Regular Debridement Is the Main Tool for Maintaining a Healthy Wound Bed in Most Chronic

practice

Regular debridement is the main tool for maintaining a healthy wound bed in most chronic

Sharp debridement is the most clinically and cost-effective way of physically removing and suppressing a bioﬁ lm. Continued debridement, as part of a multifaceted treatment strategy, will keep the bioﬁ lm in a weakened state

chronic wounds; biofilm; sharp debridement

R.D. Wolcott, MD, he concept of a ‘healthy wound’ seems by our laboratory is showing that over 80% of all CWS, Medical Director, contradictory, yet only when the wound chronic wounds evaluated have biofi lm phenotype Southwest Regional bed is vital will the affected tissue progress bacteria and only wounds that are on a positive Wound Care Center, Lubbock, Texas, US; toward dermal regeneration. A ‘healthy’ healing trajectory and are being treated with bio- J.P. Kennedy, RPh, PhD, wound surface is created when biofi lm fi lm-based wound care do not have detectable Assistant Professor for T infection, physiological stress, infl ammation, exu- biofi lm phenotype bacteria (Dowd et al., unpub- Research, South date and necrotic tissue are minimised to such an lished data). University, School of Pharmacy, Savannah, extent that the host, even the compromised host, Our previous papers have explored the ecology, Georgia, US; can dedicate physiological resources toward tissue nature and physiological effects of biofi lm in S.E. Dowd, PhD, regeneration. wounds,15,16 so we will not repeat this here. Director, Research and This can be achieved through debridement, Testing Laboratory of the although how this works is not completely under- Biofi lm-based wound care South Plains and Medical Biofi lm Research stood. Hypotheses include: Biofi lms are a wound management challenge for Institute, Lubbock, ● Removing senescent cells1 four main reasons: Texas, US. ● Balancing bioburden,2 • They are resistant to antibiotics (50 to 1500 Email: sdowd@ 3 17 ● Improving microcirculation fold) pathogenresearch.org ● Normalising the biochemistry.4 • They are highly resistant to biocides (hydrogen Debridement can be achieved through modalities peroxide, acids, bleach)18 such as: • They evade the host immune system (white blood ● Appropriate dressings cells, antibodies, complement)19,20 ● Pulse lavage • They are poorly penetrated by many antibiotics ● Maggot debridement therapy used. 21-24 ● Enzymatic debridement Physical removal and suppression of biofi lm ref- ● Autolytic debridement. ormation is therefore a necessary part of the wound However, these modalities do not work specifi cal- management regimen. Experience and the literature ly on biofi lms, whereas surgical or sharp debride- have demonstrated that debridement is the most ment does and is much quicker.5-9 effective modality to achieve this.25-28 Debridement can also facilitate an opportunity Biofi lm for antibiotic intervention: it physically disrupts the Chronic wounds are mired in a chronic infl amma- biofi lm, which then must reconstitute itself. To do tory state exhibiting markedly elevated pro-infl am- this, the biofi lm has to reattach to the host surface, matory cytokines (interleukin-1, tumour necrosing becoming metabolically active. This increases the factor-alpha, gamma interferon), elevated matrix rate of proliferation and synthesis, in turn increas- metalloproteases (MMP2, MMP8, MMP9) and exces- ing nutrient uptake. This presents a healing window sive neutrophils.10-14 of opportunity for clinicians as biofi lm phenotypes This persistent infl ammatory state may be are much more susceptible to antibiotics and bio- explained as the consequence of biofi lm phenotype cides in the fi rst 24–72 hours (depending on com- bacteria — namely, chronic infection.15 munity species) due to energy and nutrient expend- Although methods to detect and characterise iture in the growth phase and the immaturity of the biofi lm in wounds are only now being developed protective extracellular polymeric substance (EPS) and tested for sensitivity, recent unpublished work matrix.17,18

