Working together to ensure better patient outcomes - EWMA

Danish Wound
Healing Society
Working
together
to ensure
better
patient
outcomes
Volume 11
Number 2
May 2011
Published by
European
Wound Management
Association

The EWMA Journal
ISSN number: 1609-2759
Volume 11, No 2, May, 2011
Electronic Supplement May 2011
www.ewma.org
The Journal of the European
Wound Management Association
Published three times a year
Editorial Board
Carol Dealey, Editor
Sue Bale
Finn Gottrup
Martin Koschnick
Zena Moore
Marco Romanelli
Zbigniew Rybak
José Verdú Soriano
Rita Gaspar Videira
Peter Vowden
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2
EWMA
Council
Paulo Alves
Eskild Winther Henneberg
Dubravko Huljev
CO-OPERATING ORGANISATIONS’ BOARD
Christian Thyse, AFISCeP.be
Andrea Bellingeri, AISLeC
Elia Ricci, AIUC
Aníbal Justiniano, APTFeridas
Gerald Zöch, AWA
Luc Gryson, BFW
Vladislav Hristov, BWA
Els Jonckheere, CNC
Milada Francu, CSLR
Dubravko Huljev, CWA
Hans Martin Seipp, DGfW
Eskild Winther Henneberg, DSFS
Anna Hjerppe, FWCS
Pedro Pacheco, GAIF
J. Javier Soldevilla, GNEAUPP
Editorial Board Members
Sue Bale, UK
Carol Dealey, UK (Editor)
Finn Gottrup, Denmark
Martin Koschnik, Portugal
Zena Moore, Ireland
Marco Romanelli, Italy
Zbigniew Rybak, Poland
José Verdú Soriano, Spain
Rita Gaspar Videira, Portugal
Peter Vowden, UK
For contact information, see www.ewma.org
Sue Bale
Recorder
Barbara E.
den Boogert-Ruimschotel
Maarten J. Lubbers
Zena Moore
President
Sylvie Meaume
Jan Apelqvist
President Elect
Carol Dealey
EWMA Journal Editor
Gerrolt Jukema
Christian Münter, ICW
Aleksandra Kuspelo, LBAA
Mark Collier, LUF
Kestutis Maslauskas, LWMA
Corinne Ward, MASC
Hunyadi János, MSKT
Suzana Nikolovska, MWMA
Alison Johnstone, NATVNS
Kristin Bergersen, NIFS
Louk van Doorn, NOVW
Arkadiusz Jawień, PWMA
Rodica Crutescu, ROWMA
Severin Läuchli, SAfW (DE)
Hubert Vuagnat, SAfW (FR)
Goran D. Lazovic, SAWMA
Patricia Price
Secretary
Rytis Rimdeika
EWMA Journal Scientific Review Panel
Paulo Jorge Pereira Alves, Portugal
Caroline Amery, UK
Michelle Briggs, UK
Mark Collier, UK
Bulent Erdogan, Turkey
Madeleine Flanagan, UK
Milada Francu˚, Czech Republic
Peter Franks, UK
Francisco P. García-Fernández, Spain
Luc Gryson, Belgium
Alison Hopkins, UK
Gabriela Hösl, Austria
Marco Romanelli
Immediate Past President
Corrado M. Durante
Treasurer
Martin Koschnick
Robert Strohal
Luc Gryson
Severin Läuchli
Mária Hok, SEBINKO
Sylvie Meaume, SFFPC
Christina Lindholm, SSIS
Jozefa Košková, SSOOR
Guðbjörg Pálsdóttir, SUMS
Javorca Delic, SWHS
Magnus Löndahl, SWHS
Andrea Nelson, TVS
Jasmina Begić-Rahić, URuBiH
Barbara E. den Boogert-Ruimschotel, V&VN
Skender Zatriqi, WMAK
Georgina Gethin, WMAOI
Nada Kecelj Leskovec, WMAS
Bülent Erdogan, WMAT
Leonid Rubanov, WMS (Belarus)
Klaus Kirketerp-Møller, Denmark
Zoltán Kökény, Hungary
Christian Münter, Germany
Andrea Nelson, UK
Pedro L. Pancorbo-Hidalgo, Spain
Hugo Partsch, Austria
Patricia Price, UK
Rytis Rimdeika, Lithuania
Salla Seppänen, Finland
Carolyn Wyndham-White, Switzerland
Gerald Zöch, Austria

5 Editorial
Carol Dealey
Science, Practice and Education
7 The fight against biofilm infections:
Do we have the knowledge and means?
