Diabetic Wound Care: Biofilm, Ulcers, and Treatment Recommendations

This report delves into the complexities of diabetic wound care, highlighting the significant role of biofilms in the development and progression of diabetic foot ulcers (DFUs). The introduction emphasizes the increasing prevalence of DFUs and the compromised wound healing capabilities in diabetic patients due to elevated blood glucose levels and reduced blood circulation. The research problem focuses on the challenges posed by biofilms, which hinder the healing process and contribute to antibiotic resistance. The research objectives aim to identify the causes of diabetic wound ulcers, assess the role of biofilms in detection, and provide treatment recommendations. The methodology involves a positivism research philosophy, deductive reasoning, and a secondary research approach using keywords like 'diabetic wound AND biofilm'. The findings reveal that biofilms, formed by various microorganisms, increase the chronicity of DFUs and antibiotic resistance. The report also discusses the impact of biofilms on wound healing, difficulties in diagnosing biofilms, and the limitations of traditional culturing methods. The report stresses the need for effective molecular techniques for accurate visualization of biofilms and correlation with patient outcomes.

Running head: DIABETIC WOUND CARE
Diabetic wound care
Name of the Student
Name of the University
Author Notes

DIABETIC WOUND CARE
Table of Contents
Introduction:.....................................................................................................................................2
Research Problems.......................................................................................................................2
Research Objectives.....................................................................................................................2
Methodology....................................................................................................................................2
Findings:..........................................................................................................................................2
Discussion:.......................................................................................................................................3
Conclusion:......................................................................................................................................3
References:.......................................................................................................................................4

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Introduction:
It is said that nearly 15% of the diabetic patients have been suffering from diabetes suffer
from foot ulcer, which is mainly caused at the bottom of the foot (Banu, 2015). As the total
number of diabetes patients is increasing in all over the globe, the total number of cases within of
diabetic wounds is also increasing. Due to the high levels of blood glucose levels the wound
healing capability of the immune system is highly compromised. The entire process of wound
healing, which involve three steps are delayed due to high blood glucose level. Low level of
human growth hormone along with organs of rheumatoid arthritis is believed to be the major
causes of delay recovery (Wong et al. 2015).
As the level of blood glucose rises, it reduces the blood circulation flow within the body.
This prevents the blood to reach out to the area of wound, thereby delaying the overall process of
healing. The highest forms of infection can also cause gangrene. Currently, it has been identified
that biofilm formation in wound is one of the factor that increases treatment challenges and
morbidities in patient. The biofilm phenotypes found in different wounds gives rise to the
development of many multi-drug resistant bacteria which results in treatment failure. For this
reason, identifying the role of biofilm in wound healing is necessary to find out whether biofilm
screening should be made a regular procedure for treatment of diabetic foot ulcer or not. There is
also a need to find out the optimal techniques to identify and judge the effectiveness of different
molecular techniques to accurately visualize biofilms formation in diabetic foot wounds and
correlated their role in patient systems and recovery process.

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Research Problems
The wounds that are caused due to diabetes can affect the neuropathy of the cells along
with that of the blood flow circulation. The higher level of the wounds can ultimately result in
permanent damage that may even include the loss of mobility and body parts. Hence, it is highly
necessary to identify the factors that are responsible for the lower levels of blood flow eventually
responsible for the infection. The substance of biofilm is considered to be one of the major
hindrances of the healing process for the diabetic patients. This biofilm substance is believed to
have caused the adverse effects of inflammatory response that ultimately hinders the response of
recovery. Hence, the substance of bio-film can be used as a major source of indicator to detect
the occurrence of foot ulcer.
Nevertheless, currently in the given context there is very less evidence to support the
elements of biofilm that are to be used for the indication of diabetic foot ulcer. The current issue
that is caused in the given context is due to the poor detection system of diabetic foot ulcer. This
is one of the major issues that are faced by millions of diabetic patients all across the globe. It is
therefore recommended that most of the patients, who are currently suffering from diabetes need
to get aware about the matters of wounds.
The current research work will therefore analyze the relevant secondary data that are
related to the investigation works of diabetic wounds. All the relevant journals related to the
investigation will be analyzed that will help to identify the loopholes within the existing process
of treatment will be analyzed. This will help the researchers to provide recommendations for
minimizing the risks that are involved in diabetic wounds.

