For more details please refer to the original published article. AQUACEL and AQUACEL Extra are trademarks of ConvaTec Inc. © 2015 ConvaTec Inc. AP-014919-MM

Literature Review Performed to Validate Biofilm as a Factor In Wound Care Clinical Practice Decisions A Review of the Role of Biofilm in Accurately Predicting and Diagnosing Delayed Healing or Infection

Clinical Biofilms: A Challenging Frontier in Wound Care

Jennifer Hurlow, Kara Couch, Karen Laforet, Laura Bolton, Daniel Metcalf, and Philip Bowler Published in Wounds August 2014; DOI: 10.1089/wound.2014.05671

Key Highlights: Biofilms have been linked to a variety of wound complications and may be a precursor to infection.

Biofilms are tolerant to external agents such as antibiotics and antiseptics, and impair key healing processes such as inflammatory response, formation of granulation tissue, and epithelialization.

Inadequate control of moisture and exudate within a wound environment can lead to biofilm development; obtaining moisture balance in the wound is essential for reducing the opportunity for biofilms to develop and optimizing healing.

Observation of biofilm in complex chronic wounds is difficult, and requires a trained clinical eye if visible, or technical, expensive equipment if microscopic. However, in long-term urinary catheters, biofilm is easily visible and has been directly associated with an increased infection rate. Similarly, biofilm detection in other types of wounds is a first step towards improved patient care.

Specifically with regards to wound biofilm, the literature suggests:

o The capacity of biofilm formation to predict delayed healing may increase in subjects with conditions such as impaired arterial or venous circulation or diabetes.

o Wound surface biofilm may serve as an early signal to alert clinicians that wound healing is not leading to reduced wound contraction within 2-4 weeks of treatment.

o Early detection of biofilm may identify at-risk patients and enable intervention before recalcitrance and/or infection becomes a problem.

Following the literature review and analysis, the authors developed a mind map to explore the interrelated causes of delayed healing and infection, and the factors of both the host and wound environment that increase the predictive and diagnostic validity of biofilm for early screening of patients at risk of delayed healing or wound infection.

Additional research is needed to identify a technique that can identify and characterize biofilms and clarify risk factors for biofilm formation. This will help establish the importance of biofilm in guiding clinical practice in non-healing and/or infected wounds.

Methods: Literature searches conducted of relevant terms reviewed biofilm definitions and reliability and/or validation

of their role in accurately predicting infection, or diagnosing or predicting documented delayed healing.

The authors searched the MEDLINE, CINAHL, and Scopus literature databases from 1966 to January 10, 2014 for articles containing the term “biofilm” combined with the terms “wound infection” or “wound healing”.

Studies were grouped into the following brackets and reviewed to extract the key learnings: biofilm and wound infection, biofilm and wound healing, biofilm and moisture, and diagnostic validity of wound biofilm.

References:

1. Hurlow, J., Couch, K., Laforet, K., Bolton, L., Metcalf, D., Bowler, P. Clinical Biofilms: A Challenging Frontier in Wound Care. Advances in Wound Care, DOI: 10.1089/wound.2014.0567.

ZNANSTVENI I ORGANIZACIJSKI ODBORZvonko Kusić, Jasna Lipozenčić, Nastja Kučišec Tepeš,

Sandra Marinović Kulišić, Marko Pećina, Željko Reiner, Mirna Šitum, Jasenka Škrlin, Suzana Tunuković, Rado Žic

OPĆE INFORMACIJEMjesto održavanja: HLZ, Šubićeva 9, ZagrebKotizacija: 600 kuna; specijalizanti 300 kunaKotizacija uključuje prisustvovanje predavanjima i knjigu sažetaka.Hrvatska liječnička komora boduje ovaj Simpozij: 7 bodova za slušače i 9 bodova za predavače.

Molimo kotizaciju kao i cijenu za izložbeni prostor (2.500,00 kn/m2) uplatiti na račun:AMZH, Praška 2/III, Zagreb, IBAN: HR 5423600001101481831, poziv na broj 08-04-2016 s naznakom „Uloga biofilma u liječenju vrijeda“ ili pri registraciji na dan održavanja Simpozija.

Potvrdu o uplati molimo donijeti na Simpozij ili poslati na adresu:Akademija medicinskih znanosti Hrvatske, Praška 2/III, ZagrebTel: 01/4828 662; fax 01/4828 038 e-mail: amzh@zg.t-com.hr

Pod pokroviteljstvomRazreda za medicinske znanosti

Hrvatske akademije znanosti i umjetnostiAkademija medicinskih znanosti Hrvatske

organizira

Znanstveni simpozij

„Uloga biofilma u liječenju vrijeda“

Zagreb, 08. travanj 2016. godineVelika dvorana

Hrvatskog liječničkog zbora, Šubićeva 9.

Uz potporu tvrtke

Program 8. travnja 2016. godine.

