Fife et al.s retrospec- time. Also, we find that fewer wounds deteriorate to
tive analysis.24 Fife reported on 629 diabetic patients, the point that requires these therapies. Over the
48% with CLI, whose wounds responded to wound four years of the study, the use of antibiotics declined
154 j o u r n a l o f wo u n d c a r e v o l 1 7 , n o 4 , A P R I L 2 0 0 8
research
a b c
Fig 6. Standard of care application of Apligraf without addressing wound biofilm often results in degradation of
the graft into a slimy mass after one week (a), possibly due to wound biofilm. By pretreating the wound with anti-
biofilm agents and concurrently applying them when the graft is applied (b), Apligraf treatments may lead to
more favourable clinical results in as little as one week (c)
by approximately 25% and the use of HBO by 50%. However, there is much work yet to be done on
During the same time period the number of actively BBWC. No randomised studies have been per-
treated patients increased. formed, and few commercial agents are available
Bacterial biofilm seems to be detrimental to that specifically attempt to manage biofilm in
wound healing. In an ischaemic wound where the chronic wounds.
peri-wound cells are in a desperate struggle for sur- To our knowledge, this study is the first that goes
vival, it is not difficult to imagine that the presence beyond anecdotal evidence to demonstrate that spe-
of biofilm could easily tip the balance towards cell cifically managing biofilm factors increases favoura-
death and wound deterioration. We have demon- ble wound outcomes. Biofilm-based treatment strat-
strated that managing wounds as if biofilm were an egies are in their infancy and need to be developed
important barrier to healing improves wound-heal- and tested further, not only to identify key compo-
ing outcomes. nents or combinations of therapy that provide this
Amputation is a failed strategy. The risk of a trial benefit, but also to identify better agents and combi-
of therapy to heal the wound and consequently nation therapies that further increase the speed or
salvage the limb is acceptable in the context of the frequency of wound healing.
abysmal results associated with major limb ampu- Additionally, we need better diagnostic tools that
tation. Under the current standard of care, most of are able not only to identify the bacteria in wounds
the wounds included in this study would have that are culturable, but also the bacteria in wounds
been deemed unhealable and resulted in a major that are not culturable.
limb amputation, but with BBWC the majority of Agents that work to disrupt biofilms need to be
these wounds healed. studied more fervently:
This study demonstrates that the current stand- lQuorum-sensing inhibitors (RIP, furanone C30)
ard of care for chronic wounds combined with bio- lAgents that degrade the EPS (dispersin B, algi-
j o u r n a l o f wo u n d c a r e v o l 1 7 , n o 4 , A P R I L 2 0 0 8 155