Klaus Kirketerp-Møller, Thomas Bjarnsholt,
Trine Rolighed Thomsen
10 Biofilms in wounds: An unsolved problem?
António Pedro Fonseca
25 Diabetic foot ulcer pain: The hidden burden
Sarah E Bradbury, Patricia E Price
38 Topical negative pressure in the treatment of
deep sternal infection following cardiac surgery:
Five year results of first-line application protocol
Martin Šimek
Scientific Communication
43 Wounds Research for Patient Benefit: A five
year programme of research in wound care
Karen Lamb, Nikki Stubbs, Jo Dumville, Nicky Cullum
EWMA
48 EWMA Journal Previous Issues and
Other Journals
50 Introducing the Belgian Federation
of Woundcare
Brigitte Crispin, Luc Gryson
52 EWMA Patient Outcome Group
Patricia Price
55 1st EWMA Health Economics Course organised
by the EWMA Patient Outcome Group
Finn Gottrup
56 Advanced Wound Care Sector (AWCS)
Status Report
Hans Lundgren
60 EWMA Wound Surveys – Resource consumption
for wound care
Finn Gottrup
62 National collaboration for the Leg Ulcer
& Compression Seminars 2011
Hugo Partsch, Finn Gottrup
64 EWMA Corporate Sponsors Contact Data
Organisations
66 Conference Calendar
69 Conference Report: EWMA Session, 20th Annual
European Tissue Repair Society Congress
Gerrolt N. Jukema
70 FWCS: The 14th national wound healing
congress in Helsinki, Finland
Anna Hjerppe
72 Wound Treatment Organisation established
in Ukraine
Rytis Rimdeika
74 EWMA Cooperating Organisations
75 International Partner Organisations
75 Associated Organisations
ELECTRONIC SUPPLEMENT
WWW.EWMA.ORG
MAY 2011
The May 2011 edition of the EWMA
Journal Electronic Supplement consist
of all the accepted abstracts for the
EWMA 2011 Conference in Brussels.
It is divided into 150 Oral presentations
and 358 Poster presentations and it
is possible to download individual
abstracts as well as the entire supplement
(including all the abstracts) at
www.ewma.org/english/ewma-journal/
electronic-supplement.html
EWMA Journal 2011 vol 11 no 2 3

HQ024571104
Welcome to Mölnlycke Health Care
Satellite Symposium
Investigating the Impact of Topical Antimicrobials
in Wound Care
May 26, 2011 at 11.15-12.15
Wound infection is the most concerning of all wound complications. Topical antimicrobials play an
important role in preventing and managing local wound infections however there are some
outstanding questions regarding the usage of these agents that need to be answered.
The aim of this Symposium is to support the appropriate use of topical antimicrobial agents and
to promote clinical decision-making that ensures their prescription only when clinically indicated.
Chairmen: Assoc Prof Bill McGuiness & Lt Col Steven Jeffery
Speakers: Professor Kevin Chipman, Dr Paul Silverstein & Dr Jean-Charles Kerihuel
We look forward to seeing you there!
You said:
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in NPWT. Thanks to two unique products with Safetac ® technology: Avance film with
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The properties of Safetac also means you can quickly and easily reposition the film
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1. White R. A Multinational survey of the assessment of pain when removing dressings. Wounds UK 2008;Vol 4, No 1.
2. Submitted to International Journal of Orthopaedic and Trauma Nursing, 2011.
3. Meaume S et al. A study to compare a new self adherent soft silicone dressing with a self adherent polymer dressing in stage II pressure ulcers. Ostomy Wound Management
2003;49(9):44-51.
The Mölnlycke Health Care name and logo, Avance ® , Mepiseal ® and Safetac ® are registered trademarks of Mölnlycke Health Care AB.
© Copyright (2011) Mölnlycke Health Care. All rights reserved.