12.00-13.00 Registracija sudionika

13.00-13.15 Pozdravna riječ

Predsjedavajući: M. Šitum, S. Marinović Kulišić, R. Žic

13.15-13.35 Kvaliteta života i psihološki aspekti u bolesnika s kroničnim vrijedom: Mirna Šitum

13.35-13.55 Kirurška iskustva u liječenju komplikacija u vrijedu: Rado Žic

13.55-14.15 Učinci primjene plazme bogate trombocitima (PRP) u liječenju kroničnog vrijeda: Zrinjka Paštar, Sandra Marinović Kulišić

14.15-14.35 Antimikrobne obloge za inficirani vrijed i kliničke spoznaje biofilma: Sandra Marinović Kulišić, Jasna Lipozenčić

14.35-14.55 Utjecaj biofilma na cijeljenje i postupak za identifikaciju u rani: Jasenka Škrlin

14.55-15.15 Rasprava

15.15-15.35 Osvježenje

Predsjedavajući: J. Škrlin, T. Planinšek Ručigaj, N. Kučišec Tepeš

15.35-15.55 Antimikrobna sredstva u tretmanu rane s biofilmom: Nastja Kučišec Tepeš

15.55-16.15 Klinička iskustva u liječenju biofilma u vrijedu: Tanja Planinšek Ručigaj

16.15-16.35 Razvoj najnovije generacije antimikrobne obloge: Daniel Metcalf

16.35-16.55 Uloga obloga za uništenje i reformaciju biofilma u vrijedu: Suzana Tunuković

16.55-17.30 Rasprava

17.30-18.00 Zaključci sa simpozija: J. Lipozenčić, S. Tunuković, J. Škrlin, S. Marinović Kulišić, T. Planinšek Ručigaj, N. Kučišec Tepeš

Poštovani kolegice i kolege,

Pod pokroviteljstvom Razreda za medicinske znanosti HAZU, Akademija medicinskih znanosti Hrvatske u suradnji sa Stoma medical d.o.o. organizira znanstveni simpozij „Uloga biofilma u liječenju vrijeda“ 08. travnja 2016. u HLZ, Šubićeva 9 od 13.00-18.00 sati.

Kronični vrijed je zdravstveni i ekonomski problem u Hrvatskoj, koji se danas može uspješno spriječiti ranom dijagnozom i pravilnom njegom vrijeda bez komplikacija uz primjenu suvremenih antimikrobnih obloga usmjerenih na polivalentni biofilm u vrijedu. Liječenje inficiranog vrijeda je za obiteljskog liječnika dugotrajno i skupo. Brojne bolesti također sudjeluju u patogenezi vrijeda uključujuću dijabetes, pretilost i periferne vaskularne bolesti.

Danas je znanstveno dokazano da je bakterijalan biofilm odgovoran za otežano cijeljenje vrijeda. U biofilmu vrijeda značajna je ekstracelularna polimerna tvar (EPS) koja obavija bakterije i čini fizičku barijeru za fagocitozu i aktivaciju komplementa, a također sprječava penetraciju sistemskog antibiotika ili lokalno primijenjenog antimikrobnog sredstva. Prisustvo biofilma u vrijedu je značajka kroničnog vrijeda. U liječenju protiv stvaranja biofilma koriste se različiti tretmani kao debridement, antimikrobni lijekovi, lavaga, no rezultati nisu zadovoljavajući. Za redukciju biofilma u rani znanstveno su istraživane suvremene metode liječenja, ali nisu u potpunosti objašnjenje i primijenjene u praksi. Molekularna terapija kao na primjer D-amino kiselina i peptidi koji inhibiraju RNK dokazali su djelotvornost u in vitro i in vivo pokusima, no primjena je otežana u kliničkoj praksi. Unatoč porasta znanja o mehanizmu virulencije biofilma, nisu napredovala otkrića djelotvornih lijekova.

U studiji Akhil K. i sur. godine 2014. autori su primijenili lokalne antibiotike i obloge s poliheksametilen biguanidom, te obloge Aquacel hidrofiber i Aquacel Ag+ hidrofiber kao „testne oblogu“. Testna obloga sa srebrom je dokazala učinkovitost na biofilm uzrokovan multibakterijama i to posebice na razinu P. aeruginosa.

Upravo će ovaj Simpozij prikazati način prepoznavanja biofilma u vrijedu, mogućeg liječenja i uspješnost nove tehnologije u rješavanju kroničnog vrijeda kao važnog zdravstvenog problema.

