Biofilm Based Wound Care

Planktonic vs BiofilmPlanktonic vs Biofilm

OverviewOverview

Medical BiofilmsMedical Biofilms

Wound BiofilmWound Biofilm

BioburdenBioburden

Biochemical Impairment of Biochemical Impairment of Chronic WoundsChronic Wounds

Elevated proinflammatory cytokinesElevated proinflammatory cytokines

Elevated proteinase activity – MMPsElevated proteinase activity – MMPs

Diminished activity of growth factorsDiminished activity of growth factors

Degraded receptor sitesDegraded receptor sites

Excessive NeutrophilsExcessive Neutrophils

Diegelmann RF Wound Repair Regen Vol 11 2003

Biofilm and InflammationBiofilm and Inflammation

Costerton and Stewart Science Vol 284, 1999

Biofilm DefensesBiofilm Defenses

Host DefensesHost Defenses

Lam, JS Infect Immun Vol 42, 1983

Host DefensesHost Defenses

Leid, JG Infect Immun Vol 70, 2002

Antibiotic ResistanceAntibiotic Resistance MRSA, MDRPA, VREMRSA, MDRPA, VRE

BiofilmBiofilmVanc vs Staph biofilm Vanc vs Staph biofilm >1000x>1000x

Tobra vs Tobra vs Pseudomonas biofilmPseudomonas biofilm

Biocides vs. BiofilmBiocides vs. Biofilm

DakinsDakins

PeroxidePeroxide

Acetic AcidAcetic Acid

Costerton Sci Am Vol 285, 2001

Acute vs. Chronic Acute vs. Chronic WoundWound

For every mistake for not knowing ten are made for not For every mistake for not knowing ten are made for not lookinglooking

Chronic WoundChronic Wound

Acute WoundAcute Wound

Common Pathogens in SSSIs: Common Pathogens in SSSIs: SENTRY United States and Canada, 2000SENTRY United States and Canada, 2000

N=1404Staphylococcus aureus

Rennie RP et al. Diagn Microbiol Infect Dis. 2003;45:287-293.

Pull off chart

MRSA, 14%

MSSA, 32%

Other, 30%β-Hemolytic

streptococci, 2%

Coagulase-negative

Staphylococcus, 3%

Pseudomonas aeruginosa, 11%

Enterococcus spp, 8%

MRSA=methicillin-resistant S aureus.MSSA=methicillin-susceptible S aureus.

Molecular StudiesMolecular Studies

Gel LaneDistinct Bands

Bacteria cultured

Wound type

A 2 2Non-healing

surgical wound

B 1 0Venous leg

ulcerC 2 2 Calciphylaxis

D 5 2Venous leg

ulcer

E 6 3Diabetic foot

ulcer

F 1 2Venous leg

ulcer

G 11 3 Chronic wound

H 3 1Venous leg

ulcer

I 8 1Diabetic foot

ulcer

J 9 2Diabetic foot

ulcer

K 7 1 Decubitus ulcer

L 6 1Diabetic foot

ulcer

M 5 2Non-healing

surgical wound

Cystic FibrosisCystic Fibrosis

PseudomonasPseudomonas BurkholderiaBurkholderia StaphylococcusStaphylococcus

121 unique organisms121 unique organisms 25% ~ 1/3 dominant25% ~ 1/3 dominant 50% ~ 2/3 dominant 50% ~ 2/3 dominant

Harris PNAS Vol 104 2007

454 Data454 DataShana XXXX 14730 Hsp_evalue

Buttiauxella noackiae NSW11T 51607T); AJ293689 16.02 1.65E-139

Streptococcus dysgalactiae subsp. dysgalactiae ATCC 43078; AB002485 7.82 1.34E-134