Mölnlycke Health Care AB, Box 13080, SE-402 52 Göteborg, Sweden. Phone + 46 31 722 30 00. www.molnlycke.com

Welcome to the Spring Issue of the
EWMA Journal, sometimes known as
the ‘Conference Issue’ as its publication
coincides with our annual conference. It is a great
pleasure to know that conference delegates will all
receive a copy of this issue, as I imagine that there
may be a number who have not come across the
EWMA Journal before. If this is you, please be
aware that the Journal is freely available on-line via
the EWMA website and also via Ebsco Host (free
for NHS UK employees).
As ever we have a number of interesting papers for
you as well as all the news of EWMA activities and
updates from a number of our Co-operating Organisations.
I would like to draw your attention to some
in particular. We have two papers about biofilms,
one an opinion piece from a Danish group led by
Dr Klaus Kirketerp-Møller which highlights some
of the problems surrounding biofilms; the other
from Assistant Professor Pedro Fonseca which gives
us really detailed information about biofilms and
their effects. I would also recommend to you a quite
different paper which looks at the impact of pain
on the quality of life with patients with diabetic
foot ulcers. This is the second of two papers by
Bradbury and Price on this subject and they both
make interesting reading.
In this issue we have what I hope is the start of a
long series – the showcasing of large funded programmes
of research relating to wound healing and
tissue viability. Professor Nicky Cullum provides
us with details of an interesting programme of Research
for Patient Benefit funded by the English
National Institute for Health Research (NIHR).
The NIHR provides funding for programme grants
lasting 4-5 years and it is very encouraging that two
such programmes are wound management/tissue
viability related. The other programme grant called
PURPOSE will be showcased in the next issue. We
would be delighted to hear from other successful
research teams about their projects and showcase
them in the same way.
Dear Readers
I
am writing about something completely
different in the final part of my editorial – and
it could be called my farewell speech. At the Annual
General Meeting this month I will be retiring
from EWMA Council and I have decided it is also
appropriate to step down as editor of the Journal.
This will not be a shock to Council as we have
been discussing this for some time and the Journal
editorship is being passed over into the very capable
hands of Sue Bale. Sue has been on the Editorial
Board for a while, so she has a very good insight into
the workings of the Journal. I would like to take
this opportunity to thank all the members of the
Editorial Board and of the Scientific Review Panel
as well as the ‘Two Katja’s’ of EWMA Secretariat for
their support over the last few years. The Editorial
Board and the Scientific Review Panel have been
very gracious about undertaking rapid reviews for
me at short notice from time to time and I have
depended on them all for their considered reviews of
the papers we receive. As for the ‘Two Katja’s’ – they
have had the thankless task of trying to keep me to
deadlines and prompting me when I forget things!
I wish them all well and I am sure the Journal will
continue to go from strength to strength.
As for me, well it will seem strange as I have been
involved with EWMA since before it was officially
established and a member of Council all of that
time as well. I have thoroughly enjoyed being part
of EWMA and have friends in many countries in
Europe through the meetings I have attended. On
a very personal note I especially appreciated these
friendships and the love and support I received
when my husband died. So now, I am officially
winding down towards my retirement in 2012 when
I have many plans which include having more time
to spend with friends and family, especially my little
grandson who loves to help me with my digging in
my vegetable garden.
Carol Dealey, Editor
EWMA Journal 2011 vol 11 no 2 5

NEW in vitro Evidence
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*As demonstrated in vitro ConvaTec researchers used an in vitro bacteria-seeded agar overlay model simulating a colonized wound surface to
investigate the antimicrobial activity of selected silver wound dressings. The dressings were separately applied to agar surfaces seeded with S. aureus and P. aeruginosa. After 48 hours,
the dressings were removed from the agar surfaces. These photographs are representative of the visually observed results with S. aureus.
1. The Antimicrobial Activity of Silver-Containing Wound Dressings on a Simulated Colonised Wound Surface. Scientific Background Report. WHRI3415 MA162. 2011 Data on File, ConvaTec.
2. Jones S, Bowler PG, Walker M. Antimicrobial activity of silver-containing dressings is influenced by dressing conformability with a wound surface. WOUNDS. 2005;17(9):263-270.
3. Jones SA, Bowler PG, Walker M, Parsons D. Controlling wound bioburden with a novel silver-containing Hydrofiber dressing. Wound Repair Regen. 2004;12(3):288-294.
AQUACEL and Hydrofiber are registered trademarks of ConvaTec Inc. All other trademarks are the property of their respective owners.
