The Role of Systemic Antibiotics for Biofilm Removal in Chronic Wounds.
Abstract.
The influence of the microorganisms in the healing process is not completely understood, but it is well known that the infections disrupt the healing of wounds, can even lead in the worst of cases to the death of the patient. In chronic wounds, it has been shown that the bacteria delay the healing process. If this is true, then the decline of the bioburden of the wound should reduce adverse influences that hinder healing. Systemic antimicrobial therapy can be very useful to overcome the unwanted effects of bacteria in specific circumstances, for example, the elimination of biofilms, where bacteria wrapped in layers of silt are less susceptible to antibiotics and have been implicated in persistent infections. Systemic antimicrobial therapy in chronic ulcers can focus on the wound and avoid the local and systemic adverse effects of the topical anti-infective agent. We compared the efficacy of using of systemic antibiotics with the efficacy of using topical agent therapy for chronic ulcers.
Key words: Systemic antibiotics, biofilms, chronic wounds, healing process.
INTRODUCTION
The Role of Systemic Antibiotics for Biofilm Removal in Chronic Wounds.
I have decided to carry out this investigative work on a tremendously important issue such as chronic wounds, diabetic foot ulcers, pressure ulcers and venous foot ulcers, as it affects many patients in the United States and represents a challenge for health professionals and their patients. This project is absolutely necessary if we consider that chronic wounds represent a significant burden to patients, health care professionals, and the US health care system, affecting 5.7 million patients and costing an estimated 20 billion dollars annually. (Frykberg RG, 2015). To begin this work, I think that we must start from a subject not commonly known as biofilm, in the last years there has been an increase of the knowledge about biofilm as the main cause of the chronicity of the wounds. The implementation of treatments for wound biofilm has created a new perspective so that chronic wounds can be treated more effectively and potentially contributing to saving the lives of many patients.
Biofilm is defined as “a structured community of microbial cells enclosed in a self-produced polymeric matrix that is adherent to an inert or living surface (Costerton JW, Stewart PS, Greenberg EP., 1999). Chronic wound does not heal within the expected time frame because it remains in the inflammation phase of healing. The reason for this is the presence of necrotic tissue and many microorganisms, primarily bacteria that secrete the biofilm, along with ischemia, hypoxia and edema. Biofilm is present in 90% of chronic wounds and 6% of the acute ones. (N., 2016). Most dermal wounds are colonized with aerobic and anaerobic microorganisms that originate predominantly from mucosal surfaces such as those of the oral cavity and gut. The role and significance of microorganisms in wound healing has been debated for many years. (P.G. Bouler B.I. Duerden D.G. Armstrong, 2001). Chronic wounds include surgical site-associated wounds, traumatic wounds, diabetic foot ulcers, pressure ulcers and venous foot ulcers. Their chronicity is defined by the inability to successfully complete the reparative process that allows for wound healing and a return to normal functional and anatomical integrity within a span of 3 months. These wounds are commonly characterized by arrest in the inflammatory phase of healing and are often associated with bacterial infections. Bacteria in chronic wounds are frequently present as biofilm. Chronic skin wounds affect ∼3% of persons aged >60 years. (Davies CE, 2007). Patients with chronic wounds are frequently treated with either systemic or topical antimicrobial therapy. (Lipsky & Hoey, 2010). Although adequate systemic antibiotics are essential for the healing of clinically infected and worsened wounds, there is controversy over the relevance and use of antibiotics (systemic or topical) in the treatment of cicatricial delayed wounds that do not show clinical signs of infection.
The role of germs in the caused and persistence of chronic wounds remains weakly understood. The chronic wound bed includes a compound microenvironment that with more than one bacterial species. The most difficult situation is determining when the presence of bacteria impedes wound healing process, thereby justify the intervention. Indications for antibiotic therapy use and better treatment are not very well defined.
Why consider systemic antimicrobial therapy for chronic wounds if many topical antibiotics are currently available on the market? Precisely in this question is the relevance of our research.
In daily basic practice, wound care nurses, and in collaboration with the doctors in charge of the periodic assessment of chronic lesions present in a large group of patients who have been treated throughout their profession. They had noticed, that patients, to which has been added a systemic antibiotic treatment to topical treatment, have experienced a significant improvement in the characteristics of this type of wounds. The main goal of this study is to demonstrate that patients with chronic wound who receive systemic antibiotics will have greater clinical improvement of the wound features than those treated with topical agents.
Significance.
Chronic wound are those where healing process do not make adequately advance in a timely manner, and for this reason it have become a major challenge for patients and healthcare professionals in the all worldwide. Chronic wounds can be classified as vascular ulcers (e.g., venous and arterial ulcers), diabetic ulcers, and pressure ulcers (PUs). (Nunan R., Harding KG., Martin P., 2014) Some common features shared by each of these wounds include prolonged or excessive inflammation, persistent infections, formation of drug-resistant microbial biofilms, and the inability of dermal and/or epidermal cells to respond to reparative stimuli. (M., 2012)
This project is necessary if we consider that chronic wounds represent a significant burden to patients, health care professionals, and the US health care system, affecting 5.7 million patients and costing an estimated 20 billion dollars annually. (Frykberg RG, 2015). The principal aim of this project is to demonstrate the role of systemic antibiotics in chronic non healing ulcers as it pertains to elimination and disruption of biofilms at the wound surface in order to allow the wound to progress from the inflammatory in to the proliferative phase.
Problem Statement.
The use of systemic antibiotics to improve healing process in chronic wound.
Purpose.
The primary objective of this research is to compare changes in surface area of non healing chronic ulcers treated with local therapy and systemic antibiotics vs treatment of non healing chronic ulcers treated with local therapy alone. The wounds healing process will be assess by periodically measuring the wound surface area in both groups.
The main goal of this study is to demonstrate that there is a role in the use of systemic antibiotics in disrupting the wound biofilm in patient with chronic non healing ulcers. Patients treated with systemic antibiotics will have greater clinical improvement as demonstrate by decrease of wound surface area to those treated with topical agents alone.
Hypothesis.
Systemic antimicrobial therapy can disrupt biofilms of the wound surface and will improve healing process in chronic wound.
Aim of the project/outcomes to achieve.
The principal aim of this project is to demonstrate the efficacy of using of systemic antibiotics plus topical treatment over the efficacy of using just topical agent therapy for chronic ulcers due to systemic antimicrobial therapy can be very useful to eliminate biofilms of the wound surface, and will improve healing process in chronic wound. Expected changes will be wounds size diminish, less amount of exudate, and growth of granulation tissue in the wound bed in just 3 weeks.
Picot Question.
For patients with chronic wounds in nursing home (P). How does the use of systemic antimicrobial therapy(I) compared to not received the systemic antibiotics(C) influence positive in the healing process (O) in three weeks (T)?
References.