Prof.dr.sc. Jasna Lipozenčić

EKSUDAT INFEKCIJA BIOFILM

Sumnja na prisutnost biofilma

Biofilm pod mikroskopom

Na ovom in vitro modelu, sazreli biofilm izrastao je na supstratu gaze i mikroskopski je potvrđen. Potom, obloge su primijenjene na simuliranoj, biofilmom prekrivanoj površini, hidratizirane i prekrivene primjerenom sekundarnom oblogom. Po inkubaciji, efekt uništenja biofilma izveden testiranom oblogom - usađenost bakterija je ocjenjivana u nekoliko vremenskih točaka tijekom razdoblja od 96 sati. Reformacija biofilma je takodjer ocijenjivana, ucjepljenjem svježih bakterija na supstrat gaze ispod testirane obloge u razdoblju poslije 96 sati, te ponovno ocjenjivana prisutnost ili odsutnost biofilma na 120 sati.*Kako je dokazano in vitro

Ag+ Tehnologija je unikatna, srebro-sadržajna anti-biofilm formula koja:26

• RAZARA i slama zaštitni sluzavi biofilm, potpuno izlažući bakterije*1-3

• UNIŠTAVA široki spektar bakterija svojom zalihom srebra, uključivo i super štetočine otporne na antibiotike2,3,27

• PRIJEČI reformiranje biofilma*2,3

Hydrofiber™ Tehnologija pomaže u stvaranju idealnog okružja za cijeljenje - i prostor Ag + Tehnologiji za njezino djelovanje.

• ZATVARA UNUTAR SEBE višak eksudata, bakterija i biofilma, te tako pomaže značajnom smanjenju pojave ukrižene infekcije i priječi pojavu maceracije*4-7,31,32

• BLISKO PRIANJA uz dno rane, održava optimalan balans vlažnosti i otklanja “prazni prostor” gdje bakterije i biofilm mogu nesmetano nastajati*33-35

• ODGOVARA na stanje u rani stvaranjem kohezivnog gela, uz istovremeni utjecaj na značajno smanjenje boli povezane s izmjenama obloge*36-38

Extra čvrstina znači lakše uklanjanje*39

Extra moć upijanja znači duže vrijeme uporabe*39-41

AQUACEL™ Ag+ Extra (n=5)

AQUACEL™ Ag Extra (n=5)

Acticoat 7 (n=5)

Inokulacija

30,000,000,0003,000,000,000

300,000,00030,000,0003,000,000

300,00030,0003,000

300Neotkrivene

0 24 48 72 96 120 144 168 192 216

MRSA

Živ

uće

bak

teri

je (c

fu)

Priječi reformaciju biofilmaRazara biofilm / Uništava bakterije

Dan 9

*Usporedba sa standardnom AQUACEL™ Ag oblogom

AQUACEL™ Ag+ Extra™ obloga

AQUACEL™ Ag+ Trakasta obloga

30,000,000,0003,000,000,000

300,000,00030,000,0003,000,000

300,00030,0003,000

300Neotkrivene

0 24 48 72 96 120 144Vrijeme (sati)

Pseudomonas aeruginosa

Živ

uće

bak

teri

je (c

fu)

Priječi reformaciju biofilmaRazara biofilm / Uništava bakterije

Vrijeme (sati)

^10 inficiranih i 32 rizične rane*AQUACEL™ Ag+ obloga je korištena u ovoj studiji*AQUACEL™ Ag+ obloga korištena je u ovoj studiji

140

120

100

80

60

40

20

0

PHMB gaza AQUACEL™ Ag+ obloga

Zo

na g

ranu

laci

je (m

m²)

(n=

18)

140

120

100

80

60

40

20

0

PHMB gaza AQUACEL™ Ag+ obloga

Zo

na e

pit

eliz

acije

(mm

²)(n

=18

)

-20-10

01020304050607080%

Sm

anje

nja

velič

ine

vrije

da

0 1 2 3 4 5 6 7 8

AQUACEL™ Ag+ Obloga AQUACEL™ Obloga

100,000,000

10,000,000

1,000,000

100,000

10,0002 4 6

Pro

sječ

an iz

raču

n p

reži

vjel

ih

bak

teri

ja (c

fu/r

ana)

(n=

6)

Dani obrade

PHMB gaza AQUACEL™ Ag+ obloga

Značajno veći stupanj epitelizacije i granulacije naprama PHMB gazi.41

95% veće umanjenje na 6. dan (p<0.05)

48% više granuliranog tkiva na 6. dan (p<0.05)

24% više epiteliziranog tkiva na 6. dan (p<0.05)

Značajno veće umanjenje biofilma naprama PHMB gazi.41

Sve fotografije korištene su uz dozvolu njihovih vlasnika.

54% smanjenja ulcerozne zone na svim ranama

70% smanjenja ulcerozne zone na inficiranim ranama

TJEDNI

Dan 1

Dan 1

Dan 28

Dan 22

Dan 49 - zacjeljenje

Dan 56 - zacjeljenje

Sve rane Inficirane

Protocol of Care for Effective UseWounds that are infected, or at risk of infection

ASSESS1

Dressing Tips‡

• AQUACEL™ Ag+ Extra™ dressing should overlap at least 1 cm onto the skin surrounding the wound. • For cavity wounds AQUACEL™ Ag+ Ribbon dressing is recommended.• When dressing deep wounds only fill to 80% to allow for dressing expansion on contact with wound fluid.• When using AQUACEL™ Ag+ Ribbon dressing, leave 2.5 cm length of ribbon outside of the cavity to aid removal.• The absorbent pad of AQUACEL™ Foam dressing should overlap the wound by at least 1 cm.