© 2011 ConvaTec Inc. AP-011145-MM [AM/EM]

Opinion Piece
The fight against biofilm infections:
Do we have the knowledge
and means?
When a ship arrives on the shores of an
unknown territory with scarce or no
information of what is beyond the horizon,
it is only confidence in the capacity and the
skills of the crew and hardware that will convince
the commander that the land can be taken. Intelligence
is of outmost importance. Do we have the
intelligence in the battle against biofilm infections
to win?
In the present paper we will list what we believe
is the key knowledge today and identify what
science lacks, in order to suggest research strategies
to resolve biofilm infections.
A Paradox:
How wonderful that we have met with
a paradox. Now we have some hope of
making progress. Niels Bohr (1885-1962)
It is more or less accepted that chronic wounds
harbour bacterial biofilm. As illustrated later in
this paper, bacterial biofilm has the ability to interfere
with the human immune system in numerous
ways and to prevent healing. Despite that, the
majority of chronic wounds will heal if the cause
or predisposing factors are treated; the venous leg
ulcer will heal with compression therapy, the diabetic
ulcer will heal by off-loading and the cancer
ulcer will heal after radiation. The residual group,
the non-healing ulcers of mixed origin, could heal
if unrecognized and untreated factors are treated
well. One of these factors is bacterial biofilm. But
what is the difference between the biofilm in the
healing group and in the non-healing group?
To stay with the military metaphors, we have
reports of some battles we have won, but does that
give us knowledge of the bacteria’s full weaponry?
Communication and virulence factors
Communication between bacteria is pointed out
to be a target for intervention. Quorum Sensing
(QS) in general and between Pseudomonas
aeruginosa specifically is only a fragment of the
communication between the bacteria. The Nacyl
homoserine lactone QS signal molecule in
P. aeruginosa will trigger the production of virulence
factors such as rhamnolipids that, in vitro,
can eliminate Neutrophils 1 . Blocking or modification
of QS, in theory, will enable the immune
system to eradicate the bacteria even in mature
biofilms. However the QS molecules differ between
Gram-positive and Gram-negative bacteria
and even within these. A single drug to regulate
all the harmful effects of QS is hardly imaginable.
We have only a little overview of the communication
in multi-species biofilm and of the
communication between different mono-species
biofilms. To interfere with the bacteria we need to
decode their communication under different conditions.
For instance: does antibiotic treatment
alter the communication? Does surgical debridement?
Insight into this will help us develop treatment
strategies for different conditions.
Resistance
Antibiotic resistance and tolerance in bacterial
biofilm is a major problem in the treatment of
infections. The resistance is regulated in many
different ways beside the resistance carried by the
resistance genes, as in the mecA in Staphyloccocus
aureus. Tolerance is partly QS controlled, partly
influenced by different phenotypes within the
biofilm e.g., different growth rates, efflux pumps
etc, and by numerous other factors like the matrix
components 2;3 . The response from the clinician
has been newer drugs, higher dosages and polydrug
treatment. Understanding the mechanisms
of resistance and tolerance in biofilms can help us
develop new treatment strategies and hopefully
stop the rising curve of antibiotic usage and of
antibiotic resistance.
Science, Practice and Education
1 Klaus Kirketerp-Møller
MD
2,3 Thomas Bjarnsholt,
Phd
4 Trine Rolighed Thomsen,
Phd
1 Orthopedic Department
Hvidovre University Hospital
Denmark
2 University of Copenhagen
Faculty Of Health Sciences
Department of International
Health, Immunology and
Microbiology
Denmark
3 Rigshospitalet
Department for Clinical
Microbiology, afsnit 9301,
Denmark
4 Department of
Biotechnology
Chemistry and
Environmental Engineering
Denmark
Correspondence:
Klaus Kirketerp-Møller
kkm@dadlnet.dk
Conflict of interest: None
EWMA Journal 2011 vol 11 no 2 7

Science, Practice and Education
Mono or multispecies biofilm
Chronic wounds are shown to be polymicrobial with no
single bacterium exclusively colonizing the wounds 4-7 . The
microbial community is highly variable, and it has been
recently published that some primary populations exist in
each wound, but there can also be hundreds of different
species present, many of which are in trace amounts 8 .
