Risk Factors for Diabetic Foot Ulcers

Discuss about the Management of Diabetic Foot Infections with Use.

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.

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.

Formation of Biofilm in Diabetic Foot Ulcers

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. 

• 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.

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).

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.

The Role of Biofilm in Wound Healing among Diabetic Patients

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, 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), 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.

Current Challenges in Detecting Diabetic Foot Ulcers

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 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.

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 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.  

Research Methodology

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.           

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.

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 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 microbiomes can help in the management and control of DFU infection.  This study utilized latest molecular technique to get answer to the research question. In past, traditional culture technique was the main basis for assessment of wound microbiome, however now studies done using molecular methods confirm the development of diverse microbiome species in diabetic foot ulcer (Malone et al. 2017). From the analysis of these studies, it is evident that characterization of microbiome is important for the detection of biofilm producing bacteria. As biofilms contribute to the resistant of the bacteria, the eradication biofilm producing microbes can address chronic wound (Malone 2017).

According to Kim and Steinberg (2012), local care for chronic diabetic wound remains the main line of defense against the limb loss. Bi-weekly monitoring or weekly monitoring followed by proper treatment plan is critical for overall management of the diabetic wound. This regular maintenance of wound involves numerous components like compression, debridement, antimicrobial therapy and offloading. The main goal of normal wound care centers on keeping the base of the wound free from nonviable tissues. It also involves proper facilitation of accurate measurement and meaningful reduction in the size of the wound. Recently the treatment of diabetic foot ulcerations has mainly focused on biofilm reduction or subsequent eradication. Thus, application of advanced wound healing modalities mainly includes debridement technologies, bioengineered alternative tissues and hyperbaric oxygen treatment (Kim and Steinberg 2012). Debridement and biofilm disruption consist of removal of non-viable tissue along with debris of foreign matter at the base of the wound. One main concern of debate in the process of debridement is depth of the tissue, which requires debridement therapy in order to remove the biofilm. However, debridement performed in the clinic has limited success because of the potential difficulty in controlling the bleeding from the wounds and the ability of patient to withstand the pain without undergoing anesthesia. Thus, biofilm might not be removed in a sufficient manner (Attinger and Wolcott 2012). At present operating room, based excisional debridement dealing with extensive removal of tissue along with the wound base is recommended for proper eradication of biofilm (Kim and Steinberg 2012). Application of hydrosurgical scalpel in the operating room enables precise control and expedited debridement. The main advantage of such device is their ability to remover the slices of the damaged tissue in an exponential manner while decreasing the percentage of debridement (Kim and Steinberg 2012). According to Garwood, Steinberg and Kim (2015), another technique that has gained popularity if diabetic wound care is the application of bioengineered alternative tissue (BAT). BAT encompasses numerous products derived from animal, human and synthetic tissues that have been manufactures, cleaned or altered otherwise. BAT are usually recommended in conditions when a split-thickness skin graft (STSG), free or local tissue flaps or primary closure are not regarded as the feasible options. Moreover BAT products are a viable options for exposed deep tissue coverage or where wound had stalled the process of healing. Hyperbaric oxygen is important technique that is employed to treat biofilm induced DFUs. One of the benefits of hyperbaric oxygen therapy is, it cast detrimental effect on bacteria via the production of oxygen free radicals and thereby increasing the activity of leukocyte (Garwood, Steinberg and Kim 2015). According to Kim and Steinberg (2012), HBOT treatments promote increased limb salvage rate via 78.3% in comparison to those who failed to undergo the same. However, Wolcott (2015) is of the opinion that aggressive debridement and use of heavy systemic antibiotics would result in the erosion of the wound along with excessive loss of tissue. With the advent of molecular diagnostic and personalized wound management, the pattern loss of extensive tissue into the forefoot has been reduced greatly. This cannot be entirely credited to suppression of wound biofilm in that there has been some application of newer dressings, revascularization and offloading. All these along with proper management of diabetes have lead to the reduction in the cost of diabetic wound management (Wolcott 2015).