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Research Objectives
 To identify the cause of diabetic wound ulcers
 To identify the use of biofilm that is needed to detect and identify the foot ulcers for the
diabetic patients.
 To provide recommendations for proper treatment of biofilm for identification and
management of diabetic foot ulcers.
Methodology
Research methodology is the manner in which the researcher designs the approach of
research. For conducting this study, the researcher has employed numerous tools that have
facilitated the researcher to deduct his findings in suitable manner. The main research philosophy
chosen for this research is positivism research philosophy which has helped the researcher to
investigate the topic with logical flow of information and critical analysis of data (Parahoo et al.
2014). In the research approach, the researcher have utilised deductive reasoning via taking
generalised principle which is known to be true and then moving towards more specific
conclusion (Parahoo et al. 2014). In the research design, the researcher has chosen analytic or
descriptive approach in comparison to exploratory research designs as this helped the researcher
to go through numerous approaches in the descriptive and detailed manner (Parahoo et al. 2014).
The research strategy used is secondary research and broad keyword search of literary articles
are used as sampling method (Parahoo et al. 2014). The nature of data analysis that was
undertaken for this research was qualitative via thematic analysis of the secondary data
elucidated via literature search (Parahoo et al. 2014).

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The main keywords which are used for the literature search include, diabetic wound AND
biofilm, diabetic wound care, diabetic wound ulcer. The main inclusion criteria that are used to
literature search was action on biofilm in diabetic wound and latest process cantered around
biofilm based diabetic wound care. The search year bracket included 2010 to 2018. The literary
articles which centres around normal diabetic wound care via management of the hyperglycemia
were excluded from the study as those were beyond the scope of the research questions.
According to Parahoo et al. (2014) detailed explanation of the inclusion and exclusion criteria of
the research helps in setting the direction of the research. Search of the literary articles via
application of the broad keywords was done from the electronic database including EMBL and
PubMed. Upon keyword search and given time frame, 50 articles were found relevant. Then
these articles were scrutinised on the basis of the tile and summary. According to Parahoo et al.
(2014) title of the research should be designed in such a way that it clearly states the aim of the
research and the prospective methodology that is required to be undertaken. The same logic is
application for abstract. Based on the criteria as mentioned as Parahoo et al. (2014) the 50
articles were scrutinised and out of them, 20 were found to be relevant. These 20 articles were
thoroughly read and out of them 10 articles were found best fitted for the study upon which the
systematic analysis of the data was erected.
Findings:
Diabetic Foot Ulcers (DFUs) and its relation to biofilm
Diabetic Foot Ulcers (DFUs) is a serious yet common complications associated with
diabetes that affects more than 15% of the diabetic patients causing >80,000 amputations per
year and this in turn results in high financial burden (Dinh et al. 2012). According to Noor,

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Zubair and Ahmad (2015), neuropathy, peripheral vascular disease along with reduced resistance
to infection are regarded as the main risk factors behind the development of DFUs which is
known to have all properties of chronic wound. Infections are not the cause but are considered as
the consequence of diabetic foot ulcers. All infections initiates as minor complications but
progress to evolved as deep tissue infects affecting joints and bones. Infection complicates the
pathological depiction of diabetic food leading to the development of DFUs (Noor et al. 2015).
Microbial organisms starting from fungi to aerobic and anaerobic species like staphylococcus,
streptococcus, Proteobacteria, Pseudomonas and other coliform bacteria are potential causative
organisms of DFUs (Noor et al. 2015). The colonisation of bacteria at the site of infection leads
to the development of highly organised arrangement of bacterial communities known as biofilm.
The formation of biofilm increases the chronicity of diabetic foot wound (Noor et al., 2015).
Malik, Mohammad and Ahmad (2013) elucidated that biofilm formation is a multistage process
under which the microbial cells attach to the surface via reversible attachment while continuing
subsequent production of extracellular. This extracellular attachment leads to the generation of
firmer adhesion and thus gradually propagating towards irreversible attachment. The sessile cells
or biofilm associated cells are physiologically and phenotypically different from non-adhered
cells and have increased resistance towards antimicrobial agents (Malik et al. 2013). Diabetic
foot infections are polymicrobial in nature and again lead to increased antibiotic resistance
among DFU patients. This high antibiotic resistance DFU is common among the hospitalised
patients (Malik et al. 2013). This is accordance with the reports published by Hartemann-
Heurtier et al. (2004). According to Malik et al. (2013), the high level of antibiotic resistance in
DFUs may arise as a result of tertiary hospital care via the administration of broad spectrum
antibiotics causing selective survival advantage of the pathogen. According to Banu et al. (2015),

