Shepard J, Ward W, Milstone A Financial impact of surgical site infections on hospital: the hospital management perspective. JAMA Surgery. 2013; 148:(10)907-914

de Lissovoy G, Fraeman K, Hutchins V Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009; 37:(5)387-397

Herwaldt LA, Cullen JJ, Scholz D A prospective study of outcomes, healthcare resource utilization, and costs associated with postoperative nosocomial infections. Infect Control Hosp Epidemiol. 2006; 27:(12)1291-1298

World Health Organization (WHO), European Health Information Gateway. Total number of inpatient surgical procedures per year. (accessed 5 December 2016)

Hall-Stoodley L, Stoodley P, Kathju S Towards diagnostic guidelines for biofilm-associated infections. FEMS Immunol Med Microbiol. 2012; 65:(2)127-145

Percival SL. Biofilms and their potential role in wound healing. Wounds. 2004; 16:234-240

Römling U, Balsalobre C. Biofilm infections, their resilience to therapy and innovative treatment strategies. J Intern Med. 2012; 272:(6)541-561

National Institute of Health Research on microbial biofilms: PA Number: 2002, PA-03-047. (accessed 25 November 2016)

Dowd SE, Wolcott RD, Sun Y Polymicrobial nature of chronic diabetic foot ulcer biofilm infections determined using bacterial tag encoded FLX amplicon pyrosequencing (bTE-FAP). PLoS ONE. 2008; 3:(10)

Edmiston CE, Krepel CJ, Marks RM Microbiology of explanted suture segments from infected and noninfected surgical patients. J Clin Microbiol. 2013; 51:(2)417-421

Høiby N, Ciofu O, Johansen HK The clinical impact of bacterial biofilms. International Journal of Oral Science. 2011; 3:(2)55-65

Jensen PØ, Givskov M, Bjarnsholt T, Moser C. The immune system vs. Pseudomonas aeruginosa biofilms. FEMS Immunol Med Microbiol. 2010; 59:(3)292-305

Akers KS, Mende K, Cheatle KA Infectious Disease Clinical Research Program Trauma Infectious Disease Outcomes Study Group. Biofilms and persistent wound infections in United States military trauma patients: a case–control analysis. BMC Infect Dis. 2014; 14:(1)

Buchan B, Ledeboer N, Edmiston CE. Acinetobacter infections: epidemiology and pathogenesis of a significant healthcare-associated pathogen. Healthcare Infection. 2011; 16:(1)6-17

Costerton JW, Cheng KJ, Geesey GG Bacterial biofilms in nature and disease. Annu Rev Microbiol. 1987; 41:(1)435-464

del Pozo JL, Patel R. The challenge of treating biofilm-associated bacterial infections. Clin Pharmacol Ther. 2007; 82:(2)204-209

Hasanadka R, Seabrook GR, Edmiston CE. Vascular graft infections, 2nd edn. In: Rello J, Vanes J, Kollef M (eds). : Kluwer Academic Publishers; 2007

Barnes S, Spencer M, Graham D, Johnson HB. Surgical wound irrigation: a call for evidence-based standardization of practice. Am J Infect Control. 2014; 42:(5)525-529

Nemoto K, Hirota K, Ono T Effect of varidase (streptokinase) on biofilm formed by Staphylococcus aureus. Chemotherapy. 2000; 46:(2)111-115

James GA, Ge Zhao A, Usui M Microsensor and transcriptomic signatures of oxygen depletion in biofilms associated with chronic wounds. Wound Repair Regen. 2016; 24:(2)373-383

Gilbert P, Maira-Litran T, McBain AJ The physiology and collective recalcitrance of microbial biofilm communities. Adv Microb Physiol. 2002; 46:203-256

Arnold WV, Shirtliff ME, Stoodley P. Bacterial biofilms and periprosthetic infections. J Bone Joint Surg Am. 2013; 95:(24)2223-2229

Flemming HC, Wingender J. The biofilm matrix. Nat Rev Microbiol. 2010; 8:(9)623-633

Stoodley P, Sidhu S, Nistico L Kinetics and morphology of polymicrobial biofilm formation on polypropylene mesh. FEMS Immunol Med Microbiol. 2012; 65:(2)283-290

Gilbert P, Maira-Litran T, McBain AJ The physiology and collective recalcitrance of microbial biofilm communities. Adv Microb Physiol. 2002; 46:203-256

Davies DG, Marques CN. A fatty acid messenger is responsible for inducing dispersion in microbial biofilms. J Bacteriol. 2009; 191:(5)1393-1403

Percival SL, Hill KE, Williams DW A review of the scientific evidence for biofilms in wounds. Wound Repair Regen. 2012; 20:(5)647-657