Trokington-Stokes et al. (2016) studied the local barriers to the healing process of diabetic foor ulcers, and discussed the usage of dressing for the management of the ulcer exudates, its infection and the formation of bio-film. The authors considers four case studies on whose merit they demonstrate how patient outcomes can be improved in diabetic foot ulcers through the management of local barriers to the healing process using antimicrobial and anti-biofilm dressing protocols. Studies by Wukich et al., (2013), identified the three factors that has significant effect on diabetic foot ulocers as: infection, i9schaema and neuropathy. However, significant evidence exists that supports would-biofilm as another factor that affects diabetic foot ulcers and its healing process (Gurjala et al. 2011). Approximately 60% of chronic wounds are likely to develop biofilm (James et al., 2008), which can delay the healing process of the wound (Metcalf and Bowler 2013).

Study by showed that Trokington-Stokes et al. (2016), antimictobial wound dressing using AQUACEL Ag+ (AQAg+) dressing can improve the healing rate of diabetic foot ulcers diagnosed with bio-film or infection. In the study, they selected patient with slow healing or deteriorating diabetic foot ulcers to take part in the evaluation of AQAg+, where the clinicians used their disceretion in the selection of the patients to be treated with AQAG+. Four case studies were analysed by the authors, and their results show that AQAg+ can promote healing of diabetic foot ulcers by disrputing the biofilm, which is a barrier to the normal heal;ing process (Metcalf and Bowler 2013). It also prevents the reformation of the biofilms. Due to the disruption, the microorganisms in the biofilm gets exposed to the toxic effects of the silver ions (Bowler and Parsons 2016).

In Vitro studies have shown that AQAg+ dressing can remove the biofilm formation and foster epithelialization, compared to Telfa AMD dressing and non silver Hydrofiber dressing (Seth et al. 2014). Studies by Walker et al. (2015) AQAG+ have improved wound closure by 73% of challenging and recalcitrant wounds, after an average application of the dressing for 4.1 weeks. This is further supported by the studies by Metcalf et al. (2016) in the UK and Ireland, that showed 62% wound closure as well as reduction in biofilm and slough, thereby improving the wound health (Metcalf et al. 2016a; Metcalf et al. 2016b). Moreover, studies by Harding et al. (2013) even showed that antimicrobial dressing using AQAG+ can reduce the cost of treatment by 29%, through their studies on 113 cases of difficult to heal wounds. In addition to the reduction in costs, another advantage provided by the use of AQAG+ in biofilm compromised diabetic foot ulcers is that it helps to vercome the antibiotic resistance of the biofilm that is coomonly seen in diabetic foot ulcers (Harding et al. 2016). This is of significant importance in the treatment of diabetic foot ulcers since it helps to moderate the use of antibiotics, and overcome antibiotic resistance of the bio-film (Alavi et al. 2014). This can help nurses to reduce the inappropriate usage of antibiotics, instead utilizing tropical antimicrobial therapy which offers targeted action instead of a systemic one, and help to contro0l biofilm and prevents resilience of the microbes (Gottrup et al. 2013).

Studies however have shown that Cadexomer iodine can have improved effect against the microbial biofilms in vitro, compared to other tropical antimicrobials that are used to dress the wounds (Hill et al. 2010; Phillips et al. 2015). Malone et al. (2017) used Iodosorb ointment as a carrier for the delivery of iodine, so that it can penetrate the cell wall of the microbes to disrupt the structure of their proteins and nucleic acids and their synthesis (Edwards-Jones 2016). Iodosorb contains small beads of polysaccharides (cadexomer) which has 0.9% iodine. In the presence of the exudates from the wound, the beads swell up causing a slow and sustained release of iodine to the wound. Due to this, application of cadexomer iodine caused a reduction in the population of microbes in the biofilm, and therefore improved the patient outcomes for DFU treatment (Malone et al. 2017).

