How to Handle Wound Bioburden

New dressings and tests are being developed to help wound clinicians discover the nature of the bacteria contaminating their patients' wounds. It is important to interpret the results of such tests correctly, lest we fall into the trap of trying to make a wound "sterile." As we speed into the future, let's review some lessons from high quality past research that has withstood the test of time.

Some microbes assist in wound healing: let's not kill our friends along with our enemies.(1) Also, we need to recognize that our job is not to heal the wound - only the patient's own body (designed by God) can do that. Our job is to support healing by removing barriers and promoting a healing environment. The goal is to foster the development of a balanced ecosystem under the dressing (like a fish tank that never needs cleaning because the microbes in the undergravel filter and the scavengers in the tank are working in harmony).

Alexander Fleming cautioned that all of the substances that kill bacteria also kill human cells, or at least slow WBC motility.(2) He found that attempts to kill bacteria in wounds often increase infection rates. Rather than trying to kill bacteria, Fleming found that it is better to simply remove the bulk of the contaminants with copious irrigation with water or saline and let the body take care of the rest. 

Rodeheaver found the same to be true for physically removing bacteria with soft scrubbing.(3) That process increased infections because it created microtears in the human cells. It is better to simply remove the bulk of the microbes with saline or a non-ionic surfactant irrigation and then allow the body to take care of the rest. Even diabetics with compromised immune systems have sufficient resources to do this if they are properly supported.(4)

In order for the body to "take care of the rest" we need to promote an appropriately moist healing environment. It is my belief that even most modern wound dressings keep wounds too dry, because wound specialists are terrified of maceration. Dressings which maintain appropriate moisture balance while protecting from maceration are, however, readily available.(5)

1. Hutchinson JJ, McGuckin M. Occlusive dressings: a microbiologic and clinical review. Am J Infect Control. 1990 Aug;18(4):257–68.

2. Fleming A. The action of chemical and physiological antiseptics in a septic wound. Br J Surg. 1919 Jan 1;7(25):99–129.

3. Rodeheaver GT, Kurtz L, Kircher BJ, Edlich RF. Pluronic F-68: a promising new skin wound cleanser. Ann Emerg Med. 1980 Nov;9(11):572–6.

4. Agathangelou C. Three years experience of treating 46 painful diabetic foot ulcers with polymeric membrane dressings. Poster #47 presented at: European Wound Management Association (EWMA); 2012 May 23; Vienna, Austria.

5. Benskin LL. Polymeric Membrane Dressings for Topical Wound Management of Patients With Infected Wounds in a Challenging Environment: A Protocol With 3 Case Examples. Ostomy Wound Manage. 2016 Jun;62(6):42–50.