Biofilm, Pilonidal Cysts and Sinuses

By Melvin A. Shiffman

This book discusses the latest findings in the fields of biofilm, pilonidal cysts and sinuses. The first part provides detailed information on biofilm formation, antibiofilm properties and activity as well as their potential clinical application in wound management. The second part then examines pilonidal sinus disease and the surgical treatment options. Written by leading experts in the field, the book is a valuable resource for beginners and experienced surgeons alike.

• Language: English
• Publisher: Springer
• Release date: Dec 5, 2019
• ISBN: 9783030030773

Book preview

Part IBiofilm

© Springer International Publishing AG 2017

M. A. Shiffman, M. Low (eds.)Biofilm, Pilonidal Cysts and SinusesRecent Clinical Techniques, Results, and Research in Wounds1https://doi.org/10.1007/15695_2017_1

Biofilm: History, Cause, and Treatment

Melvin A. Shiffman¹  

(1)

17501, Chatham Drive, Tustin, CA 92780-2302, USA

Melvin A. Shiffman

Email: [e-mail]

1 Introduction

Biofilm is a very persistent problem in chronic wounds. The bacteria grouping is protected from the effect of antibiotics by a polymer film covering. Antibotics cannot penetrate that film and destroy the offending organisms. Debridement followed by antibiotics has been the only method to treat chronic wounds. Recently antibiofilm products have been identified that will uncover the organisms and allow antibiotics to work.

2 History

On April 24, 1676, van Leeuwenhoek examined his steeped-pepper preparation with a microscope and with great wonder (groote verwondering) observed several kinds of microorganisms in the water, including what are now called bacteria [1]. The report of the discovery of bacteria was contained in a letter sent to the Royal Society and dated at Delft on 9 October 1676 [2].

Pasteur observed and sketched aggregates of bacteria as the cause of wine becoming acetic, which led to his discover of pasteurization [3]. Pasteur described Mycoderma aceti as the causative agent in la matière visqueuse, a membrane removed from vinegar barrels known as mère du vinaigre [4].

Originally described as slime or film, the terms were referring to bacterial adhesion, aggregation, and multiplication on surfaces. The earliest use of biofilm was by ZoBell and Allen [5] who studied the adherence and growth of bacteria on submerged glass slides in sea water. They found that fouling was initiated by biofilm-growing bacteria and, to a lesser extent, other microorganisms and that such films favor the subsequent attachment of the larger and more inimically fouling organisms.

A publication by Mack et al. [6] had an abstract that read: After the deposit of a small amount of debris upon a hard surface, the bacterial cells attach and develop the matrix on which the biofilm is formed. The transmission and scanning electron microscopes were used to visualize the sequence of the biofilm development in the trickling wastewater filter.

Jendresen and Glantz [7] used the term biofilm in dental circumstances. Serralta et al. [8] hypothesized that biofilms do exist in wounds. Biofilms, like other communities, form gradually over time. In order for a biofilm to form, bacteria must be able to attach to a substrate. This attachment is largely based on nutritional signals and a critical number of organisms assembling. Once attached, the bacteria relinquish their planktonic state and begin to recruit other bacteria. The aggregates proliferate and recruit new members that can be of different species of bacteria, fungi, or protozoa. Attached bacteria excrete an extracellular polysaccharide matrix, which forms the structural architecture of the biofilm. The biofilm colonies are constantly changing and adapting to their environment.

3 Cause

Given the right conditions, all bacteria can grow a biofilm. Biofilm forms when microbial cells attach to a hard surface or lining tissue and evolve into a microbial community encased within a self-produced polymer matrix. Biofilm bacteria are less susceptible to the immune system and can persist for long periods of time. Phagocytes have difficulty ingesting bacteria within a biofilm due to the antiphagocytic properties of the biofilm matrix [8, 9]. Biofilms display innate resistance to antimicrobial agents [10]. Biofilms increase the opportunity for gene transfer between and among bacteria and can convert previous avirulent organisms into highly virulent pathogens [11].

Antibiotics do not penetrate the biofilm matrix [11, 12]. It is possible that a biofilm-specific phenotype may be induced in a subpopulation of the biofilm [11] and these subpopulations express active mechanisms to reduce the efficacy of antibiotics [13, 14].