DFU is one of the serious complications that is associated with chronic diabetes. Apart from the known reasons behind the occurrence of DFU like peripheral neuropathy, peripheral vascular disease, infection from microbial organisms especially bacterial is also getting prominence in present day scenario. The colonisation of the micro-organism at the site of wound give rise to the formation of biofilm and this in turn complicates the healing of the wound (Noor et al. 2015). The application of broad spectrum antibiotic in order to treat the bacterial infection further complicates wound and its healing and this in turn give rise of antibiotic resistant wound (Malik et al. 2013). The main impact of biofilm in wounds is difficulty in healing and this subsequently leads to gangrening (Cooper et al. 2014). However, the microbial analytical techniques, which are used for detecting the nature and type of bacteria residing inside the biofilm, are mostly ineffective (cooper et al. 2014). Thus Cooper et al. (2014) opined that the swabs collected from the biofilm coated bacterial colonized wounds are not true representatives for the microbiota and there are numerous threats of generating false negative results. Therefore, Cooper et al. (2014) has suggested the thorough swab of entire surface of the wound via various biopsies in order to detect and discriminate the aerobic and anerobic bacteria via molecular biology technique.

Kim and Steinberg (2012) have suggested regular maintenance of wounds as an important apprach for controlling bacteria mediated diabetic wound and thereby preventing or reducing the advrse effects arising out of biofilm. Of them the most important technique include debridement technologies, bioengineered alternative tissues and hyperbaric oxygen treatment. Debridement biofilm disruption technique consist of successful removal of non-viable tissues at the site of wound and tereby helping to eradicate biofilm from the grass root level. HOwever, this steps is also associated with certain drawbacks at it may lead to significant tissue damage (Kim and Steinberg). Other approaches like hyperbaric oxygen treatment have been found to be effective as it involves application reactive oxygen species for the treatment of bacterial colonization at the biofilm. Bioengineered alternative tissue is mainly recommended in case of local tissue flaps or primary closure and hence, not regarded as feasible options for the majority of cases (Garwood, Steinberg and Kim 2015). At present proper management of diabetes along with personalized wound care approach is recommended for effective treatment of diabetic wound (Wolcott 2015).

The theme related to utilization of different microscopic techniques for detection of biofilms in DFU showed that screening process for multi-drug resistant organism with biofilms can be easier and cost effective approach if it is done by means of advanced microscopic technique. The important of the study outcome by Oates et al. (2014) was that bacterial microcollines and biofilms matrix in DFU can be easily visualized using the flourescence miscroscopy and ESEM method. It showed that along with conventional staining method, high resolution microscopy are effective in detecting atleast two of the three criteria (microbial surface attachment, structured assembly of cells and presence of exopolymer matrix) (Marks, Parameswaran and Hakansson 2012). In contrast, the uniqueness of the study by Johani et al. (2017) was that it focused on comparing microscopic observation with clinical cues to find correlation between the biofilms and DFU wound characteristics. By finding such link, it could pave way for identifying presence of biofilms by assessing morphology of wounds in DFU patient. Therefore, combination of microscopic visualization with molecular approach can encourage a paradigm shift in health care setting and implementation of anti-biofilm strategies for treatment of DFU (Hurlow, Blanz and Gaddy 2016). Another advantage of microscopic visualization is that in setting where cost efficiency is needed, microscopy technique can be easily adopted as it requires equipment which is most commonly found in diagnostic laboraties.

Another important results that emerged from thematic analysis of the importance and effectiveness of biofilm detection in DFU is that getting information related to microbiome characteristics can help in visualization and detection of biofilm producing microbiome (Murali et al. 2014). By the assessment of antimicrobial sensitivity patterns of bacterial isolates in DFU and detection of biofilm formation, Murali et al. (2014) was able to prove that polymicrobes are mostly found in diabetic wound samples and this has a significant impact on wound healing process. Hurlow, Blanz and Gaddy (2016) also suggested that proper characterization of microbes present in the DFU wound can promote optimal treatment of infection. It gave an important implication that he wound flore should not be underestimated and microbe characteristics should be routinely assessed as this would help to identify whether appropriate antibiotic is given to patient or not. Hence, by focusing on the process to characterize the microbriome of wound samples, critical factors involved in overcoming wound infection can be identified. The clinical significance of identifying biofilm bacteria is that these bacteria are antibiotic resistant bacteria and proper screening of multi-drug resistant bacteria can help to identify appropriate antibiotics to decrease mortality and morbidity in patient with DFU infection (Lavigne et al. 2015).