Wolcott RD, Rhoads DD, Dowd SE. Biofilms and chronic wound inflammation. J Wound Care. 2008; 17:(8)333-341

Wolcott RD, Rhoads DD, Bennett ME Chronic wounds and the medical biofilm paradigm. J Wound Care. 2010; 19:(2)45-53

Wolcott RD, Rhoads DD. A study of biofilmbased wound management in subjects with critical limb ischaemia. J Wound Care. 2008; 17:(4)145-155

Leaper D, Ousey K. Evidence update on prevention of surgical site infection. Curr Opin Infect Dis. 2015; 28:(2)158-163

Wolcott RD, Rumbaugh KP, James G Biofilm maturity studies indicate sharp debridement opens a time-dependent therapeutic window. J Wound Care. 2010; 19:(8)320-328

Wolcott RD, Kennedy JP, Dowd SE. Regular debridement is the main tool for maintaining a healthy wound bed in most chronic wounds. J Wound Care. 2009; 18:(2)54-56

Wolcott RD, Cox S. More effective cell-based therapy through biofilm suppression. J Wound Care. 2013; 22:26-31

Engelsman AF, van der Mei HC, Ploeg RJ, Busscher HJ. The phenomenon of infection with abdominal wall reconstruction. Biomaterials. 2007; 28:(14)2314-2327

British Hernia Society. Association of Surgeons of Great Britain and Ireland Commissioning guide: groin hernia. 2013. (accessed 5 December 2016)

Engelsman AF, van der Mei HC, Busscher HJ, Ploeg RJ. Morphological aspects of surgical mesh as a risk factor for bacterial colonization. Br J Surg. 2008; 95:(8)1051-1059

Sanchez CJ, Mende K, Beckius ML Biofilm formation by clinical isolates and the implications in chronic infections. BMC Infect Dis. 2013; 13:(1)

Edmiston CE, Goheen MP, Seabrook GR Impact of selective antimicrobial agents on staphylococcal adherence to biomedical devices. Am J Surg. 2006; 192:(3)344-354

Bandyk DF, Black MR. Infection in prosthetic vascular grafts, 6th edn. In: Rutherford RB, Johnson KW (eds). : Elsevier Saunders; 2005

Del Pozo JL, Patel R. Clinical practice. Infection associated with prosthetic joints. N Engl J Med. 2009; 361:(8)787-794

Public Health England. Surgical site infections (SSI) surveillance: NHS hospitals in England (2014/2015). (accessed 5 December 2016)

Portillo ME, Corvec S, Borens O Propionibacterium acnes: an underestimated pathogen in implant-associated infections. Biomed Res Int. 2013; 2013

Costerton JW, Lewandowski Z, Caldwell DE Microbial Biofilms. Annu Rev Microbiol. 1995; 49:(1)711-745

Edmiston CE. Prosthetic device infections in surgery. In: Nichols RL, Nyhus LM (eds). : JB Lippincott; 1993

Kim DH, Spencer M, Davidson SM Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am. 2010; 92:(9)1820-1826

Gilbert P, Maira-Litran T, McBain AJ The physiology and collective recalcitrance of microbial biofilm communities. Adv Microb Physiol. 2002; 46:203-256

Stewart PS. Antimicrobial tolerance in biofilms. Microbiol Spectr. 2015; 3:(3)

Hunt SM, Werner EM, Huang B Hypothesis for the role of nutrient starvation in biofilm detachment. Appl Environ Microbiol. 2004; 70:(12)7418-7425

Werner E, Roe F, Bugnicourt A Stratified growth in Pseudomonas aeruginosa biofilms. Appl Environ Microbiol. 2004; 70:(10)6188-6196

Jayaraman R. Bacterial persistence: some new insights into an old phenomenon. J Biosci. 2008; 33:(5)795-805

Gilbert P, Maira-Litran T, McBain AJ The physiology and collective recalcitrance of microbial biofilm communities. Adv Microb Physiol. 2002; 46:203-256

Bigger JW. Treatment of staphylococcal infection with penicillin. Lancet. 1944; 2:497-500

Conlon BP, Rowe SE, Lewis K. Persister cells in biofilm associated infections. Adv Exp Med Biol. 2015; 831:1-9

Hall MR, McGillicuddy E, Kaplan LJ. Biofilm: basic principles, pathophysiology, and implications for clinicians. Surg Infect (Larchmt). 2014; 15:(1)1-7

Elgharaby H, Mann E, Awad H First evidence of sternal wound biofilm following cardiac surgery. PLoS ONE. 2013; 8

Cardinal M, Eisenbud DE, Armstrong DG Serial surgical debridement: a retrospective study on clinical outcomes in chronic lower extremity wounds. Wound Repair Regen. 2009; 17:(3)306-311