4 Treatment

Treatment for biofilm is to disrupt and removing the biofilm by debridement of the wound. After this, specific antibiotic treatment can be instituted.

Molecular diagnostics provide the first objective means of assessing wound bioburden. The accuracy and comprehensive data from such diagnostic methodologies provide clinicians with the ability to employ patient-specific treatment options, targeted to each patient’s microbial wound census [15]. Based on current outcomes data, the most effective therapeutic options are topical antibiofilm agents combined with topical antibiotics. In specific patients, systemic antibiotics and selective biocides are also appropriate.

Molecular diagnostics are available to provide comprehensive, rapid, and accurate microbial detection and quantification of previously unidentifiable organisms, including yeast and fungi. However, although major resistance factors are also elucidated, classical species susceptibility is not provided. Wolcott et al. [16] reported that they were able to increase complete closure rates from 48 to 62% over a 6-month study period utilizing multiple concurrent strategies including frequent debridement and molecular diagnostics to guide systemic antibiotic intervention. As a result, systemic antibiotic usage increased from 32 to 67% of patients receiving therapy. Although there was an overall increase in antibiotic usage, the increased utilization remains in alignment with the literature for this patient population [17, 18].

Dowd et al. [19] reported significantly increased rates of wound closure with the multiple concurrent strategies of biofilm-based wound care and the combination of individualized topical antibiofilm therapy guided by molecular diagnostics.

Many antibiofilm compounds have been identified by Rabin et al. [20] from diverse sources.

1.

Natural sources

(a)

Brominated furanones

(b)

Garlic

(c)

Ursine triterpenes

(d)

Corosolic acid and asiatic acid

(e)

Ginseng and 3-indolylacetonitrile

2.

Imidazole derivatives

(a)

Bromoageleferin and oroidin, which were isolated from the sponge

Agelas conifer

3.

Indole derivatives

(a)

Resveratrol 3-Indolylacetonitrile

(b)

Indole–triazole-amide analogs

(c)

Benzimidazoles analogs

4.

Plant-derived compounds

(a)

Emodin

(b)

Phloretin

(c)

7-Epiclusianone

(d)

Isolimonic acid

(e)

Casbane diterpene

(f)

Chelerythrine

(g)

Hyperforin and its hydrogenated analog

(h)

Proanthocyanidin A2-phosphatidylcholine

(i)

Ellagic acid

(j)

Ellagic acid mannopyranoside

(k)

Ellagic acid xylopyranoside

(l)

Ginkgoneolic acid

(m)

Tannic acid

(n)

(R)-Norbgugaine

(o)

Ginkgolic acid C15:1

5.

Marine-derived compounds

(a)

Auromomycin

(b)

Halogenated furanones

(c)

Brominated alkylidene lactams

(d)

Bromopyrrole alkaloids

6.

AHLs-based inhibitors

(a)

N-Acyl homoserine lactones

(b)

Cationic peptides

(c)

Cathelicidin peptide LL-37

(d)

d-Amino acids

Conclusions

There are now some measures besides debridement to attack the biofilm in chronic wounds allowing access for antibiotics to reach the infective bacteria in the wound. It behooves those physicians treating wounds to become familiar with antibiofilm agents.

References

1.

Bardel D (1982) The roles of the sense of taste and clean teeth in the discovery of bacteria by Antoni van Leeuwenhoek. Microbiol Rev 47(1):121–126

2.

van leeuwenhoek A. Letter of 9 October 1676 to the Royal Society, London. Royal Society, MS. L 1. 22

3.

Pasteur L (1922) Memoire sur la fermentation acetique. Ann Scient L'Ecole Normale Superiure. In: Oeuvres des Pasteur, réunies par Pasteur Valerie-Radot, Tome II. Fermentations et generations dites spontanees. Masson, Paris

4.

Pasteur L (1864) Memoire de la fermentation acétique. Ann Scient de L'ÉNS I serie, Tome I Gauthier Villars, pp. 113–58

5.

ZoBell CE, Allen E (1935) The significance of marine bacteria in the fouling of submerged surfaces. J Bacteriol 29:239–251

6.