Cleanse and debride.• Cleanse and debride the wound where necessary to remove barriers to healing, e.g. slough, necrosis, biofilm.

Dress.• Apply an AQUACEL™ Ag+ dressing to the wound to disrupt biofilm, kill bacteria, and prevent biofilm reformation*1,2 whilst managing exudate and infection.• Cover with an AQUACEL™ Foam dressing.

2MANAGE

Reassess and document the wound at each dressing change.• If the wound remains infected or at risk of infection continue to use AQUACEL™ Ag+ Extra™ or AQUACEL™ Ag+ Ribbon dressing covered with AQUACEL™ Foam dressing.• For a shallow wound infected or at risk of infection and no longer requiring the use of a primary and secondary dressing combination, use AQUACEL™ Ag Foam dressing.• If an antimicrobial dressing is no longer required, use AQUACEL™ Extra™ or AQUACEL™ Ribbon dressing in combination with AQUACEL™ Foam dressing, or for a shallow wound, AQUACEL™ Foam dressing alone.

* As demonstrated in vitro†Require specialist skills and equipment. Referral to the appropriate specialist may be required.‡Refer to product pack insert(s) for complete directions for use.Reference: 1. WHRI3850 MA232: Physical Disruption of Biofilm by AQUACEL® Ag+ Wound Dressing. 2013. Data on file, ConvaTec Inc. 2. WHRI3857 MA236: Antimicrobial Activity and Prevention of Biofilm Re-

formation by Ag+ EXTRA. 2013. Data on file, ConvaTec Inc. 3. Effective debridement in a changing NHS: a UK consensus. London: Wounds UK,2013. Available from www.wounds-uk.com. 4. Vowden K, Vowden P.

Debridement Made Easy. Wounds UK. 2011;7(4). Available from www.wounds-uk.com. TM indicates a trademark of ConvaTec Inc. AQUACEL is a registered trademark of ConvaTec Inc. in the US. ©2013 ConvaTec Inc. AP-014142-MM

Diabetic foot ulcer showing a sloughy wound bed and presence of localised infection. Evidence of devitalised tissue on the wound bed.

Stage 4 pressure ulcer with a heavily colonised, sloughy wound bed, and a suspected layer of biofilm (right).

Infected leg ulcer which is heavily exuding causing maceration to the surrounding skin. Dull red wound bed with areas of slough.

Minor traumatic injury resulting in chronic ulceration and infection.

Cleanse and Debride Tips• Irrigate with water or cleanse with an appropriate wound cleanser e.g.

Irriclens™ cleanser.• Select the appropriate debridement method according to the wound and patient goals:3,4

• Mechanical, e.g. using gauze or cotton pad.

• Larval therapy.• Ultrasonic, hydrosurgical, sharp,

surgical.†

Dehisced surgical wound with suspected biofilm prior to debridement.

Wound post debridement using a curette.

Extra™ or Ribbon (with strengthening fibre) dressing

Adhesive or non-adhesive dressing

Fig. 1

Evaluate both the patient and the wound.• Carry out a holistic patient assessment, e.g. co-morbidities, medication etc.• Assess the wound: • Wound type. • Wound bed appearance (tissue type and %: slough, necrosis, granulation, biofilm). • Size (length, width, depth). • Exudate (colour, consistency, level). • Associated pain and/or odour. • Peri-wound skin condition (swelling, discolouration, maceration). • Signs and symptoms of infection (pain, odour, heat, redness, swelling, purulence).

Images reproduced with kind permission of R Mathison, Stockport NHS Trust, UK (Fig. 1), D Copson, Nottingham University Hopitals NHS Trust, UK (Fig. 2), D Nelson, Derby Hospitals NHS Foundation Trust (Fig 3&4).

Fig. 2Fig. 3

Fig. 4

AP014142-AQAg+ProtocolPstr.indd 1

12/12/13 11:30 AM

AQUACEL™ Ag+ Extra

5 cm x 5 cm

10 cm x 10 cm

15 cm x 15 cm

20 cm x 30 cm

AQUACEL™ Ag+ Trakasta obloga

2 cm x 45 cm

AQUACEL™ Ag Foam Ljepive

8 cm x 8 cm

10 cm x 10 cm

12.5 cm x 12.5 cm

17.5 cm x 17.5 cm

21 cm x 21 cm

19.8 cm x 14 cm (peta)

20 cm x 16.9 cm (sakrum)

AQUACEL™ Ag Foam Neljepive

5 cm x 5 cm

10 cm x 10 cm

15 cm x 15 cm

20 cm x 20 cm

15 cm x 20 cm

AQUACEL, Extra, ConvaTec, ConvaTec logo, Hydrofiber i Hydrofiber logo su zaštitni znaci ConvaTec Inc. i registrirani su zaštitni znaci u SAD-u. Svi ostali zaštitni znaci svojina su njihovih odnosnih vlasnika.

