Authors

● Christine Murphy, PhD, RN, WOC(C), Vascular Nurse Specialist, The Ottawa Hospital Limb Preservation Centre, Ottawa, Canada
● Leanne Atkin, MHSc, RGN, PhD, Vascular Nurse Consultant, Mid Yorkshire Hospitals NHS Trust and University Hadderseld, UK
● Terry Swanson, Nurse, Wound Management, Warrnambool, Victoria, Australia
● Masahiro Tachi, MD, PhD, Professor, Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Tohoku University, Sendai, Japan
● Yih Kai Tan, MD, FRCSEd, CWSP, Director of Vascular Services, Consultant Vascular and Endovascular Surgeon, Changi General Hospital, Singapore
● Melina Vega de Ceniga, MD, Consultant Angiologist, Vascular and Endovascular Surgeon, Galdakao-Usansolo Hospital, Bizkaia, Spain
● Dot Weir, RN, CWON, CWS, Saratoga Hospital Center for Wound Healing and Hyperbaric Medicine, Saratoga Springs, New York, USA
● Randall Wolcott, MD, CWS, Southwest Regional Wound Care Center, Lubbock, Texas, USA

Reviewer panel

● Christine Murphy, PhD, RN, WOC(C), Vascular Nurse Specialist, The Ottawa Hospital Limb Preservation Centre, Ottawa, Canada
● Leanne Atkin, MHSc, RGN, PhD, Vascular Nurse Consultant, Mid Yorkshire Hospitals NHS Trust and University Hadderseld, UK
● Terry Swanson, Nurse, Wound Management, Warrnambool, Victoria, Australia
● Masahiro Tachi, MD, PhD, Professor, Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Tohoku University, Sendai, Japan
● Yih Kai Tan, MD, FRCSEd, CWSP, Director of Vascular Services, Consultant Vascular and Endovascular Surgeon, Changi General Hospital, Singapore
● Melina Vega de Ceniga, MD, Consultant Angiologist, Vascular and Endovascular Surgeon, Galdakao-Usansolo Hospital, Bizkaia, Spain
● Dot Weir, RN, CWON, CWS, Saratoga Hospital Center for Wound Healing and Hyperbaric Medicine, Saratoga Springs, New York, USA
● Randall Wolcott, MD, CWS, Southwest Regional Wound Care Center, Lubbock, Texas, USA

The huge health and financial burdens associated with delayed wound healing - often uninspiredly called "chronic wounds" - are recognized globally in research papers with alarming frequency. Affected people suffer from increased pain and are susceptible to recurrent infections because they live with a health condition that is poorly understood by many healthcare professionals. These wounds are expected to never heal at all. It can even be almost as if this outcome is simply accepted. In recent years, evidence has been mounting that the key pathology of non-healing wounds is biofilm plaque in dental disease. In biofilm disorders, pain and infection increase the need for analgesics, opioids and antibiotics, making it highly desirable to address this pathology before the disease progresses. Biofilm management is therefore essential to achieve better outcomes and reduce the burden of disease. Much like dental hygiene, wound hygiene aims to eradicate the cause a common pathology among the world's population. The concept of wound hygiene emerged during an expert advisory board meeting held in early 2019. There, the international panel agreed that almost all difficult-to-heal wounds have a biofilm that delays or prevents healing. This led to the publication of an expert opinion article in JWC that raised the important question: is the current standard of care considered sufficient for wound healing now that you know about biofilm? There was a growing sense on the panel that wound care is in crisis. Perhaps it is. Globally, there is a perfect storm in wound care: an aging population; age- and lifestyle-related increases in conditions such as vascular disease, diabetes (i.e., the pandemic) and obesity; economic strains on healthcare systems around the world; the overuse of antibiotics, along with increasing antibiotic resistance; and the impact of ongoing severe wounds on quality of life. Despite all the new products and best practices, the burden of wounds is not decreasing. There is no magic formula that consistently heals non-healing wounds rapidly, with reproducible results across all settings. It is clear that a piece of the puzzle is missing. Evidence is mounting that this piece is biofilm management, which is increasingly recognized as a factor in many chronic disease conditions. It may be time to rethink what is best practice, especially for wounds that have been colonized or infected by biofilm. The expert advisory panel discussed ways to implement real change into general practice. So he developed the concept of wound hygiene, meaning that just as we practice basic hygiene by washing our hands, brushing our teeth, and showering every day to keep ourselves clean and protected from germs we should practice basic hygiene on wounds. The panel met in the summer of 2019 to discuss the structure of this concept with the aim of publishing a consensus document at JWC. The result is a publication that describes wound hygiene how it can help reduce antibiotic use and advises how it can be implemented into daily practice. The The international panel acknowledges that it may be necessary to take into account local standards and guidelines.