Staphylococcus aureus CCM 7213; AY727530 7.03 7.00E-129

Enterococcus spp. 5.90 4.71E-136

Kluyvera georgiana ATCC 51603; AF047186 5.90 8.83E-139

Streptococcus pneumoniae 5.32 7.78E-136

Corynebacterium spp. 5.14 1.09E-128

Raoultella planticola ATCC 33531T; AF129443 5.11 1.99E-138

Peptoniphilus harei DSM 10020; SBH432; Y07839 4.60 2.24E-140

Cedecea davisae DSM 4568; AF493976 4.53 1.28E-137

Finegoldia magna ATCC15794; GIFU 7881; D14149 4.49 1.38E-128

Actinomyces europaeus CCUG 32789A; Y08828 3.26 2.36E-142

Streptococcus agalactiae ATCC 13813, NCTC 8181; AB002479 3.22 5.21E-137

Burkholderia spp. 2.81 2.25E-128

Delftia spp. 1.92 2.89E-134

Escherichia spp. 1.85 2.38E-140

Pseudomonas spp. 1.78 8.34E-132

Stenotrophomonas maltophilia ATCC 13637T; AB008509 1.23 6.43E-118

Yersinia intermedia ATCC 29909; AF366380 1.23 1.18E-133

Streptococcus anginosus NCTC 10713 X58309 1.17 1.98E-133

Achromobacter denitrificans DSM 30026, type strain; Y14907 1.06 6.39E-127

Peptoniphilus ivorii DSM 10022; SBH093; Y07840 1.03 3.11E-117

Peptostreptococcus spp. 1.03 2.05E-133

Ecology of WoundsEcology of Wounds        

Acidovorax* Acidovorax* Enterococcus Enterococcus Peptoniphilus*Peptoniphilus*

Acinetobacter Acinetobacter Escherichia*Escherichia* Prevotella* Prevotella*

Actinomyces* Actinomyces* Eubacterium*Eubacterium* ProteusProteus

Alcaligenes* Alcaligenes* Ferrimonas* Ferrimonas* Pseudomonas Pseudomonas

Anaerococcus* Anaerococcus* Finegoldia* Finegoldia* Rhodopseudomonas* Rhodopseudomonas*

Bacillus* Bacillus* Fusobacterium* Fusobacterium* Riemerella* Riemerella*

Bacteroides* Bacteroides* Gemella* Gemella* Salmonella* Salmonella*

Bradyrhizobium* Bradyrhizobium* Gordonia* Gordonia* Selenomonadaceae* Selenomonadaceae*

Brevibacterium* Brevibacterium* Haemophilus* Haemophilus* Serratia Serratia

Brevundimonas* Brevundimonas* Hydrogenophaga* Hydrogenophaga* Sphingomonas* Sphingomonas*

Clostridium* Clostridium* KlebsiellaKlebsiella Staphylococcus Staphylococcus

CorynebacteriumCorynebacterium Morganella* Morganella* Stenotrophomonas* Stenotrophomonas*

Delftia* Delftia* Paenibacillus*Paenibacillus* Streptococcus Streptococcus

Dendrosporobacter*Dendrosporobacter* Pantoea* Pantoea* Varibaculum* Varibaculum*

Dialister* Dialister* Pectobacterium* Pectobacterium* Veillonella* Veillonella*

Eikenella* Eikenella* Peptococcus*Peptococcus* Xanthomonas* Xanthomonas*

Enterobacter Enterobacter      

* Not cultured

Proof of Principle resultsProof of Principle results

  Sanger Sanger

shotgunshotgunQt PCR Qt PCR

assayassay

all bacteriaall bacteria 100100 100.0100.0

Pseudomonas Pseudomonas 13.513.5 21.721.7

Klebsiella sp.Klebsiella sp. 2.12.1 0.00.0

Serratia Serratia marcescensmarcescens 1.61.6 1.91.9

Clostridium Clostridium perfringensperfringens 1.11.1 1.01.0

Enterococcus Enterococcus faecalisfaecalis 1.11.1 1.01.0

Escherichia coliEscherichia coli 0.50.5 1.21.2

AnaerobesAnaerobes

0%

20%

40%

60%

80%

100%

Ba

cte

ira

l Po

pu

lati

on

Venous Ulcer Diabetic Ulcer Pressure Ulcer

Distribution of Bacterial Populations in Chronic Wounds in Relation to Aerotolerance

Aerobes

FacultativeAnaerobesStrictAnaerobes

SloughSlough

Treating BiofilmTreating Biofilm

Sharp DebridementSharp Debridement

Frequently Frequently New Wound BedNew Wound BedBiofilmsBiofilms

Wet to Dry DressingsWet to Dry Dressings

78% of Physicians78% of Physicians

Cost moreCost more

PainfulPainful

No margin of safetyNo margin of safety

Detrimental…Detrimental…

Do No HarmDo No Harm

Think Outside the BoxThink Outside the Box

Antibiofilm AgentsAntibiofilm Agents

Short TermShort TermLactoferrinLactoferrin

XylitolXylitol

GalliumGallium

FarnasolFarnasol

DeferoxamineDeferoxamine

EDTAEDTA

Dispersin BDispersin B

Fatty Acid GelFatty Acid Gel

Nitric OxideNitric Oxide

Long TermLong Term

Quorum Sensing Quorum Sensing InhibitorInhibitor

RNA III Inhibitory PeptideRNA III Inhibitory Peptide

FuranonesFuranones

AutoinducerAutoinducer

D Davies et al. Science. 1998 Apr 10; 280(5361): 295-8.

Biofilm Based Wound CareBiofilm Based Wound Care

Debridement- Frequent and aggressive

Selective biocides Silver, Iodosorb, Hydrofera Blue

Antibiofilm Agents

Lactoferrin, Xylitol, Farnasol Plant Products, Fatty Acid Gel

Antibiotics Adjunct Strong and long

Multiple Concurrent Strategies

Biofilm Based Wound CareBiofilm Based Wound Care

www.woundcarecenter.netwww.woundcarecenter.net

Critical Limb IschemiaCritical Limb Ischemia

Lubbock 0%

Kalani 15%

Fife 65%

www.woundcarehospital.com

All CLI

CLI w /oOsteo orDiabetes

CLI +Diabetes CLI + Osteo

CLI + Osteo +Diabetes

77%91%

75%

67%67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Healing Rates in Wounds with Critical Ischemia

Orthopedic Management

Biofilm Management

The Biofilm SurpriseThe Biofilm Surprise