©2013 ConvaTec Inc. AP-014140-MM AGE25112015 SAMO ZA ZDRAVSTVENE DJELATNIKE.

1. Physical Disruption of Biofilm by AQUACEL® Ag+ Wound Dressing. Scientific Background Report. WHRI3850 MA232, 2013, Data on file, ConvaTec Inc. 2. Antimicrobial activity and prevention of biofilm reformation by AQUACEL™ Ag+ EXTRA dressing. Scientific Background Report. WHRI3857 MA236, 2013, Data on file, ConvaTec Inc. 3. Antimicrobial activity against CA-MRSA and prevention of biofilm reformation by AQUACEL™ Ag+ EXTRA dressing. Scientific Background Report. WHRI3875 MA239, 2013, Data on file, ConvaTec Inc. 4. Newman GR, Walker M, Hobot JA, Bowler PG, 2006. Visualisation of bacterial sequestration and bacterial activity within hydrating Hydrober™ wound dressings. Biomaterials; 27: 1129-1139. 5. Walker M, Hobot JA, Newman GR, Bowler PG, 2003. Scanning electron microscopic examination of bacterial immobilization in a carboxymethyl cellulose (AQUACEL™) and alginate dressing. Biomaterials; 24: 883-890. 6. Bowler PG, Jones SA, Davies BJ, Coyle E, 1999. Infection control properties of some wound dressings. J. Wound Care; 8: 499-502. 7. Walker M, Bowler PG, Cochrane CA, 2007. In vitro studies to show sequestration of matrix metalloproteinases by silver-containing wound care products. Ostomy/Wound Management. 2007; 53: 18-25. 8. Assessment of the in vitro Physical Properties of AQUACEL EXTRA, AQUACEL Ag EXTRA and AQUACEL Ag+ EXTRA dressings. Scientific background report. WHRIA3817 TA297, 2013, Data on file, ConvaTec Inc. 9. Bjarnsholt T, 2013. The role of bacterial biofilms in chronic infections. APMIS. 121. 1-51. 10. Research on microbial biofilms. National Institute of Dental and Craniofacial Research. http://grants.nih.gov/grants/guide/pa-files/PA-03-047.html; Sept. 9, 1997. 11. Marsh PD, Bradshaw DJ, 1995. Dental plaque as a biofilm. J. Industr. Microbial; 15: 169-175. 12. Trautner BW, Darouiche RO, 2004. Role of biofilm in catheter-associated urinary tract infection. Am J Infect Control; 32: 177-183. 13. Elder MJ, Stapleton F, Evans E, Dart JK, 1995. Biofilm-related Infections in Ophthalmology. Eye (Lond.) 9: 102-109. 14. James GA, Swogger E, Wolcott R, Pulcini EL, Secor P, Sestrich J, et al, 2008. Biofilms in Chronic Wounds. Wound Rep Regen; 16: 37-44. 15. Metcalf D, Bowler P, 2013. Biofilm delays wound healing: A review of the evidence. Burns & Trauma. 1: 5-12. 16. Percival SL, Bowler PG, 2004. Biofilms and their potential role in wound healing. WOUNDS, 16: 234-240. 17. Wolcott RD, Rumbaugh KP, James G, Schultz G, Phillips P, Yang O, et al, 2010. Biofilm maturity studies indicate sharp debridement opens a time-dependent therapeutic window. J Wound Care; 19: 320-328. 18. Wolcott RD, Kennedy JP, Dowd SE, 2009. Regular debridement is the main tool for maintaining a healthy wound bed in most chronic. J Wound Care; 18: 54-56. 19. Gurjala AN, Geringer MR, Seth AK, Hong SJ, Smeltzer MS, Galiano RA, et al, 2011. Development of a novel, highly quantitative in vivo model for the study of biofilm-impaired cutaneous wound healing. Wound Rep Reg. 19: 400-410. 20. Brackman G, De Meyer L, Nelis HJ, Coenye T, 2013. Biofilm inhibitory and eradicating activity of wound care products against Staphylococcus aureus and Staphylococcus epidermidis biofilms in an in vitro chronic wound model. J Appl Miocrobial; 114: 1833-42. 21. Darouiche RO, Mansouri MD, Gawande PV, Madhyastha S. Antimicrobial and antibiofilm efficacy of triclosan and DispersinB combination. J Antimicrob Chemother. 2009 Jul;64(1):88-93. 