DIABETIC WOUND CARE
microscopic structure of biofilm reveals multiple layers of bacteria which is found remained
encasing under biofilm containing matrix protein, polysaccharide and DNA. This mechanism
leads to increased cell-to-cell contact and is thus highlighted as the reason behind the generation
of multidrug resistant bacteria. Thus from the above discussion, it can be summarized that main
reason behind the formation of biofilm in wound via infection of numerous degree of bacterial
microorganisms. These microorganisms colonized and forms irreversible extracellular matrix
coating over the wound leading which in turns delays the wound healing.
Impact of biofilms in wounds
The phenotype of biofilm provides protection to bacteria from antibiotics and other
antimicrobial agents like silver and other defense mechanism of host. This signifies that if the
bacterial cells are succeeded in forming biofilm in the bed of the wound, the bacterial will
difficult to eradicate. According to the reports published by Cooper, Bjarnsholt and Alhede
(2014), presence of Pseudomonas aeruginosa in diabetic wound induce enlargement of ulcer
followed by delay in healing and thereby leading to the failure of split skin transplantation.
Cooper et al. (2014) further opined that bioflims are not the main reason behind the development
of chronic wound but in turn prevents wound from healing fast. Cooper et al. (2014) conducted a
research in order to explore the role of biofilms in wound colonization and subsequent infection
over animal model (pig) and Staphylococcus aureus. Their research revealed that wounds treated
with antibiotics within 15mins of introduction of bacteria have no visible microscopic clue
behind the formation of biofilm. Thus stating that planktonic bacteria have been inhibited and the
formation of biofilm has been successfully prevented. However, antibiotic applied after 48 hours
bacterial inoculation showed appearance of biofilm and failed eradication of biofilm (Cooper et
al. 2014). Thus from the above discussion it can be said that as the time laspsed, the degree of

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bacterial colonization over the diabetic wound increases and this llead to the formation of
biofilm. The antibiotic applied after 48 hours of wound formation have no significant effect on
the wound or over the biofilm.
Difficulties in diagnosing biofilms formed over diabetic wounds
The research conducted by Cooper et al. (2014), showed that Staphylococcus aureus is
present in the majority of the diabetic wounds in comparison to Pseudomonas aeruginosa.
Colonization of Pseudomonas aeruginosa was visualized in inside the wound bed where as
Staphylococcus aureus were detected on the surface of the wounds. This reveals that culturing is
not the gold standards for the detection for diagnosing biofilms. Kirketerp-Møller et al. (2008)
and Dowd et al. (2008) have also highlighted the same results. According to them, molecular
techniques used to establish the microbiota like culturing bacteria from the samples of wound
does not truly reveal the bacterial diversity in the wounds. According to Dowd et al. (2008), the
localization of bacteria, presence and flowed by slow growth of biofilms make the entire process
of culturing difficult. Moreover, a huge population of anaerobic bacteria causing diabetic wound
have been identified and these bacteria are also difficult to culture. Molecular techniques have
numerous qualitative drawbacks which signifies that these processes does not reveal the
comparative ratio of different bacteria present at the wound site how they are organized and
distributed in the wounds. Another significant drawback of the molecular method of detection is,
they fail to identify the main role of bacteria, which is responsible behind the delay in wound
healing. Cooper et al. (2014), further stated that bacteria which are responsible for the formation
of chronic wound are extremely small and are distributed heterogeneously and thus sampling
from the chronic wound via employing biopsies might provide false negative results. Thus, it can
be summarized that swabs taken from the chronic wounds are not actual representatives for the