The secondary research also gave an important insight that adopting accurate process to identify biofilms can help clinician to understanding the microbial load factors that influences the wound healing process. Currently, many revolutionary molecular methods have emerged that can facilitate routine monitoring of DFU infection and findings effective ways to disrupt the biofim (Sibley, Peirano and Church 2012).  The secondary research related to the research question also gave idea about some innovative technique to manage and treat biofilms detected in diabetic ulcer. For instance, Malone et al. (2017) gave idea about the utility of cadexomer iodine on the microbial load and diversity of chronic non-healing diabetic foot ulcers. (Trokington-Stokes et al. 2016) explained about the role of AQUACEL Ag+ dressing on patient with slow healing outcomes for DFU. The advantage of this technique was that the dressing consisted of a metal chelating agent that facilitated wound healing by recognizing barrier to wound healing. Another advantage of this technique was that it addressed the disadvantages found in the mechanical debridement method where biofilms appeared again (Metcalf and Bowler 2013).  By utilizing such evidence in clinical setting, novel opportunities for replacing antimicrobial therapy with other effective intervention can be obtained. Hence, emerging anti-biofilm wound care technologies can be act a clinically significant to control inappropriate use of antimicrobial agents and improving quality of life of DFU patient.

Diabetic foot ulcer is a form of chronic non-healing wound, which creates the risk of amputation in patient. This is an important clinical problem as it leads to prolonged treatment and health care cost. Hence, new technologies are desired by clinician to know the status of wound and get a proper guide to treat difficult wounds. (Uccioli et al., 2015). As there has been many conflicting evidenced related to the identification and management of biofilms in chronic wounds, Schultz et al. (2017) emphasized that having a guideline for treatment of non-chronic wound particularly the importance of biofilms need to be developed. The researcher utilized modified Delphi process and recruited 10 clinicians and researchers with clinical and laboratory expertise to discuss concensus statement for identifying and treating biofilms. Based on face-to-face discussion, concensus was achieved on understanding biofilms, clinical indicators of biofilm and screening anti-biofilm agents. From the review of this evidence, it has emerged that there is a need for strong debridement technique along with effective antiobiofilm treatment to reduce the adverse effect of biofilms in chronic non-healing wounds like diabetic foot ulcer. This research gives implication for the implementation of strong early intervention to promote rapid wound healing and reducing cost involved in care.

Conclusion: 

Diabetic foot ulcer is one of the complicated issues found in poorly controlled diabetes patient. Due to the argumenst regarding the role of biofilms in chronic diabetic foot ulcer infection, the research aimed to get better understanding about the importance of biofilms for detection of diabetic foot ulcer by means of secondary research method. The review and analysis of research studies clarified knowledge and understanding related to the causes of biofilm formation, antibiotic resistance, role of biofilms on wound healing process and different technique for visualization and proper treatment of biofilms. From the thematic analysis and discussion on different themes, it can be said that focus on biofilm is crucial for optimal wound management as the physiology of biofilms indicate how it offers resistance to bacteria from different antibiotics. Apart from this, the research also gave the implication that advanced microscopic and molecular techniques are efficient in detecting biofilms and establishing their correlation with clinical wound characteristics. Hence, by the application of microscopic and molecular techniques and by the emphasis of characterization of microbiome of DFU tissue sample, it can help to identify appropriate therapy for recovery of patient. The research also points out to the possibility of analyzing the efficacy of many new innovative techniques like anti-biofilm techniques and debridement method to facilitate wound healing procedure.