Mack WN, Mack JP, Ackerson AO (1975) Microbial film development in a trickling filter. Microb Ecol 2(3):215–226

7.

Jendresen MD, Glantz PO (1981) Clinical adhesiveness of selected dental material. An in-vivo study. Acta Odontol Scand 39(1):39–45

8.

Serralta VW, Harrison-Balestra C, Cazzaniga AL, Davis SC, Mertz M (2001) Lifestyles of bacteria in wounds: presence of biofilms? Wounds 13(1):29–34

9.

Johnson GM, Lee DA, Regelmann WE, Gray ED, Peters G, Quie PG (1986) Interference with granulocyte function by Staphylococcus epidermidis slime. Infect Immun 54(1):13–20

10.

Evans RC, Holmes CJ (1987) Effect of vancomycin hydrochloride on Staphylococcus epidermidis biofilm associated with silicone elastomer. Antimicrob Agents Chemother 31(6):889–894

11.

Lewis K (2001) Riddle of biofilm resistance. Antimicrob Agents Chemother 45(4):999–1007

12.

Shigeta M, Tanaka G, Komatsuzawa H, Sugai M, Suginaka H, Usui T (1997) Permeation of antimicrobial agents through Pseudomonas Aeruginosa biofilms: a simple method. Chemotherapy (Tokyo) 43(2):340–345

13.

Gilbert P, Das J, Foley I (1997) Biofilms susceptibility to antimicrobials. Adv Dent Res 11(1):160–167

14.

Maira-Litrán T, Allison DG, Gilbert P (2000) An evaluation of the potential of the multiple antibiotic resistance operon (mar) and the multidrug efflux pump acrAB to moderate resistance towards ciprofloxacin in Escherichia coli biofilms. J Antimicrob Chemother 45(6):789–795

15.

Jones CE, Kennedy JP (2012) Treatment options to manage wound biofilm. Adv Wound Care (New Rochelle) 1(3):120–126

16.

Wolcott RD, Cox SB, Dowd SE (2010) Healing and healing rates of chronic wounds in the age of molecular pathogen diagnostics. J Wound Care 19(7):272–278. 280–1

17.

Tammelin A, Lindholm C, Hambraeus A (1998) Chronic ulcers and antibiotic treatment. J Wound Care 7(9):435–437

18.

Howell-Jones RS, Price PE, Howard AJ, Thomas DW (2006) Antibiotic prescribing for chronic skin wounds in primary care. Wound Repair Regen 14(4):387–393

19.

Dowd SE, Wolcott RD, Kennedy J, Jones C, Cox SB (2011) Molecular diagnostics and personalised medicine in wound care: assessment of outcomes. J Wound Care 20(5):232, 234–9

20.

Rabin N, Zheng Y, Opoku-Temeng C, Du Y, Bonsu E, Sintim HO (2015) Agents that inhibit bacterial biofilm formation. Future Med Chem 7(5):647–671

© Springer International Publishing AG 2017

M. A. Shiffman, M. Low (eds.)Biofilm, Pilonidal Cysts and SinusesRecent Clinical Techniques, Results, and Research in Wounds1https://doi.org/10.1007/15695_2017_2

Biofilm: Clinical Experience

Tanja Planinšek Ručigaj¹, ²  

(1)

University Medical Centre Ljubljana, Ljubljana, Slovenia

(2)

Dermatovenerological Clinic, University Clinical Centre Ljubljana, Ljubljana, Slovenia

Tanja Planinšek Ručigaj

Email: [e-mail]

1 Introduction

Biofilm is an assemblage of microbial cells which have an extracellular polysaccharide matrix on a surface [1, 2]. In the 1650s van Leeuwenhoek discovered the biofilm. In 1978 research on biofilm has exploded [3]. In the last decade the concept of biofilm in clinical practice was emerged [3].

The development of infection delays the normal wound healing process [4, 5]. Endotoxin and exotoxin produced by the microorganisms and local inflammatory processes cause the wound infection signs: pain, redness, swelling, pain and odor or pus [6–8], and fragile, brown granulation. Biofilms play a significant role of infections special at chronic wounds too [1].