22. Thorn RM, Greenman J. A novel in vitro flat-bed perfusion biofilm model for determining the potential antimicrobial efficacy of topical wound treatments. J Appl Microbiol. 2009 Dec 1;107(6):2070-9. 23. Bjarnsholt B, Kirketerp-Moller K, Kristiansen S, Phipps R, Nielsen AK, Jensen Po, et al, 2007. Silver against Pseudomonas aeruginosa biofilms. APMIS 115: 921-8. 24. Stewart PS, Costerton JW, 2001. Antibiotic resistance of bacteria in biofilms. Lancet; 358: 135-138. 25. Thurlow LR, Hanke ML, Fritz T, Angie A, Aldrich A, Williams SH, Engebretsen IL, et al, 2011. Staphylococcus aureus biofilms prevent macrophage phago-cytosis and attenuate inflammation in vivo. J Immunol; 186: 6585-96. 26. Composition comprising antimicrobial metal ions and a quaternary cationic surfactant. Scientific Background Report. WO 2012136968 A1, 2012, Data on file, ConvaTec Inc. 27. Bowler PG, Welsby S, Towers V, Booth V, Hogarth A, Rowlands V, Joseph A, et al, 2012. Multidrug-resistant organisms, wounds and topical antimicrobial protection. Int Wound J. 9: 387-396. 28. Antimicrobial activity against CA-MRSA and prevention of biofilm reformation by AQUACEL™ Ag+ EXTRA Dressing and Acticoat 7 Dressing. Scientific Background Report. WHRI3876 MA240, 2013, Data on file, ConvaTec Inc. 29. Antimicrobial Activity and Prevention of Biofilm Reformation by AQUACEL® Ag+ EXTRA Dressing and Acticoat 7 Dressing. WHRI3858 MA237, 2013, Data on file, ConvaTec Inc. 30. Antimicrobial Activity and Prevention of Biofilm Reformation by AQUACEL® Ag EXTRA Dressing and Silvercel® Non Adherent Dressing. WHRI3877 MA241, 2013, Data on file, ConvaTec Inc. 31. Walker M and Parsons D, 2010. Hydrofiber Technology: its role in exudate management. Wounds UK; 6: 31-38. 32. Parsons D, Bowler PG, Myles V, Jones SA, 2005. Silver antimicrobial dressings in wound management: A comparison of antibacterial, physical and chemical characteristics. WOUNDS; 17: 222-232. 33. Jones SA, Bowler PG, Walker M, 2005. Antimicrobial activity of silver-containing dressings is influenced by dressing conformability with a wound surface. WOUNDS; 17: 263-270. 34. Bowler P, Jones S, Towers V, Booth R, Parsons D, Walker M, 2010. Dressing conformability and silver-containing wound dressings. Wounds UK; 6: 14-20. 35. Walker M, Jones S, Parsons D, Booth R, Cochrane C, Bowler P, 2011. Evaluation of low-adherent antimicrobial dressings. Wounds UK; 7: 32-45. 36. Barnea Y, Armir A, Leshem D, Zaretski A, Weiss J, Shafir R, et al, 2004. Clinical comparative study of Aquacel and paraffin gauze dressing for split-skin donor site treatment. Ann Plast Surg; 53: 132-136. 37. Kogan L, Moldavsky M, Szvalb S, Govrin-Yehudain J, 2004. Comparative study of Aquacel and Silverol treatment in burns. Ann Burns Fire Disasters; 17: 201-207. 38. Brunner U, Eberlein T, 2000. Experiences with hydrofibres in the moist treatment of chronic wounds, in particular of diabetic foot. VASA; 29: 253-257. 39. Assessment of the in vitro physical properties of AQUACEL Ag, AQUACEL Ag EXTRA and AQUACEL Ag+ Dressings, Scientific Background Report. WHRI3817 TA297, 2013, Data on file, ConvaTec Inc. 40. Harding K, Ivans N, Cains J, An opened randomized comparative study to evaluate the clinical and economic performance of two absorbent dressings in venus leg ulcers. Poster presented at EWMA; May 15-17 2013; Copenhagen, Denmark. 41. Parsons D, Mustoe T, Seth A. A new anti-biofilm Hydrofiber™ dressing: an in vivo investigation. Poster presented at Wounds UK; Nov 11-13 2013; Harrogate, UK. 42. Harding K, Ivans N, Cains J, Peters K, Parsons D. A new anti-biofilm dressing – a clinical study. Poster presented at EWMA; May 15-17 2013; Copenhagen, Denmark.