By critically analyzing and reviewing research evidence, there is a need to focus on novel interventions to treat non-healing DFU and find out the most optimal method for treatment of biofilms in wound. It is recommended that before initating any treatment for DFU in diabetic patient, the involvement of biofilms in chronicity should be routinely observed. If presence of biofilms is identified, then it could support clinician to implement right intervention for patient instead of giving those antibiotics which does not have an impact on patient group. Some of the strategies that promote the treatment of diabetic foot wounds include focusing on biofilm degradation process by use of advanced techniques. Negative pressure therapy is one of the most effective approach to mechanically remove wound disruption and it is a promising approach for biofilm treatment in clinical setting (Kim and Steinberg 2012June). Apart from this, the outcome for this research can be utilized to find out novel topical therapy that can reduce chronic wound infection. For instead, the clinical effectiveness of topical therapies like iodine based and silver-based antimicrobials can be evaluated  as these agents do not rely on metabolic activity of the bacteria.

References:

Alavi, A. (2014). Management of Diabetic Foot Infections with Appropriate Use of Antimicrobial Therapy. Clinical Research on Foot & Ankle, s3(01).DOI:  https://doi-org.ezproxy.lib.uts.edu.au/10.4172/2329-910X.S3-010 

Attinger, C. and Wolcott, R., 2012. Clinically addressing biofilm in chronic wounds. Advances in wound care, 1(3), pp.127-132.

Banu, A., Hassan, M.M.N., Rajkumar, J. and Srinivasa, S., 2015. Spectrum of bacteria associated with diabetic foot ulcer and biofilm formation: a prospective study. The Australasian medical journal, 8(9), p.280.

Cooper, R.A., Bjarnsholt, T. and Alhede, M., 2014. Biofilms in wounds: a review of present knowledge. Journal of wound care, 23(11), pp.570-582.

Cross, K.M., 2016. The Challenge of Biofilms in Chronic Wounds. Wound Care Canada, 14(2).

Dinh, T., Tecilazich, F., Kafanas, A., Doupis, J., Gnardellis, C., Leal, E., Tellechea, A., Pradhan, L., Lyons, T.E., Giurini, J.M. and Veves, A., 2012. Mechanisms involved in the development and healing of diabetic foot ulceration. Diabetes, 61(11), pp.2937-2947.

Dowd, S.E., Sun, Y., Secor, P.R., Rhoads, D.D., Wolcott, B.M., James, G.A. and Wolcott, R.D., 2008. Survey of bacterial diversity in chronic wounds using pyrosequencing, DGGE, and full ribosome shotgun sequencing. BMC microbiology, 8(1), p.43.

Edwards-Jones, V., 2016. Essential microbiology for wound care. Oxford University Press.

Garwood, C.S., Steinberg, J.S. and Kim, P.J., 2015. Bioengineered alternative tissues in diabetic wound healing. Clinics in podiatric medicine and surgery, 32(1), pp.121-133.

Gottrup, F., Apelqvist, J., Bjarnsholt, T., Cooper, R., Moore, Z., Peters, E. and Probst, S. (2013). EWMA Document: Antimicrobials and Non-healing Wounds: Evidence, controversies and suggestions. Journal of Wound Care, 22(Sup5), pp.S1-S89. DOI: : https://doi-org.ezproxy.lib.uts.edu.au/10.12968/jowc.2013.22.Sup5.S1

Hajishengallis, G. and Lamont, R.J., 2012. Beyond the red complex and into more complexity: the polymicrobial synergy and dysbiosis (PSD) model of periodontal disease etiology. Molecular oral microbiology, 27(6), pp.409-419.

Hartemann-Heurtier A, Robert J, Jacqueminet S, Ha Van G, Golmard JL, Jarlier V, et al. Diabetic foot ulcer and multidrug-resistant organisms: risk factors and impact. Diabetic Medicine 2004;21:710–5.

Hill, K.E., Malic, S., McKee, R., Rennison, T., Harding, K.G., Williams, D.W. and Thomas, D.W., 2010. An in vitro model of chronic wound biofilms to test wound dressings and assess antimicrobial susceptibilities. Journal of Antimicrobial Chemotherapy, 65(6), pp.1195-1206.

