Introduction

It is estimated that between 2% and 6% of the global population currently live with wounds, a figure that is expected to increase as more people age.¹ The cost of wound care in the United States is approximately $60 billion annually. This figure is also expected to increase unless wound care strategies adapt.²

Wound hygiene promotes the healing of hard-to-heal wounds by assuming that biofilm is present in every wound and contributes to delayed healing. Hard-to-heal wounds are those that have failed to respond to evidence-based standards of care. However, it is vital to understand that factors that define a wound as hard-to-heal may also be present from the start of a wound's course, such as a complex anatomic location or underlying conditions.³ Therefore, the authors advocate for early intervention with wound hygiene instead of waiting for signs of stalled healing.³ Wound hygiene addresses early biofilm formation with a strategy that is comprised of the following³:

• Cleansing the wound and surrounding skin
• Mechanical debridement (both initial and for maintenance, if needed)
• Refashioning the wound edges
• Biofilm-targeted management (or antibiofilm therapies) and prevention

The 4 aspects of wound care listed above must be carried out regularly and repeatedly as the wound progresses through the stages of healing.³

Why is Wound Hygiene Important?

Acting quickly is imperative with wound hygiene, as biofilm forms and reforms rapidly. Biofilm is thought to be the primary cause of delayed healing.⁴ For example, researchers discovered that oral biofilm reforms within 24 hours of performing oral hygiene, and gingivitis could develop within 10-21 days.⁵ Similar to oral biofilm, biofilm can form and reform on hard-to-heal wounds within hours of disruption. It is not possible to make a definitive diagnosis by appearance alone since advanced molecular biology, and microscopy techniques are required to confirm the presence of biofilm. Since these tests are expensive and not available to all clinicians, the presence of biofilm may be assumed for all wounds.⁴

The increased number and complexity of microbes in any tissue will heighten the risk of infection. This risk rises when there is increased microbial virulence, antibiotic/antimicrobial resistance, and tolerance, or the patient's immune system is compromised.⁵ To support healing, biofilm must be disrupted and removed.⁶

Because of the speed of biofilm formation, a wound with exudate or slough that shows an increase in size by the third day of its occurrence may already be defined as a hard-to-heal wound.⁷ At its core, wound hygiene attempts to remove or minimize all unwanted materials on a wound, including biofilm, devitalized tissue, and foreign debris. It addresses any residual biofilm and prevents its reformation to improve the healing environment.⁷

When Should Staff Begin a Wound Hygiene Protocol?

Since clinicians should start wound care with the assumption that biofilm is present, they may begin the wound hygiene protocol without delay to minimize the chances that biofilm will result in delayed healing. However, timing is essential due to the speed at which biofilm can form and reform, as it forms within hours and reaches maturity within 48 and 72 hours.⁸ In fact, by the time clinical signs of infection are present, the biofilm will be near maturation.⁷ At each stage of the wound hygiene protocol, biofilm is addressed to inhibit proliferation and reduces the microbial burden. Consider the following steps⁷:

• Cleansing the wound and periwound area: This step removes unwanted materials and microbes to promote a balanced environment for healing. In addition to biofilm, periwound skin may contain lipids, fragments of keratinized cells, sebum, and sweat, which also contain small amounts of electrolytes, lactate, urea, and ammonia. These materials create ideal conditions for microbial proliferation and the formation of biofilm. Cleansing the wound and surrounding area with products containing surfactants may disrupt microbial proliferation.⁶
• Debride the wound: Proactive debridement removes or minimizes all unwanted material to disrupt biofilm formation or reformation. The type of debridement selected for initial or maintenance treatment should only be selected after a full wound assessment. Wound characteristics may support one type of debridement method over another.
• Refashioning the wound edges: Biofilm has been observed at the wound edges, and polymerase chain reaction (PCR) examinations have consistently found higher numbers of bacterial cells on wound tissue samples from the wound edges than at the center of the wound. Therefore, refashioning these edges to remove devitalized tissue and biofilm can promote healing.
• Dress the wound: Dressing the wound in antimicrobial dressings can prevent reformation as the antimicrobials in the dressings will kill planktonic bacteria, preventing colonization and biofilm formation.

Conclusion

The benefits of wound hygiene may include lower rates of infection and chronic inflammation and higher and faster rates of healing. Both goals can lead to better clinical outcomes related to wound care and a higher quality of life for patients suffering from hard-to-heal wounds. Regardless, a well-planned wound hygiene regime can help remove some barriers that negatively impact wound healing so that patients may have a better healing outcome. Recent literature challenges clinicians to evaluate the timing of various wound care interventions with an eye toward these barriers and encourages early intervention through an antibiofilm paradigm.

References

1. Jarbrink K, Ni G, Sonnergren H, et al. The humanistic and economic burden of chronic wounds: A protocol for a systematic review. Syst Rev. 2017;6(15). doi: 10.1186/s13643-016-0400-8
2. Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds. Value Health. 2018;21(1):27-32. doi: 10.1016/j.jval.2017.07.007
3. Murphy C, Atkin L, Vega de Ceniga M, et al. Embedding Wound Hygiene into a proactive wound healing strategy. J Wound Care. 2022;31(Sup4a):S1-S19. doi:10.12968/jowc.2022.31.Sup4a.S1
4. Murphy C, Atkin L, Swanson T, et al. Defying hard-to-heal wounds with an early antibiofilm intervention strategy: wound hygiene. J Wound Care. 2020;29(Sup3b):S1-S26. doi:10.12968/jowc.2020.29.Sup3b.S1
5. Mancl KA, Kirsner RS, Ajdic D. Wound biofilms: lessons learned from oral biofilms. Wound Repair Regen. 2013;21(3):352-362. doi:10.1111/wrr.12034
6. Percival, SL, Mayer, D, Kirsner, RS, et al. Surfactants: Role in biofilm management and cellular behaviour. Int Wound J. 2019;16: 753–760. https://doi.org/10.1111/iwj.13093
7. Metcalf DG, Bowler PG. Biofilm delays wound healing: A review of the evidence. Burns Trauma. 2013;1(1):5-12. doi:10.4103/2321-3868.113329
8. Temple School of Podiatric Medicine. Review: Defying hard-to heal wounds with an early antibiofilm intervention strategy: wound hygiene. WoundSource. Published September 18, 2020. Accessed November 21, 2022. https://www.woundsource.com/blog/review-defying-hard-heal-wounds-early-…

The views and opinions expressed in this vlog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.