Using FISH, it has been illustrated that some individual
microcolonies in chronic wounds only consist of a single
species 9 . Mono and polyspecies biofilms probably exist in
the same ulcer, but the importance or relevance of this is
not yet established 10 .
The uneven distribution
The appearance of improved sampling techniques and
molecular biology methods have illustrated that the traditional
culture-dependent methods often underestimate the
micro-organisms present and that a non-random distribution
pattern of bacteria exists in the wounds. Differences
in bacterial populations across the surface and also deep
inside the wounds were found in several studies. S.aureus
was primarily located close to the wound surface and P.
aeruginosa was primarily located deeper in the wound 5;11 .
This is highly relevant for the clinician. How and when
is the sample taken? In an ideal world, the whole wound
would be taken out to identify every single pathogen, but
this is not possible nor does it provide us with the full
answer. Which bacterial strain or even subgroup is important?
The newer culture-independent methods such as
16S rRNA gene-based pyrosequencing, 16S rDNA cycle,
PCR, real time PCR and fingerprinting techniques like
denaturant gradient gel electrophoresis are identifying
bacteria never before associated with chronic wounds.
The problem for the clinician to evaluate the result of a
culture-independent method is paramount. Which bacteria
is truly a pathogen and which is merely passing by in
search of a friendlier environment? How about a cut-off
limit that indicates that this bacterium is abundant enough
to be a pathogen? Well, the pathogenecity between different
strains and phenotypes differs and probably differs
over time within the same phenotype. Adding detection
of known virulence genes to the molecular methods would
be helpful in the process of interpretation.
The role of revision before sampling
Neither the traditional culturing technique nor the culture-independent
methods can compensate for the threedimensional
uneven distribution of micro-organisms in
chronic ulcers. When designing a protocol for sampling,
we think the following should be considered: 1. Revise
the ulcer before sampling. The surface is likely to host
commensal flora, and it is more likely that an in-depth
residing bacteria is pathogenic than a superficial one. 2:
Swab a large area or take a big biopsy.
8
The introduction of a stringent protocol for sampling
in diabetic foot ulcers reduced the frequency of MRSA by
almost two-thirds in the ulcer and reduced the number
of bacteria believed to be colonizers by three-fourths 12 .
Are the predominant bacteria the villain?
Well they probably are, but some strains are highly virulent
and co-exist very well with other species. The betahaemolytic
Streptococcus and the Staphylococcus aureus are
an example. Yet we do not know whether the virulence
of a certain strain is dependent upon another. The most
abundant bacteria found by traditional methods could
just be the one easiest to grow.
The paradigm shift in research:
Instead of only finding the bacteria, look for what they
are doing. The questions we, both researchers and clinician,
should ask are: What role does every single bacterial
and fungal species have in the ulcer? What role does the
biofilm formation play and is it the same for all species?
Which virulence factors are the most important, and does
QS play a role etc. Only by having thorough knowledge
of this, will we be able to develop sufficient treatment
strategies for each individual ulcer.
Until then we have to rely on “Best-Practice Principles”.
m
References
1 van Gennip M, Christensen LD, Alhede M, Phipps R, Jensen PO, Christophersen L,
et al. Inactivation of the rhlA gene in Pseudomonas aeruginosa prevents rhamnolipid
production, disabling the protection against polymorphonuclear leukocytes. APMIS
2009 Jul;117(7):537-46.
2 Percival SL, Hill KE, Malic S, Thomas DW, Williams DW. Antimicrobial tolerance and
the significance of persister cells in recalcitrant chronic wound biofilms. Wound
Repair Regen 2011 Jan;19(1):1-9.
3 Lewis K. Persister cells, dormancy and infectious disease. Nat Rev Microbiol 2007
Jan;5(1):48-56.
4 Wolcott RD, Gontcharova V, Sun Y, Dowd SE. Evaluation of the bacterial diversity
among and within individual venous leg ulcers using bacterial tag-encoded FLX and
titanium amplicon pyrosequencing and metagenomic approaches. BMC Microbiol
2009;9:226.
5 Thomsen TR, Aasholm MS, Rudkjobing VB, Saunders AM, Bjarnsholt T, Givskov M,
et al. The bacteriology of chronic venous leg ulcer examined by culture-independent
molecular methods. Wound Repair Regen 2010 Jan;18(1):38-49.