Christine Murphy
Panel chair

Justification of wound hygiene

Despite advances in dressing technology and best practice, wound care is in crisis: the number of wounds that are difficult to heal, including the increasing impact on the healthcare system and the increasing use of antibiotics. Improving the management of difficult to heal wounds, most of which are caused by the persistent biofilms present, needs to be addressed. Biofilm management involves routine debridement followed by antibiotic film reapplication strategies including the use of topical antimicrobial dressings.14 This consensus document suggests the need to go further by implementing a new strategy called wound hygiene, This involves two additional steps: cleaning and regenerating the wound and the surrounding skin the wound edge. Wound hygiene is a structured approach to overcoming barriers to healing associated with biofilm. This document therefore abandons the term chronic wounds in favor of difficult-to-heal wounds, which implies that these barriers can be overcome.

Biofilm

A wound that is difficult to heal has an incision The healing process is largely associated with the presence of a persistent biofilm (a community of many types of microbes). Although other major host factors may also be barriers to healing, it is increasingly recognized that a Most (though not all) non-healing wounds contain a biofilm, the main barrier to healing. The increasing number and complexity of microbes in any tissue environment will increase the risk of infection. This risk is increased where microbes are abundant due to virulence, antibiotic/microbial resistance and tolerance, and/or host defenses are compromised, for example, due to diabetes and obesity

Oral hygiene

In oral health, the presence of biofilm (dental plaque) on teeth and between the enamel and gums (gingival crevices) is the most commonly accepted cause of periodontal disease. Oral biofilm rapidly re-forms within 24 hours of ingestion. This is why it is recommended to brush and floss twice a day, each time approximately half the time the biofilm re-forms. It is estimated that 50-90% of adults worldwide are affected by gingivitis, which is a mild, reversible form of periodontal disease that can be managed with improved oral hygiene. The importance of repeated, regular, and frequent oral hygiene cannot be overstated

Wound hygiene: Stage 1 - cleaning

Debridement helps achieve wound hygiene goals by removing loose material, excess exudate and debris, and disrupting biofilm. Residual biofilm and prevention of biofilm re-formation. The wound bed and periwound skin, as well as the skin around the wound, are likely to contain biofilm, both of which should be cleaned. This should be done as physically as possible the patient's tolerance. The procedure should be repeated at each dressing change and after debridement. The choice of cleaning agents and cleaning methods will be based on clinical judgment

Skin and wound cleaning

Cleaning the periwound skin and wound bed to remove unwanted material—both visible and invisible to naked eye is the cornerstone of wound care because it provides a balanced environment in which healing can occur. Like biofilm, periwound skin can contain debris consists of lipids, fragments of keratinized cells, sebum and sweat, which contains small amounts of electrolytes, lactate, urea and ammonia are detected. These create an ideal environment for the proliferation of microbes and the formation of a bio lm. Figure 7 shows an example of cleaning the skin.

The importance of using the right cleaner

Standard saline or water rinses will not remove biofilm. Instead, surfactants are widely used to help remove foreign bodies, biological debris5 and biolm. A surfactant reduces the surface or interfacial tension between a liquid and a solid (e.g., debris and biofilm), helping to disperse the latter, which can then be removed more easily with a cleaning pad or cloth. According to Malone and Swanson, loose, non-viable or devitalized tissue can be removed if it is covered with a surfactant-based wound solution or gel for a sufficient period of time (usually 10-15 minutes) and gently cleaned with sterile gauze. However, evidence for the ability of surfactants to remove biofilm wounds is low and mainly in vitro

Wound hygiene: Stage 2 - cleaning

The goal of debridement is to remove/reduce all unnecessary material, even some healthy tissue is also removed. Debridement is required as part of the biofilm 'weeding' process, transforming the hostile battlefield wound into a flourishing "garden of tissue". Various debridement techniques can be used, starting with potentially more intensive methods, and then progressing to mechanical debridement if necessary. This process is an essential part of wound hygiene and should be applied to all difficult-to-heal wounds. Autolytic debridement - the use of the body's own natural enzymes to break down devitalized tissue - is insufficient to meet the debridement requirements of wound hygiene because it takes a long time to occur, requires multiple dressing changes, and may increase the risk of infection in difficult-to-heal wounds. In addition, it is based on the effectiveness and efficiency of the treatment. Host processes that are likely to be disrupted in difficult-to-heal wounds. Disrupting the biofilm, any residual biolm and Preventing re-formation in difficult-to-heal wounds: debridement

The importance of proactive debridement in wound hygiene

Proactive debridement is an integral part of wound hygiene, as it will help any wound that is not covered progress toward healing with granulation tissue. The choice of debridement method should be based on an assessment of the wound bed, periwound skin, and the patient's pain and tolerance levels. Mechanical force in combination with a surfactant or an antimicrobial solution are effective ways to break down and decontaminate biofilm. The combined use of a topical surfactant-based wound cleaning solution and a cleaning pad or gauze will increase the cleaning sufficiently to disrupt and remove the biofilm. If physical debridement is contraindicated, it may be possible to use this approach instead. The result is a well-maintained “garden” where the unwanted matter has been “weeded out” to provide a healthy environment for growth—in this case, new tissue. Debridement disinfects the wound bed and removes biofilm, preparing it for dressing application in accordance with wound bed preparation principles.