Hurlow, J., Blanz, E. and Gaddy, J.A., 2016. Clinical investigation of biofilm in non-healing wounds by high resolution microscopy techniques. Journal of wound care, 25(Sup9), pp.S11-S22.

Johani, K., Malone, M., Jensen, S., Gosbell, I., Dickson, H., Hu, H. and Vickery, K., 2017. Microscopy visualisation confirms multi?species biofilms are ubiquitous in diabetic foot ulcers. International wound journal, 14(6), pp.1160-1169.

Kang, W.J., Shi, L., Shi, Y., Cheng, L., Ai, H.W. and Zhao, W.J., 2017. Analysis on distribution, drug resistance and risk factors of multi drug resistant bacteria in diabetic foot infection. Biomedical Research, 28(22).

Kim, P.J. and Steinberg, J.S., 2012, June. Wound care: biofilm and its impact on the latest treatment modalities for ulcerations of the diabetic foot. In Seminars in vascular surgery (Vol. 25, No. 2, pp. 70-74). WB Saunders.

Kirketerp-Møller, K., Jensen, P.Ø., Fazli, M., Madsen, K.G., Pedersen, J., Moser, C., Tolker-Nielsen, T., Høiby, N., Givskov, M. and Bjarnsholt, T., 2008. Distribution, organization, and ecology of bacteria in chronic wounds. Journal of clinical microbiology, 46(8), pp.2717-2722.

Lavigne, J.P., Sotto, A., Dunyach-Remy, C. and Lipsky, B.A., 2015. New molecular techniques to study the skin microbiota of diabetic foot ulcers. Advances in wound care, 4(1), pp.38-49.

Malik, A., Mohammad, Z. and Ahmad, J., 2013. The diabetic foot infections: biofilms and antimicrobial resistance. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 7(2), pp.101-107.

Malone, M., 2017. The Microbiome of Diabetic Foot Ulcers and the Role of Biofilms. In The Microbiology of Skin, Soft Tissue, Bone and Joint Infections (pp. 41-56).

Malone, M., Bjarnsholt, T., McBain, A.J., James, G.A., Stoodley, P., Leaper, D., Tachi, M., Schultz, G., Swanson, T. and Wolcott, R.D., 2017. The prevalence of biofilms in chronic wounds: a systematic review and meta-analysis of published data. Journal of wound care, 26(1), pp.20-25.

Malone, M., Johani, K., Jensen, S.O., Gosbell, I.B., Dickson, H.G., Hu, H. and Vickery, K., 2017. Next Generation DNA Sequencing of Tissues from Infected Diabetic Foot Ulcers. EBioMedicine, 21, pp.142-149.

Malone, M., Johani, K., Jensen, S.O., Gosbell, I.B., Dickson, H.G., McLennan, S., Hu, H. and Vickery, K., 2017. Effect of cadexomer iodine on the microbial load and diversity of chronic non-healing diabetic foot ulcers complicated by biofilm in vivo. Journal of Antimicrobial Chemotherapy, 72(7), pp.2093-2101.

Marks, L.R., Parameswaran, G.I. and Hakansson, A.P., 2012. Pneumococcal interactions with epithelial cells are crucial for optimal biofilm formation and colonization in vitro and in vivo. Infection and immunity, 80(8), pp.2744-2760.

Metcalf, D. and Bowler, P. (2013). Biofilm delays wound healing: A review of the evidence. Burns & Trauma, 1(1), p.5. DOI: https://doi-org.ezproxy.lib.uts.edu.au/10.4103/2321-3868.113329

Metcalf, D., Parsons, D. and Bowler, P. (2016a). A next-generation antimicrobial wound dressing: a real-life clinical evaluation in the UK and Ireland. Journal of Wound Care, 25(3), pp.132-138. DOI:  https://doi-org.ezproxy.lib.uts.edu.au/10.12968/jowc.2016.25.3.132

Metcalf, D., Parsons, D. and Bowler, P. (2016b). Clinical safety and effectiveness evaluation of a new antimicrobial wound dressing designed to manage exudate, infection and biofilm. International Wound Journal, 14(1), pp.203-213. DOI:  https://doi-org.ezproxy.lib.uts.edu.au/10.1111/iwj.12590

Metcalf, D.G. and Bowler, P.G., 2013. Biofilm delays wound healing: A review of the evidence. Burns & Trauma, 1(1), p.5.