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microbiota and there are threats coming from false negative results. Hence, it is suggested to
combine a thorough swab covering the entire surface of the wound via numerous biopsies and
the same should be investigated via both culturing (anaerobically and aerobically) and through
molecular techniques.
Identification of biofilms in diabetic foot ulcer by microscopic technique:
Since biofilms are less susceptible to antimicrobial agents, the detection of biofilms in
chronic wound has become a main goal for detection and treatment of many wound related
problems (Cross 2016). Oates et al. (2014) focused on visualizing biofilms in diabetic foot
wounds by the use of fluorescence microscopy as microscopic methods are more effective in
highlighting the morphology of biofilms in wound. Wound tissue samples were collected from
diabetic wound patient and transported to the laboratory. Slide mounted gram stained sections
were fixed and examined using bright-field, fluorescence and scanning electron microscopy. The
findings of the study showed that microcolonies were identified by all microscopic methods,
however bright field and fluorescence miscroscopy was found to be more effective in
visualization of biofilm morphology compared to ESM. Hence, the use of diagnostic culture
techniques and microscopy technique favored identifying biofilm phenotypes. This research
outcome can be great clinical implication as it can fulfill the need to identify biofilms in the
wound for their detection and treatment. Another advantage of using this method in the
laboratory is that the process is cost effective simple compared to other diagnostic method.
Malone et al. (2017) also showed that as biofilms has an impact of diabetic wound healing and
chronicity, detection of microfilms can pave way for implementing targeted and effective
intervention for patient.

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The study by Johani et al. (2017) also confirmed the effectiveness of microscopic
visualization for biofilm detection in patients with diabetic foot ulcer. The research adopted the
primary method of microscopy and molecular approach to investigate about the presence of
biofilm in diabetic foot ulcer (DFU) and correlated miscroscopic observation with wound
observation to confirm if clinical cues can help to detect wound biofilm or not. The DFU tissue
specimen was collected from 65 patient with DFU and scanning electron miscroscopy and
peptide-nucleic acid fluorescent in-situ hybridization technique to assess and detect biofilm
structure. The clinical cues that were compared with the study outcome included excess exudate,
gel material on the wound and presence of slough. The study findings showed presence of both
mono and multispecies of bacteria surrounded by extracellular matrix. The strength of the study
is that it proved that biofilms plays a role in diverse ecology of wounds. The study is clinically
significant as it gave the evidence regarding the fact that biofilm has a pathogenic role in DFU
presentation. The methodological rigour helped to come to this conclusion as the study focused
on identifying biofilm in three types of wound (short duration DFUs, chronic DFUs and non
healing DFUs. However, one limitation of the study is that it could not prove whether
multispecies can have an impact on the outcome of patienst with DFUs or not. Hajishengallis and
Lamont (2012) explained the contribution of multispecies involvement in chronicity and greater
virulence properties of bacterias.
Characterization for microbial drug resistance to detect and identify biofilms in diabetic foot
ulcers:
Proper management of diabetic foot ulcer is not only dependent on knowledge about
etiology, but also bet getting information related to antibiotic susceptibility of different microbes
found in the wound. The importance of characterization of microbial characteristics for

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management of chronic diabetic foot ulcer is understood from the review of the research done by
(Murali et al. 2014). The main aim of Murali et al. (2014) was to characterize common bacteria
associated with DFU and analyze their role in wound healing patterns. Following debridement of
tissue samples, isolation of microbe was done and antimicrobial sensitivity assessment of
bacterial isolates was done by disc diffusion method. Furthermore biofilm formation was
evaluated using the tissue culture plate method. The analysis of the characterization results for
the samples revealed that gram negative bacteria was more prevalent within DFU wound
environment and the gram positive type was found in non-diabetic ulcer. The assessment of
microbial strains regarding their ability to form biofilms revealed that Pseudomonas aeruginosa
was one of the most predominant strain that produced maximum amount of biofilms. This
finding is consistent with many other studies as Kang et al. (2017) gave evidence regarding the
role of gram positive bacteria in DFU. Hence, the research study gives the clinical direction that
antibiotic resistance profile of microbes involved in DFU infection should be assessed to
determine the role of biofilms in wound healing. The detection of biofilm producing microbes is
clinically significant for management of DFU patient as such organisms are more resistant to
antibiotics due to the physiology of biofilms.
Smith et al. (2016) also applied the approach of characterizing microbomes of new and
recurrent approach to understand the chronicity of wounds and it utilize conventional laboratory
culture method to characterize the bacteria. Research in this area was important due to the
hypothesis that microbe associated with new and recurrent DFUs differs which may have an
impact on wound management. 16S amplification sequencing (16AS) technology was used to
characterize the new microbiome in new ulcers. The study revealed that diverse polymicrobial
biofilm population is common in diabetic patient and detecting and characterizing such