Leaper DJ, Meaume S, Apelqvist J Debridement methods of non-viable tissue in wounds. In: Farrar D (ed). : Woodhead Publishers; 2011

Edmiston CE, Daoud FC, Leaper D. Is there an evidence-based argument for embracing an antimicrobial (triclosan)-coated suture technology to reduce the risk for surgical-site infections?: A meta-analysis. Surgery. 2013; 154:(1)89-100

Edmiston CE, Bruden B, Rucinski MC Reducing the risk of surgical site infections: does chlorhexidine gluconate provide a risk reduction benefit?. Am J Infect Control. 2013; 41:S49-S55

Griffin JW, Guillot SJ, Redick JA, Browne JA. Removed antibioticimpregnated cement spacers in two-stage revision joint arthroplasty do not show biofilm formation in vivo. J Arthroplasty. 2012; 27:(10)1796-1799

Barber KE, Werth BJ, McRoberts JP, Rybak MJ. A novel approach utilizing biofilm time-kill curves to assess the bactericidal activity of ceftaroline combinations against biofilm-producing methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother. 2014; 58:(5)2989-2992

Seaton RA, Malizos KN, Viale P Daptomycin use in patients with osteomyelitis: a preliminary report from the EU-CORESM database. J Antimicrob Chemother. 2013; 68:(7)1642-1649

Oates A, Bowling FL, Boulton AJ The visualization of biofilms in chronic diabetic foot wounds using routine diagnostic microscopy methods. J Diabetes Res. 2014; 2014

A narrative review of microbial biofilm in postoperative surgical site infections: clinical presentation and treatment

02 February 2019
Volume 3 · Issue 1



The global impact of surgical site infections (SSIs) on health-care systems is considerable: many are related to the formation of a microbial biofilm. Biofilm plays a significant role in the pathogenesis of implantable device-related infections and are also important in persistent postoperative skin and soft tissue wound infections.


PubMed and OVID databases were searched for relevant articles regarding biofilm-associated infection in surgery, including epidemiology, diagnosis, treatment and management.


Biofilm-associated infections increase the use of health-care resources, prolong length of stay, increase cost of antibiotic therapy, result in additional surgical revisions and extend rehabilitation after discharge from health care. Staphylococcus aureus and Staphylococcus epidermidis are the most common isolates recovered from device-related infections. Early infection occurs within two weeks of implantation and is associated with intraoperative wound contamination; late-onset infections are often occult prolonging recognition by weeks, months and in some cases, years. Biofilm is a physical barrier against antibodies and granulocytic cell populations which may also impede the penetration of antibiotics. The ideal strategy for preventing biofilm-associated SSI is to prevent intraoperative contamination through compliance with effective surgical care bundles. Management of postoperative biofilm-associated infections involves surgical debridement followed by irrigation with antimicrobial agents and removal of infected devices, followed by insertion of antimicrobial adjuncts such as antimicrobial spacers, beads or sutures together with selective therapeutic agents that penetrate the mature biofilm.


Biofilm-associated infections are a significant source of postoperative morbidity and mortality. Appropriate interventional strategies are warranted to reduce the risk of intraoperative contamination.

The Centers for Disease Control and Prevention of the United States (CDC) has reported that 51.4 million inpatient surgical procedures were performed in the US in 2011, and approximately 400,000 of these procedures were complicated by a surgical site infection (SSI) with an associated mortality as high as 25%.1,2,3 Data available from Europe in 2009 indicate that in excess of 61 million surgical procedures were undertaken for inpatient surgery alone and it is likely that infection rates are similar to elsewhere in the world, imposing a significant burden on health-care resources, much of which in Europe is publicly funded.4

This global impact of SSIs on health-care systems is considerable and, according to some reports, as many as 80% of these SSIs may be related to the formation of a microbial biofilm.5,6,7,8 Many of the microbial populations associated with SSIs, and other chronic wounds, exist within the biofilm matrix as a heterogeneous community.9,10 The presence of a microbial biofilm, within host tissue or on the surface of a biomedical device, poses a significant clinical dilemma when attempting to eradicate subsequent infections. Biofilm-mediated infections exhibit resistance to host defences, often contributing to an excessive or inappropriate inflammatory response, leading to complement activation and formation of immune complexes, that in turn lead to tissue injury.11,12 In addition, biofilms are notoriously recalcitrant to antimicrobial therapy; often resulting in therapeutic failure following traditional parenteral antibiotic therapy.7,10

Register now to continue reading

Thank you for visiting Wound Central and reading some of our peer-reviewed resources for wound care professionals. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Access to clinical or professional articles

  • New content and clinical updates each month