Most often bacteria are found in two forms: like sessile biofilm cells and like free-flowing bacteria in suspension—planktonic form which is rare [3]. The solid-liquid interface is an ideal environment for the attachment and growth of microorganisms (water, blood). The solid surface which is hydrophobic, nonpolar (Teflon, plastics) attaches more rapidly the microorganisms than hydrophilic materials (glass, metals). A material surface exposed in an aqueous medium will almost immediately become coated by polymers from that medium. That will result in chemical modification and affect the rate and extent of microbial attachment [9]. Loeb and Neihof were found that biofilms were formed within minutes and grow for several hours [10]. Tolker-Nielsen and Molin [11] noted that every microbial biofilm community is unique. Bacteria from the oral cavity colonize pellicle-conditioned surfaces within hours of exposure [12]. Blood, saliva, tears, intervascular fluid, urine, and respiratory secretions influence the attachment of bacteria to biomaterials [13].

Nutrient levels, ionic strength, pH, and temperature of aqueous medium have an important role of microbial attachment to a substratum. An increase in the concentrations of ferric iron, sodium, and calcium is important to attachment of Pseudomonas fluorescens to glass surfaces (they represent repulsive forces between the glass surface and the negatively charged bacterial cells) [14]. The hydrophobic cell surface of microbial cells, fimbriae, flagella, and extracellular polymeric substance matrix influence the rate of attachment [9]. Amino acids from fimbriae contribute to hydrophobicity of cell surface and that influence initial electrostatic repulsion barrier too [15].

The biofilm on water system contains filamentous bacteria, freshwater diatoms, and corrosion products with clay. On the other hand the biofilms on the medical device are composed from one species of bacteria with extracellular polymeric substance matrix [9].

2 Forming of Biofilm

Stages of development of biofilms are as follows:

1.

Reversible fastening of the freely floating bacteria on the surface.

2.

Irreversible fastening, which allows the creation of communities or colonies of bacteria. Bacteria with fimbriae or flagels surface can easier be attached [15]. They can attach to different surfaces (like medical devices, plumbing system) (corrosion) and to living tissue (wounds, teeth). Biofilm is formed on places where liquid and solid media surface comes together [9]. The easiest it sticks to is on hydrophobic, nonpolar surface [16]. Gram-positive bacteria that secrete myolitic acid are easier to attach to the hydrophobic substrate, while the extracellular polymeric substances and lipopolysaccharide (O antigens) of Gram-negative bacteria are important in attaching onto the hydrophilic substrate (Table 1) [9, 17, 18]. Even the regulation of genes encoding enzymes involved in glycolysis or fermentation (phosphoglycerate mutase, alcohol dehydrogenase, and triosephosphate isomerase) of Staphylococcus aureus influences biofilm formation [19]. Genes that control the synthesis of polyphosphokinase and algD, algU, and rpoS are important in the formation of biofilm of Pseudomonas aeruginosa [20].

3.

Bacteria grow quickly in the colonies under a protective matrix, which makes it even easier to reproduce and provides a higher survival rate. The matrix is largely composed of polysaccharides from Gram-negative bacteria (mostly neutral or polyanionic). The presence of d-glucuronic, d-galacturonic, and mannuronic acid or ketal tied pyruvates decide on anionic properties [15]. These properties enable the calcium and magnesium divalent cation binding easier. Polymer extracellular matrix not only protects the bacteria against antibiotics, disinfectants, and certain procedures of debridements, but also protects the bacteria from other external influences. Coat is permeable to oxygen from the environment, and it allows the passage of carbon dioxide into the environment. Coat is permeable to nutrients. The bacteria dismiss the degradation products in the neighborhood through a special water channel. Bacteria in biofilm metabolize more slowly, reproduce less frequently, and show different phenotype traits than the same planktonic bacteria. Bacteria in biofilm are 1000 times more resistant to antimicrobial therapy (as opposed to planktonic bacteria) [21].

4.

So a mature biofilm is formed. Quorum-sensing molecules (pheromones) manage with the planktonic and sessile microorganism [22].

5.

In the next stage, there is a partial decomposition of the biofilm with the help of various enzymes. The greater is the flow of liquid on the surface of the biofilm and the modification of the base on which they are fastened bacteria, the faster is the decomposition of a biofilm, and the release of individual bacteria [23].

6.

Individual bacterial cells are re-released into the environment.

