Recommendations for the management of biofilm: a consensus document
The potential impact of biofilm on healing in acute and chronic wounds is one of the most controversial current issues in wound care. A significant amount of laboratory-based research has been carried out on this topic, however, in 2013 the European Wound Management Association (EWMA) pointed out the lack of guidance for managing biofilms in clinical practice and solicited the need for guidelines and further clinical research.
In response to this challenge, the Italian Nursing Wound Healing Society (AISLeC) initiated a project which aimed to achieve consensus among a multidisciplinary and multiprofessional international panel of experts to identify what could be considered part of ‘good clinical practice’ with respect to the recognition and management of biofilms in acute and chronic wounds. The group followed a systematic approach, developed by the GRADE working group, to define relevant questions and clinical recommendations raised in clinical practice.
An independent librarian retrieved and screened approximately 2000 pertinent published papers to produce tables of levels of evidence. After a smaller focus group had a multistep structured discussion, and a formal voting process had been completed, ten therapeutic interventions were identified as being strongly recommendable for clinical practice, while another four recommendations were graded as being ‘weak’.
The panel subsequently formulated a preliminary statement (although with a weak grade of agreement): ‘provided that other causes that prevent optimal wound healing have been ruled out, chronic wounds are chronically infected’. All members of the panel agreed that there is a paucity of reliable, well-conducted clinical trials which have produced clear evidence related to the effects of biofilm presence. In the meantime it was agreed that expert-based guidelines were needed to be developed for the recognition and management of biofilms in wounds and for the best design of future clinical trials. This is a fundamental and urgent task for both laboratory-based scientists and clinicians
Treatment of non-healing, or hard-to-heal, wounds is a critical issue which is being addressed by health-care systems worldwide. This affects a considerable number of the population of the Western World, requires expensive investigation, intervention and treatment, and accounts for 2–4% of health-care budgets.1
Overt infection, or an increasing colonising bioburden, are the most common complications of chronic wounds which lead to prolonged treatment and increased the use of resources. In the last 40 years the use of products with an antimicrobial activity to prevent and treat increasing bioburden and infection has dramatically increased.
On the other hand, there is an increasing need to reduce the non-appropriate use of antibiotics, to tackle antimicrobial resistance and to avoid adverse or tissue toxic effects caused by topical antimicrobial agents.
Published studies have associated the development from the classically cultured planktonic growth microorganism phenotype to a complex, diverse biofilm phenotype in chronic wounds which leads to impairment of wound healing.2
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