Section: New Board Review Category: Wound Care

Managing Infection and Biofilm in the Wound Setting - New Modalities for DFU's

Matthew Garoufalis, CWS, DPM

Matt Garoufalis, DPM discusses the role of biofilm in the diabetic wound, the use of medications to control biofilm, as well as reviewing the choices available to treat these conditions.

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Goals and Objectives
  1. • Review the role biofilm plays in the diabetic wound
  2. • Describe the use of medications in controlling infection and biofilm
  3. • Review the range of choices available to treat these conditions
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    Release Date: 12/28/2018 Expiration Date: 12/31/2020

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    Matthew Garoufalis has disclosed that he is a consultant, adviser and speaker for Ortho Dermatologic, MiMedx, Acelity.

  • Lecture Transcript
  • 00:00:00:00
    MALE SPEAKER: Okay, diabetic foot infections, not a big deal, right? We see them all the time. Well, just a few little nuggets about diabetic foot infections, and biofilm, things like that. So things that might be happening in that field, we’ll take a look at it.

    Okay. Complicated soft tissue infections. We know that that’s the biggest reason our diabetic patients are hospitalized because of these soft tissue infections, and because of their comorbidities. And as a result, the statistics go sky high as to what’s going on with these patients.

    These are the... they may require INDs, but the initial assessment is, as you all know, are what’s listed here, these are the facts that we need to get, we need to get these things taken care of, upon admission. These are the dangerous things that we’re looking for in a diabetic patient, not just staff, but MRSA, and with the immuno-compromised patient, that we know that we have to look a little bit deeper all the time, which comes back on the report may not be exactly what’s going on. So we need to do the physical exam of the patient as well, because if they’re immono-compromised, meaning, diabetic, there could be other things going on, so these are the multi-drug resistant infections that we’re always afraid of, that we have to take a little bit extra care to make sure that we’re not involved with these.

    Now, of course, I’m in the VA Hospital for part of my week, and MRSA is just a given, everybody has MRSA, so we see that all the time, it’s the other stuff, the VRE that we don’t want to see, or the CRE that we don’t want to see. So anti-biotic selection, it’s very important to include infectious disease people. And for years and year, and years, the infectious disease and podiatry were at war with each other, because they just looked at the paperwork, and said, “Oh, well, you need to do this, you need to do that, you need to take them to surgery,” and all that. [00:02:08:01]And they didn’t understand that these patients weren’t candidates for their suggestions.

    Finally, when we brought infectious disease folks on rounds with us, then they got to see what we see in the wound, all of a sudden, their whole way of looking at a patient, a diabetic patient with infection, changed. And now, ID is part of... part of their rotation, is with us on rounds because they become educated, and they want to see what we see, because when we involve them, they just don’t want to read the paperwork.

    So pseudomonas is important, can we heal a wound in spite of pseudomonas? Often, we can, but often, we can’t. We also have to be aware that when we’re giving them antibiotics, there’s other things going on as a result of the antibiotics that we’re prescribing, so we need to be aware of these too. It’s not just, “Oh yeah, well, ID said that’s the one that matches, that’s the one that they’re susceptible to, let’s just give it to them.” And you wonder why that it’s not being effective in three days, and you’re wondering why there’s other things going on, and their weight count continues to decline. But it could be other things like this, that are happening, that we need to be aware of.

    So then we have biofilm, biofilm is always a pain, it is always there, we just need to control to what extent it is there. And now, the people are doing a lot of studying on biofilms. And we’re getting... we’re getting to understanding that biofilms have this extracellular polymeric that protects the biofilm that we can’t just wipe it away very easily, we can’t just put something on it and expect it to work. [00:04:03:05] That biofilm now has this protective covering that protects the biofilm and makes it resistant to some of the things that we do, which it creates another challenge.

    So we… these are the characteristics of biofilm, the part of things that we understand. We also know that we have this EPS now, this film that shields bacteria. And we’re trying to now get beyond that because that is why we do a great debridement, and the wound looks great, and it begins to finally respond. And then three days, it stops again because that biofilm is still there. We still can’t get it out.

    So as a result, it does cause a lot of infections. We now know that the EPS is inhibiting some of the things that we put on there, so we have to be aware of that. There’s… biolfilms now have an amazing number of classifications that we have to be aware of. There is complete conferences that just talk about biofilms. That’s how big of deal this has become.