Za sve informacije molimo nazovite besplatni telefon 0800 8000 ili pošaljite upit e-mailom: stomam@stoma-medical.hr

Unesite AQUACEL™ Ag+ Obloge u vaš protokol o zbrinjavanju kroničnih i akutnih rana koje su inficirane ili su rizične za pojavu infekcije.

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AQUACEL™ Foam Ljepive

10 cm x 10 cm

12.5 cm x 12.5 cm

17.5 cm x 17.5 cm

21 cm x 21 cm

20 cm x 16.9 cm (sakrum)

19.8 cm x 14 cm (peta)

25 cm x 30 cm

AQUACEL™ Foam Neljepive

5 cm x 5 cm

10 cm x 10 cm

15 cm x 15 cm

20 cm x 20 cm

15 cm x 20 cm

Kom./pak.

HZZO šifra pomagala

Šifraproizvoda

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Veličina obloge

Veličina obloge

Folnegovićeva 1c/VIII, 10000 ZagrebTEL: 01/5508-999; FAX: 01/6177-217

Prodaja i savjetovalište: Ozaljska 148 (REMIZA), 10110 ZagrebTEL: 01/3090-359, 3015-949, 3015-950 FAX: 01/3090-358

• Sadašnjespoznajeukazujudabiofilmpostojiuvećiniranakojenecijele.1,2

• Rastućijebrojznanstvenihikliničkihdokazakojipovezujubiofilmsodgođenimcijeljenjemrana.3

• Uodsutnostiodredišnogtestazapotvrdupostojanjabiofilmaurani,predloženjekliničkialgoritam,čijomprimjenomseolakšavaprepoznavanjebiofilmaukroničnimranama.4

Fotografija je prikazana uz dopuštenje Jennifer Hurlow, Memphis, USA.

Suspektni biofilm preko granulacijskog tkiva na venskom vrijedu.

Iz Metcalf DG, Bowler PG, Hurlow J. Journal of Wound Care. 2014;23(3):137-142.

Klinički algoritam za prepoznavanje biofilma u rani.

• Ovajalgoritammožeslužitikliničarimakaopomoćnosredstvozaprepoznavanjebiofilmatijekomrutinskihprocjenastanjarane,kaoizaizborpostupakapostupakazbrinjavanja,štouključujeiizboroblogakojećebitiprimijenjene.

AQUACEL and AQUACEL Extra su zaštitni znaci ConvaTec Inc.©2014 ConvaTec Inc. AP-014670-MM

• Biofilmsemožekontroliratičišćenjem,debridmanomiprimjenomprimjereneantimikrobneobloge.5

• Primjenomtakvogprotokolaonjezi,pomažeseusmanjenjumogućnostidabiofilmusporiprocescijeljenjaidoprinesepojaviinfekcije.5

• AQUACEL™Ag+oblogadokazanorazara,uništavaipriječiobnavljanjebiofilma.*,6-8

* Kako je dokazano in vitro† Dokazana sposobnost za zbrinjavanje viška eksudata, infekcije i biofilma.

Reference: 1. James GA, Swogger E, Wolcott R, et al. Biofilms in chronic wounds. Wound Repair Regen 2008; 16: 37-44. 2. Kirketerp-Møller K, Jenson PO, Fazli M, et al. Distribution, organization, and ecology of bacteria in chronic wounds. J Clin Microbiol 2008; 46: 2712-22. 3. Metcalf DG, Bowler PG. Biofilm delays wound healing: a review of the evidence. Burns Trauma 2013; 1: 5-12. 4. Metcalf DG, Bowler PG, Hurlow J. Clinical Algorithm for Wound Biofilm Identification. Journal of Wound Care. 2014;23(3):137-142. 5. Wolcott RD, Rhoads DD. A study of biofilm –based wound management in subjects with critical limb ischaemia. J. Wound Care. 2008;17(4):145-155. 6. Antimicrobial activity and prevention of biofilm reformation by AQUACEL® Ag+ EXTRA dressing. Scientific background report WHRI3857 MA236. 2013. Data on file, ConvaTec Inc. 7. Antimicrobial activity against CA-MRSA and prevention of biofilm reformation by AQUACEL® Ag+ EXTRA dressing. Scientific background report WHRI3875 MA239. 2013. Data on file, ConvaTec Inc. 8. Physical Disruption of Biofilm by AQUACEL® Ag+ Wound Dressing. Scientific Background report WHRI3850 MA232. 2013. Data on file, ConvaTec Inc.

Za sve informacije molimo nazovite besplatni telefon 0800 8000 ili pošaljite upit e-mailom: stomam@stoma-medical.hr.

Protocol of Care for Effective UseWounds that are infected, or at risk of infection

ASSESS1

Dressing Tips‡

• AQUACEL™ Ag+ Extra™ dressing should overlap at least 1 cm onto the skin surrounding the wound. • For cavity wounds AQUACEL™ Ag+ Ribbon dressing is recommended.• When dressing deep wounds only fill to 80% to allow for dressing expansion on contact with wound fluid.• When using AQUACEL™ Ag+ Ribbon dressing, leave 2.5 cm length of ribbon outside of the cavity to aid removal.• The absorbent pad of AQUACEL™ Foam dressing should overlap the wound by at least 1 cm.

Cleanse and debride.• Cleanse and debride the wound where necessary to remove barriers to healing, e.g. slough, necrosis, biofilm.

Dress.• Apply an AQUACEL™ Ag+ dressing to the wound to disrupt biofilm, kill bacteria, and prevent biofilm reformation*1,2 whilst managing exudate and infection.• Cover with an AQUACEL™ Foam dressing.