Wound bed fragility and pain

The notion that a wound bed is fragile should not be a major obstacle to debridement. Although all removal should be done with care to prevent damage to devitalized tissue, it is an essential first step in wound hygiene. A single assessment should help determine the extent to which aggressive debridement can be performed. When it is safe to perform mechanical debridement, it is important to manage the patient's pain expectations. Topical anesthetics, such as lidocaine combination gels or creams, may be applied as needed, in accordance with local standards of care. Surfactants may reduce pain because they help loosen debris and make it easier to remove. Warming solutions to body temperature may also help reduce pain.

Wound hygiene: Stage 3 - repair wound edges

Primary cells that facilitate epithelialization in all full-thickness wounds wound edges and hair follicles. Bio lm is most active at the wound edges, where it promotes cellular senescence (loss of cell division and growth capacity), thereby preventing the ingrowth of new, healthy tissue. Therefore, wound edge renewal is an important component of wound hygiene. Refashioning goes a step further than simply neutralizing and removing the wound edges devitalized tissue, as it uses debridement in the form of sharp debridement or gentle debridement pads or gauze to blend the wound edges to the extent that local bleeding will occur experience, patient tolerance, and consent allow for this. Regeneration of the wound edges is usually presented as part of the healing process with little risk to the tissue that naturally regenerates. Promotion will stimulate the expression of growth factors to initiate the formation of healthy skin

Practical tips for updating

Biofilm has been observed at the wound margins. The bioburden on the periwound skin, particularly the devitalized tissue, affects the bioburden on the wound and, therefore, its margin. Clinical evidence for this is presented by panel member Randy Wolcott. In his experiment, an advanced molecular biology technique, polymerase chain reaction (PCR), consistently identified a higher number of bacterial cells in wound tissue samples from the edges than from the center. Resurfacing the edges to remove devitalized tissue (and thus biofilm) will promote healing. One way to visualize how much tissue will be removed at the edges of the wound is to think of "cliffs" and "beaches." Low beaches need a bit of scraping to make them smooth, whereas cliffs need some cutting to make them smooth. In Wolcott's clinical experience, normal skin regrows as healthy tissue within 7 to 14 days. Wolcott says the key tip is to pay special attention to the surfaces that touch the wound, such as the lightly damaged or bare areas, which are especially prone to harboring extra-epithelial tissue, or biofilm. More information on wound debridement is provided. There are contraindications for wound debridement as described for debridement on page S14. If you are in doubt about mechanically cleaning the wound edges consult a more specialist to determine the exact cause of the bleeding

Wound hygiene: Step 4 - apply a dressing to the wound

Once the wound bed and periwound skin are cleaned, the wound bed is debrided and the wound edges are re-arranged, providing a window of opportunity to dissolve any residual biofilm that may be present and prevent its re-formation. To maximize this, antimicrobial dressings may be used if indicated after a thorough assessment

Use of antimicrobial wound dressings

The previous stages of wound hygiene remove obstacles to help wounds heal, antimicrobial dressings achieve maximum effectiveness. Some antiseptics used in antimicrobial wound dressings can play an important role in wound hygiene because they can help disrupt the biofilm, kill organisms prevent its re-formation within and through the biofilm different modes of action. it is important to be able differentiate antimicrobials and antibiolm agents. When incorporated into dressings, antimicrobials kill planktonic bacteria, prevent colonization and biofilm formation, which may facilitate antimicrobial efficacy. Antibio lm agents are designed to penetrate and disrupt the biofilm itself. Antimicrobial and antibiofilm agents are described in Table 4. When selecting an antimicrobial dressing, in addition to its antibiofilm properties, other requirements should be considered, such as its exudate management capabilities. Before selecting a dressing, a thorough assessment of the patient and wound bed and surroundings should be carried out to ensure that it meets the needs of the patient and the local wound environment. The volume of exudate should be a key consideration as excess production exudate levels can promote biofilm proliferation and impair cell proliferation and wound healing

Top/bottom
approach

Although all wounds deserve standard wound hygiene care, not all more aggressive forms of wounds require debridement, repainting, or topical antimicrobial dressings. A step-up/step-down approach should be taken to ensure that antimicrobial dressings are only used when required. This in turn will increase the cost-effectiveness of management. It is important to assess the wound and the effectiveness of the dressing every 2-4 weeks, using a validated or standardized assessment tool to determine whether it is necessary to switch to a non-antimicrobial dressing as the wound progresses toward healing or to try a different dressing as the wound has stopped healing. If wound assessment indicates that antimicrobial dressings are no longer needed, the other three aspects of wound hygiene should be considered until the wound is in the final stages of wound healing. Dressing selection should also be made in the context of local protocols, the availability of dressings, and any current socio-economic constraints faced by patients