Murali, T.S., Kavitha, S., Spoorthi, J., Bhat, D.V., Prasad, A.S.B., Upton, Z., Ramachandra, L., Acharya, R.V. and Satyamoorthy, K., 2014. Characteristics of microbial drug resistance and its correlates in chronic diabetic foot ulcer infections. Journal of medical microbiology, 63(10), pp.1377-1385.

Noor, S., Zubair, M. and Ahmad, J., 2015. Diabetic foot ulcer—a review on pathophysiology, classification and microbial etiology. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 9(3), pp.192-199.

Oates, A., Bowling, F. L., Boulton, A. J., Bowler, P. G., Metcalf, D. G., and McBain, A. J. 2014. The visualization of biofilms in chronic diabetic foot wounds using routine diagnostic microscopy methods. Journal of diabetes research, 2014.

Parahoo, K., 2014. Nursing research: principles, process and issues. Palgrave Macmillan.

Phillips, P.L., Yang, Q., Davis, S., Sampson, E.M., Azeke, J.I., Hamad, A. and Schultz, G.S., 2015. Antimicrobial dressing efficacy against mature Pseudomonas aeruginosa biofilm on porcine skin explants. International wound journal, 124), pp.469-483.

Schultz, G., Bjarnsholt, T., James, G.A., Leaper, D.J., McBain, A.J., Malone, M., Stoodley, P., Swanson, T., Tachi, M. and Wolcott, R.D., 2017. Consensus guidelines for the identification and treatment of biofilms in chronic nonhealing wounds. Wound Repair and Regeneration.

 Seth, A., Zhong, A., Nguyen, K., Hong, S., Leung, K., Galiano, R. and Mustoe, T. (2014). Impact of a novel, antimicrobial dressing on in vivo,Pseudomonas aeruginosawound biofilm: Quantitative comparative analysis using a rabbit ear model. Wound Repair and Regeneration, 22(6), pp.712-719. DOI:  https://doi-org.ezproxy.lib.uts.edu.au/10.1111/wrr.12232

Sibley, C.D., Peirano, G. and Church, D.L., 2012. Molecular methods for pathogen and microbial community detection and characterization: current and potential application in diagnostic microbiology. Infection, Genetics and Evolution, 12(3), pp.505-521.

Smith, K., Collier, A., Townsend, E.M., O’Donnell, L.E., Bal, A.M., Butcher, J., Mackay, W.G., Ramage, G. and Williams, C., 2016. One step closer to understanding the role of bacteria in diabetic foot ulcers: characterising the microbiome of ulcers. BMC microbiology, 16(1), p.54.

Torkington-Stokes, R., Metcalf, D. and Bowler, P. (2016). Management of diabetic foot ulcers: evaluation of case studies. British Journal of Nursing, 25(15), pp.S27-S33. Available at: https://www-magonlinelibrary-com.ezproxy.lib.uts.edu.au/doi/full/10.12968/bjon.2016.25.15.S27

Uccioli, L., Izzo, V., Meloni, M., Vainieri, E., Ruotolo, V. and Giurato, L., 2015. Non-healing foot ulcers in diabetic patients: general and local interfering conditions and management options with advanced wound dressings. Journal of wound care, 24(Sup4b), pp.35-42.

Wolcott, R., 2015. Economic aspects of biofilm-based wound care in diabetic foot ulcers. Journal of wound care, 24(5), pp.189-194.

Wong, S. L., Demers, M., Martinod, K., Gallant, M., Wang, Y., Goldfine, A. B., … & Wagner, D. D. (2015). Diabetes primes neutrophils to undergo NETosis, which impairs wound healing. Nature medicine, 21(7), 815.