7.

Individual free-floating bacteria find new areas for settlement.

8.

New re-formed colonies are protected by polimeric matrix (slime) and biofilm occurs (Fig. 1).

9.

We measure speed of creating of biofilm in hours. The acceptance of microbes to the surface lasts only a minute. The growth of microcolonies takes a 2–4 h. The development of the initial extracellular polysaccharide matrix lasts 6–12 h. The mature biofilm is constructed in 2–4 days, depending on the species and growth conditions [24].

Table 1

Important factors which influence cell attachment and biofilm formation [9]

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Fig. 1

Forming of biofilm

Some of the frequent microorganisms which make a biofilm on the wounds are S. epidermidis, S. aureus, and P. aeruginosa [25, 26]. Biofilms can be found in 6% on acute wounds and in 60% on chronic wounds [23, 27].

Pseudomonas aeruginosa grow primarily as a base of biofilm and growth faster as a pure culture in biofilm than in the mixed culture. It rapidly colonized the surface K. pneumoniae form localized microcolonies (covering around 10% of the area) so they have greater access to oxygen and nutrients [28]. Gilbert et al. [29] showed that hydrophobicity of newly dispersed cells is low and increases with continued incubation and growth.

3 Identification of Biofilm

Indirect clinical indicator of biofilm in the wound is shiny, slough, devitalized fibrin which is opaque loosely attached in same parts of the wound bed (Table 2) (Fig. 2) [23, 30]. It was a big problem to prove the biofilm formation in wounds because biofilms are very small size and wound biofilm bacteria are difficult or impossible to culture [31]. Now identification of biofilm formation is possible by light or electron microscopy and confocal laser scanning microscopy and using the fluorescent dye [23, 32–37]. Extracellular polymeric, polysaccharide matrix which surrounds the bacteria in biofilm can be demonstrated with staining with ruthenium red, carbohydrate stains, and concanavalin A [38].

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Fig. 2

The flowchart of clinical algorithm of biofilm in the wound

Table 2

Indirect clinical indicator of biofilm

4 Biofilm Response to Different Treatments

For chronic wounds to begin to heal, we need to remove the biofilm. The greatest role alongside with sharp debridement is of biological and ultrasound debridement and changes in electrical charge. Last but not least important are antiseptics, which can slightly slow down the formation of biofilm. Significant antimicrobials against biofilm are silver and polyhexene-biguanides (PHMB) [3, 39].

Different studies have shown that treatment of adsorbed cells with proteolytic enzymes caused a release of attached bacteria [40, 41]. The antibiotic tolerance of the biofilm in vitro studies shows that the biofilm can withstand treatment with very high dosages of antibiotics. It can be up to 1000 times higher than the minimal inhibitory concentration is [42]. The biofilm matrix from proteins, extracellular DNA, and polysaccharides reduces penetration and bind of the antibiotics [43–49].

For removing the biofilms, antiseptics are preferred over antibiotics [24, 50]. Silver and PHMB are very effective against planktonic bacteria and immature biofilms (Table 3). Applied on mature biofilms they can only inhibit further growth and prevent bacteria from spreading beyond the biofilm but not resolve the infection [2, 51–53]. The antimicrobial efficacy of silver dressings against bacterial biofilms was investigated by in vitro and in vivo models. Hegger and his colleagues show that dressings with silver reduced biofilm less than 90% in 1-week treatment in an animal model [54]. But in vitro methodes show better results as proven by Percivaletal. They reported that Hydro fiber dressings with silver acting against bacterial bio films after 24 h of treatment, and total killed bacterial biofilm within 48 h [55].

Ultrasound waves can disrupt biofilm but the decrease in bacterial counts was not significant [56–63]. Bio-debridement with larvae and debridement with negative pressure therapy also have positive secondary effects on combining disruption of biofilms [64–66]. But gold standard and most important and effective to remove biofilm is sharp debridement which we repeated during 48–72 h. With that we allow the opening of the therapeutic window and can apply the antiseptics [23]. Reformation of biofilm after mechanical destruction is possible within 24 h, depending on species, from planktonic bacteria from biofilm or growth from bacteria newly introduced into the wound [24, 53, 67, 68].

Therapy against biofilm will be successful if we:

1.