    So they stimulate chronic inflammation, at least to highly increased levels of proteases, which is why we get stuck in the mud on some of these things.

    So frequent debridement is important, absolutely, baseline, first line of defense is debridement, effective microbial dressings after debridement, very important. And we need biofilm-based wound care with time preparation. We’ve heard of that theory before.

    So these are just the benefits of debridement. I mean, it’s been long-stated that if we’re not debriding, we’re not doing good work. And we have to debride the bleeding tissue, because if it doesn’t bleed, it’s not going to heal, very important.

    So there’s plenty of literature out there. [00:06:00:15] And every time that we see a wound, it must be debrided. Every single time a patient comes in, the wound is debrided at least along the wound edge, at least along the wound edge to freshen that up.

    So these are the reasons to cleanse wounds, no matter what type of things we’re cleansing the wound with, it’s important to always cleanse the wound. There’s lots of things out there now that we can use, and I would urge all of you have a residents try as many different products as you can to see what works in your hands on the patients that you’re treating.

    So we know that debridement works but there’re some things, the ultrasonic cleaning larva, you know, that, you know, the larva worked really good. Those bugs clean up the wounds really well. And now, they come in these neat little pouches that you can leave on for a few days.

    We also know that there’s antimicrobial fluids and dressings, silver, PHMB, methylene blue, cadexomer iodine, those have been around for a while and they work extremely well. There’s a new product that’s coming out in the marketplace. This… and I’ll use the trade name, I don’t have to say the whole term, BlastX, that kills this shield over the biofilm. So that’s going to be coming to marketplace soon. It’s just been patented and packaged.

    We also have negative pressure that works really well. So installation, negative pressure, where we’re putting fluids through negative pressure, cleansing the wound and then sucking all that back out in a cyclic fashion. We have seen this work very nicely in controlling bioburden and in controlling wound infection. There are different materials that you can use. You can use straight saline or you can use some of these materials, some of these products that are known to defeat bioburden and defeat the bugs.

    And I could tell you from personal experience on my patients in the last, probably 18 months, we have increased our use of installation therapy by about 800% because we find it to be extremely effective in keeping these wounds clear. [00:08:06:30]

    So this is what these units look like. They are very nice. They take a little bit more effort to use because you don’t want to do… you don’t want any maceration to occur. But the outcomes on some of these complicated patients with a lot of co-morbidities is extremely wonderful outcomes.

    So they are even experimenting with these enzymes, these molecules. This is a molecule that has been discovered that can defeat pseudomonas and so this is something that is still being studied, but pyocyanin demethylase, PodA’s what it is called, and it is in development right now so that this little molecule is what we can put on a wound with pseudomonas and the pseudomonas evaporates in about a day which is incredible. So it comes from the soil, surprisingly enough.

    So this is what we know about biofilms. This is from Greg Schultz who is the guru in Florida on biofilms. He has produced that how many articles on biofilms, but we know they are in high percentage in chronic wounds and may impair healing. We know that they are encased in a self-produce matrix, the polysaccharides, that’s that little sac we talked about earlier. We know that top of the dressing can reduce it. We know that negative pressure plus installation is a big plus. We can use larval debridement. That can be beneficial, and biofilm-based wound care is beneficial.

    But this is what we don’t know. We don’t know can wounds heal with some low level of bioburden? Well I always thought the answer was yes. But it seems like recently with more complicated cases of bioburden, that’s becoming difficult to answer yes to. So we’re having some new levels of bioburden there.

    What is the optimum method of debridement of biofilms? [00:10:01.31] We don’t know that’s why we say debride as often as you can. And how do we kill the biofilms? Well, that’s why there’s so many products out there. That’s why there are so many products because we don’t know which is the best method to get rid of the biofilm.

    So there’s been a Cochrane review, topical antimicrobial agents for treating foot ulcers and people with diabetes. Use of antimicrobial dressings is what is suggested. They don’t have too many adverse effects, but they still should be used and that is far as they go. They don’t tell us anymore and say, “Well, topical antimicrobial seem to do some work and they don’t look like they have too many complications. But… and you should probably use them.” Well, thanks, Cochrane for all that insight, that’s great. We already knew that. But anyways, when it comes to bioburden and biofilms continue to debride, continue to cleanse, it needs to become of our… become part of our daily rational or daily treatment plan.

    So thanks. I know that was short and sweet. But after all, you guys are monstrous for staying. Thank you and I think we’re all done now so congratulations. Thanks.