54 JOURNAL OF WOUND CARE VOL 18, NO 2, FEBRUARY 2009 ▲ 55 practice In rela- 21.0 lm strate- lm 8,16 20.0 19.0 Concurrent biofi lm Tx lm biofi Concurrent Debridement only It has also been It has also been 33 18.0 17.0 and experiential- cally 16.0 15.0 14.0 day lm-based wound care in a multi- lm. When debridement is com- Debridement lm’s recovery, the healing window recovery, lm’s lm. In this illustration, which is based on our clinical In this illustration, which is based on our While these are not absolute numbers relative to Cost-effectiveness The premise of this article is that debridement is pivotal to chronic wound healing. It represents a minor portion of the total US wound-care budget: $188 million dollars in 2005, less than 0.8% of the total amount spent on wounds. demonstrated, both scientifi to decrease back-end costs such as antibiotics, ly, hospitalisation, amputation and death. concurrent strategies to inhibit the reformation of concurrent strategies to inhibit the reformation biofi model for wound care, maintenance debridement model for wound care, maintenance debridement of the host alone keeps the wound balance in favour between (healing) for approximately 43% of the days immediately visits, although the rate of healing in this post-debridement is more rapid. However, in 57% scenario, the wound is capable of regressing shifts back of the days between visits as the balance to favour the biofi to further bined with multiple concurrent strategies inhibit the biofi 86% of the (clinical opportunity) remains open for net rate of days between visits; furthermore, the healing is also augmented. In this multiple concur- only 14% of the days between visits rent strategy, are capable of regression. every wound, the order and separation of the rates for single versus multiple concurrent biofi gies are in alignment with what we see in the clinic. Regardless, the primary intent of Fig 1 is to illustrate the strategy of biofi heal- faceted approach; this maximises the wound’s ing potential. lm-based wound care lm-based wound

7.0 8.0 9.0 10.0 11.0 12.0 13.0 30 day Debridement 6.0 lm in lm

les are lm with

32 lm, temporar- lm,

within 24 hours evidence, extensive 31 0.0 1.0 2.0 3.0 4.0 5.0 cial clinically. cial day VOL 18, NO 2, FEBRUARY 2009 2009 FEBRUARY NO 2, 18, VOL in vitro 0 90 80 70 60 50 40 30 20 10 Debridement 100 debridement will also pre-

{ { 17,18 lm phenotype bacteria, complete lm-based wound care is to ensure the therapy maintains its balance within the healing window, as described in as described window, maintains its balance within the healing the therapy is to ensure care lm-based wound le using debridement with multiple le with debridement alone within 48 hours adhesion. Maintenance debridement lm Healing window (therapeutic balance) (therapeutic Wound stall point Wound Wound regression Wound in vivo nding to highly benefi (balance is subtherapeutic) and, based on both lm can reform in wounds very rapidly. in wounds verylm can reform rapidly. The goal of biofi The goal of debridement could be the frequency strategy, concurrent without that, gure this fi It can be assumed from the text. the primary ensuring the Debridement remains tool for the healing stall point. falling below from the wound to keep increased the stall point above stays wound Fig 1. Graphical illustration of the effects of biofi effects illustration of the Graphical Fig 1. 29 However, complete eradication of biofi However, Although debridement can remove the vast Although debridement can remove Thus, a powerful combination of debridement, Thus, a powerful combination of debridement, To take advantage of the healing wound, advanced take advantage of the healing To As well as physically removing biofi Healing profi Healing profi debridement is not possible. Continued maintenance debridement is able to keep wound biofi a weakened and susceptible state. Fig 1 is provided healing profi in part to illustrate this. Two shown: • CARE WOUND JOURNAL OF • and pare the wound bed by opening all undermining and tunnels, removing all devitalised and poorly perfused tissue, and shaping the wound topography. The resulting smooth, well-perfused wound bed will inhibit biofi prevents re-establishment. biofi majority of biofi sterilisation of an active wound is unlikely, even sterilisation of an active wound is unlikely, as bacteria with the most vigorous debridement, capillar- have been shown to integrate around deep ies rapid molecular diagnosis of infecting agents, topi- rapid molecular diagnosis of infecting cal application of treating agents, and systemic antibiotics give a multiple concurrent strategy that we are fi and rapid diagnostic methods are required to iden- and rapid diagnostic methods are required sus- tify the bacteria and their potential antibiotic are now ceptibilities. These diagnostic methods being utilised effectively in our clinic. ily disrupting its colony defences and forcing it to ily disrupting its colony defences and forcing become more susceptible to antibiotics, biocides and host immunity, practice

tion to the expense of other treatments that have biofi lm phenotype community to continually re- not been proven as broadly effective,34,35 debride- attach to the host, reform its extracellular polymeric ment would appear to be the most cost-effective substance, and increase its metabolic activity for cell option. division, synthesis and colony activity. Each of these factors provides a clinical opportunity as the biofi lm Conclusion is more vulnerable to antibiotics and selective bio- Biofi lm is an important, and until recently, an cides during the recovery phase of the biofi lm post- unrecognised barrier to chronic wound healing. debridement. Debridement as part of a multiple Clinical experience demonstrates that frequent dis- concurrent strategy for wound care is an effective ruption of biofi lm, through debridement, forces the tool for the suppression of biofi lm. ■

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