Break down quorum-sensing molecules

2.

Degrade extracellular polymeric substances

3.

Block acceptance of biofilm on surface (Fig. 3) [23, 24, 69]

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Fig. 3

The principles of operating on biofilm

Table 3

Antiseptics against biofilm

5 Clinical Experience

In all studies we measured only the wound size and isolated bacteria, but did not search for biofilm, because at that time we did not have the possibilities for that. All the studies included patients with the wounds that were lasting for a long time and the wound bed was slough, so there were big possibilities for biofilms on them.

5.1 Study 1: Honey and Metal Ions’ Positive Effects [70]

1.

60 venous leg ulcers (ABPI > 0.8) were randomly positioned into one of the two groups by closed numbered envelopes.

2.

Patients were observed for 6 weeks or less (if ulcers were healed).

3.

Exclusion criterias: Insulin-dependent diabetes mellitus, rheumatoid arthritis, uncontrollable hypertension, cardiac decompensation, carcinoma, and immobility.

4.

Including criterias: Ankle brachial pressure index (ABPI) higher than 0.8.

5.

Wound bed: Staging in B or C class by Falanga’s classification, and delayed or stopped healing, risk of infection, foul odor, or discoloration of granulation tissue.

6.

First group, with mean age 72, was treated with honey-based dressings (MelMax®).

7.

Second group was treated with silver/charcoal-based dressings (Actisorb silver®).

8.

Furthermore compression with long-stretch bandages was used at every patient.

9.

Mean duration of ulcer in group 1 before study was 27 months, while in group 2 that time was 38 months.

10.

At the beginning of the study, ulcers’ areas were drawn into appointed film dressings and precisely measured with a digital planimeter (Placom KP-90N; Japan); the latter was repeated at the end as well.

11.

As for the size of the ulcers in MelMax® group they show a great reduction from mean 28 cm² (min. 1 cm², max. 133 cm²) to 17 cm² (min. 0 cm², max. 72 cm²), which represents impressive 36.7% in mean duration of treatment of 44 days (Figs. 4 and 5).

12.

In Actisorb® group they show stagnation with little or no improvement over time (mean duration of therapy was 42 days) from the beginning mean size of 16 cm² (min. 1 cm², max. 74 cm²) to the final 15 cm² (min. 1 cm², max. 70 cm²), which represents merely 2.8% decrease in area (Tables 4 and 5).

13.

Because of the possible risk of systemic infection each day one swab from the wound bed was taken in 15 patients, 9 from group 1 and 6 from group 2. Of those in group 1 after 1 week of therapy with honey-based dressing only one patient needed additional systemic antibiotic therapy, while of those in group 2 after 1 week of therapy with silver/charcoal-based dressing all needed additional systemic antibiotic therapy.

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Fig. 4

Patients treated with honey before study

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Fig. 5

Patients treated with honey after study

Table 4

Differences of wound sizes from both dressings

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Table 5

Wound size reductions in both dressings in percentage

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5.2 Study 2: The Effects of Alginate Dressings with Silver on Healing Rate and Pain

In a randomized study we evaluated the effects of two alginate dressings on the healing:

1.

Patients with 20 pain venous leg ulcers in stage C3 were included.

2.

They were randomly included into one of the groups by closed numbered envelopes.

3.

Compression with long-stretch bandage was used in every patient.

4.

Half of the ulcers were treated with alginate dressings with silver Silvercel®.

5.

Other half of the ulcers were treated with another calcium alginate dressing Algisite M®.

6.

At the beginning and at the end of the study the ulcer areas were drawn onto film dressing and then precisely measured by using digital planimeter (Table 6) (Figs. 6 and 7).

7.

At the beginning and at the end of the study questionnaires, concerning pain was filled (Table 7).

8.

Only one of the four categories was possible to choose (no, mild, moderate, and severe pain).

9.

Results: Ulcers treated with alginate with silver (Silvercel®) were smaller for 15.4% and ulcers treated with calcium-alginate without silver were larger for 0.7% (Table 6) and pain was smaller at the patients treated with alginate dressings with silver (Table 7) [71].