2MANAGE

MONITOR

Reassess and document the wound at each dressing change.• If the wound remains infected or at risk of infection continue to use AQUACEL™ Ag+ Extra™ or AQUACEL™ Ag+ Ribbon dressing covered with AQUACEL™ Foam dressing.• For a shallow wound infected or at risk of infection and no longer requiring the use of a primary and secondary dressing combination, use AQUACEL™ Ag Foam dressing.• If an antimicrobial dressing is no longer required, use AQUACEL™ Extra™ or AQUACEL™ Ribbon dressing in combination with AQUACEL™ Foam dressing, or for a shallow wound, AQUACEL™ Foam dressing alone.

3* As demonstrated in vitro†Require specialist skills and equipment. Referral to the appropriate specialist may be required.‡Refer to product pack insert(s) for complete directions for use.Reference: 1. WHRI3850 MA232: Physical Disruption of Biofilm by AQUACEL® Ag+ Wound Dressing. 2013. Data on file, ConvaTec Inc. 2. WHRI3857 MA236: Antimicrobial Activity and Prevention of Biofilm Re-

formation by Ag+ EXTRA. 2013. Data on file, ConvaTec Inc. 3. Effective debridement in a changing NHS: a UK consensus. London: Wounds UK,2013. Available from www.wounds-uk.com. 4. Vowden K, Vowden P.

Debridement Made Easy. Wounds UK. 2011;7(4). Available from www.wounds-uk.com. TM indicates a trademark of ConvaTec Inc. AQUACEL is a registered trademark of ConvaTec Inc. in the US. ©2013 ConvaTec Inc. AP-014142-MM

Diabetic foot ulcer showing a sloughy wound bed and presence of localised infection. Evidence of devitalised tissue on the wound bed.

Stage 4 pressure ulcer with a heavily colonised, sloughy wound bed, and a suspected layer of biofilm (right).

Infected leg ulcer which is heavily exuding causing maceration to the surrounding skin. Dull red wound bed with areas of slough.

Minor traumatic injury resulting in chronic ulceration and infection.

+

Cleanse and Debride Tips• Irrigate with water or cleanse with an appropriate wound cleanser e.g.

Irriclens™ cleanser.• Select the appropriate debridement method according to the wound and patient goals:3,4

• Mechanical, e.g. using gauze or cotton pad.

• Larval therapy.• Ultrasonic, hydrosurgical, sharp,

surgical.†

Dehisced surgical wound with suspected biofilm prior to debridement.

Wound post debridement using a curette.

Extra™ or Ribbon (with strengthening fibre) dressing

Adhesive or non-adhesive dressing

Fig. 1

Evaluate both the patient and the wound.• Carry out a holistic patient assessment, e.g. co-morbidities, medication etc.• Assess the wound: • Wound type. • Wound bed appearance (tissue type and %: slough, necrosis, granulation, biofilm). • Size (length, width, depth). • Exudate (colour, consistency, level). • Associated pain and/or odour. • Peri-wound skin condition (swelling, discolouration, maceration). • Signs and symptoms of infection (pain, odour, heat, redness, swelling, purulence).

Images reproduced with kind permission of R Mathison, Stockport NHS Trust, UK (Fig. 1), D Copson, Nottingham University Hopitals NHS Trust, UK (Fig. 2), D Nelson, Derby Hospitals NHS Foundation Trust (Fig 3&4).

Fig. 2Fig. 3

Fig. 4

AP014142-AQAg+ProtocolPstr.indd 1

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UnesiteAQUACEL™ Ag+ Oblogeuvašprotokolozbrinjavanjukroničnihiakutnihranakojesuinficiraneilisurizične za pojavu infekcije.

AQUACEL™ Ag+ Extra

5 cm x 5 cm

10 cm x 10 cm

15 cm x 15 cm

20 cm x 30 cm

AQUACEL™ Ag+ Trakasta obloga

2 cm x 45 cm

AQUACEL™ Ag Foam Ljepive

8 cm x 8 cm

12.5 cm x 12.5 cm

17.5 cm x 17.5 cm

21 cm x 21 cm

19.8 cm x 14 cm (peta)

20 cm x 16.9 cm (sakrum)

AQUACEL™ Ag Foam Neljepive

15 cm x 15 cm

20 cm x 20 cm

15 cm x 20 cm

AQUACEL™ Foam Ljepive

10 cm x 10 cm

12.5 cm x 12.5 cm

17.5 cm x 17.5 cm

21 cm x 21 cm

19.8 cm x 14 cm (peta)

20 cm x 16.9 cm (sakrum)

25 cm x 30 cm

AQUACEL™ Foam Neljepive

5 cm x 5 cm

10 cm x 10 cm

15 cm x 15 cm

20 cm x 20 cm

15 cm x 20 cm

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020903111906

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Veličina obloge

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