Table 6

Wound size before and after study with different alginate dressings

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Fig. 6

Patients treated with alginate dressing with silver before study

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Fig. 7

Patients treated with alginate dressing with silver after study

Table 7

Pain before and after study with different alginate dressings

5.3 Study 3: Comparative Clinical Trial

Comparing the hydrofiber dressing and ointments in changing microbial colonization and healing:

1.

24 patients with 42 venous leg ulcers (ABPI 0.80–1.40; B 2–3)

2.

Treated: 12 hydrofiber and 12 with ointments 7 weeks

Results: The most frequently isolated bacteria in group with using hydrofibre-dressings (Aquacel®) was P. aeruginosa (at the beginning: 44.4%; at the end: 20%) in group with ointment was most frequently P. aeruginosa (at the beginning: 53.3%; at the end: 60%). Mean wound size at treating wounds with hydrofiber dressing was 9.6 cm² at the beginning and 8.8 cm² at the end. Mean wound size at the treating wounds with ointments was 16.4 cm² at the beginning and 19.5 cm² at the end (Figs. 8 and 9) [72].

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Fig. 8

Patients treated with hydrofiber dressing before study

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Fig. 9

Patients treated with hydrofiber dressing after study

5.4 Study 4: Wound Management with Foam with PHMB

This small study included five patients with no progress in healing venous leg ulcers for 5.2 years (mean). At the beginning their wound beds were in stage C3 and size was 24.44 cm² (mean). Foam AMD with PHMB® changed every 3–4 days. The treatment lasted (mean) 44.7 days or until wound did not healed. Results: One wound healed. The others were smaller and measurement at the end 17.69 cm² mean (Figs. 10 and 11). The wound beds were in stage A2 in all patients (Table 8) [73].

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Fig. 10

Patients treated with dressing with PHMB before study

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Fig. 11

Patients treated with dressing with PHMB after study

Table 8

Wound bed and size before and after applying the dressing with PHMB

5.5 Study 5: Experience with the First Slovenian Dressing for the Treatment of Chronic Infected Wounds

In a randomized clinical study, effects were evaluated on healing and pain in 14 venous leg ulcers with wound beds C2–3 treated with honey (Vivamel®—group 1) and 16 venous leg ulcers with wound bed C3 treated with antiseptic (AMD with PHMB®—group 2). Results: In group 1 healing was fasters (after one week), but patients in group 2 experienced less pain than patients in group 1. After 2 weeks all the ulcers from both groups were in B2 stage by Falanga’s classification of wound bed (Table 9) (Figs. 12, 13, 14, and 15) [74].

Table 9

Wound bed and pain before and after applying dressings with PHMB and honey

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Fig. 12

Patients treated with dressing with PHMB before study

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Fig. 13

Patients treated with dressing with PHMB after study

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Fig. 14

Patients treated with dressing with honey before study

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Fig. 15

Patients treated with dressing with honey after study

5.6 Study 6: Treatment with Different Alginate Dressings

In a small clinical trial seven patients were included (five women, two men; average age of 77.14 years) with venous leg ulcers (ABPI 0.8 and higher) in stage C3 (Falanga V. classification of wound bed). Average time of treatment was 4.43 days. Alginate dressings are used for sloughy wounds with fibrinous bed. One half of ulcer was treated with calcium alginate dressing with added manganese and zinc ions and chlorophyllin alginate dressing (Trionic®) and the other half of the same ulcer with another alginate dressing (Algisite M®). Compression with long-stretch bandages was used at every patient. Results: Half of the ulcer treated with calcium alginate dressing with added manganese and zinc ions and chlorophyllin alginate dressing showed better progress in 100% whether the other half of the same ulcer treated with another Ca alginate dressing showed progress in only 28% (Table 10) (Figs. 16 and 17) [75, 76].

Table 10

Wound bed at the beginning and at the end of the study

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Fig. 16

Patient during the study with different alginate dressings

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Fig. 17

Patient at the end of the study with different alginate dressings

Conclusions

At our studies we were demonstrated that wounds with critical colonization and probably biofilms were faster healing if we were using dressings with antiseptics. Bacteria organized in biofilm formation significantly affect the healing of chronic wounds. Identification of biofilm is still no part of the daily routine. But the sharp debridment is still the most efficient option for removing the biofilm.

References

1.

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