6 Dowd SE, Sun Y, Secor PR, Rhoads DD, Wolcott BM, James GA, et al. Survey of
bacterial diversity in chronic wounds using pyrosequencing, DGGE, and full ribosome
shotgun sequencing. BMC Microbiol 2008;8:43.
7 Gjodsbol K, Christensen JJ, Karlsmark T, Jorgensen B, Klein BM, Krogfelt KA.
Multiple bacterial species reside in chronic wounds: a longitudinal study. Int Wound J
2006 Sep;3(3):225-31.
8 Smith DM, Snow DE, Rees E, Zischkau AM, Hanson JD, Wolcott RD, et al.
Evaluation of the bacterial diversity of pressure ulcers using bTEFAP pyrosequencing.
BMC Med Genomics 2010;3:41.
9 Kirketerp-Moller K, Jensen PO, Fazli M, Madsen KG, Pedersen J, Moser C, et al.
Distribution, organization, and ecology of bacteria in chronic wounds. J Clin
Microbiol 2008 Aug;46(8):2717-22.
10 Burmolle M, Thomsen TR, Fazli M, Dige I, Christensen L, Homoe P, et al. Biofilms in
chronic infections – a matter of opportunity – monospecies biofilms in multispecies
infections. FEMS Immunol Med Microbiol 2010 Aug;59(3):324-36.
11 Fazli M, Bjarnsholt T, Kirketerp-Moller K, Jorgensen B, Andersen AS, Krogfelt KA, et
al. Nonrandom distribution of Pseudomonas aeruginosa and Staphylococcus aureus
in chronic wounds. J Clin Microbiol 2009 Dec;47(12):4084-9.
12 Sotto A, Richard JL, Combescure C, Jourdan N, Schuldiner S, Bouziges N, et al.
Beneficial effects of implementing guidelines on microbiology and costs of infected
diabetic foot ulcers. Diabetologia 2010 Oct;53(10):2249-55.
EWMA Journal 2011 vol 11 no 2

Lohmann & Rauscher
“Simplifying wound management
by means of new technology and
new definitions.”
A symposium - (60 min, Thursday 26.05.11, 11:15 - 12:15h)
“Wounds at risk – a new definition
(Chair: Thomas Eberlein, Sa Cabaneta/E, Andrew Kingsley, Devon/UK)”
■ Wound at risk and its new definition by the W.A.R. Score – Thomas Eberlein, Sa Cabaneta/E (15 min)
■ Sign Checker – symptoms, diagnosis, therapy – Andrew Kingsley, Devon/UK (15 min)
■ Reduction of SSI in a paediatric population: using a new postoperative polihexanide containing
dressing regimen in a paediatric cardiology unit – Thomas Witter (RN Child) & Dr. Aaron Bell,
London/UK (15 min)
■ Randomised controlled single center study comparing a polihexanide containing bio-cellulose
dressing with silver sulfadiazine cream in partial thickness dermal burns – Andrzej Piatkowski de
Grzymala, Aachen/DE (15 min)
B symposium - (60 min, Wednesday 25.05.11, 15:30 - 16:30h)
“Gentle Debridement – rapid and effective
(Chair: Trudie Young, Aneurin Bevan Health Board, Bangor/UK)”
■ Consensus guidance for the use of debridement techniques in the UK – Trudie Young (Aneurin
Bevan Health Board), Bangor/UK (30 min)
■ The wound debrider – a new fibre technology for debridement: results on 60 patients – Michael
Schmitz, Rengsdorf/DE (15 min)
■ Gentle debridement: first clinical experience in UK – Sylvie Hampton (Tissue Viability Consultancy
Services), Eastbourne/UK (15 min)
Meet us at the
EWMA 2011, stand 26!
Suprasorb ® X + PHMB
specifi cally for wounds at risk of infection
or infected wounds.
quick and effective pain reduction
wide antimicrobial spectrum
good tissue compatibility
independent moisture control by
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EWMA Journal 2011 vol 11 no 2 9
www.Lohmann-Rauscher.com
9503227 0411 e

António Pedro Fonseca
PhD, Assistant Professor 1,2
1 Faculdade de Medicina,
Universidade do Porto,
2 REQUIMTE,
Faculdade de Farmácia,
Universidade do Porto,
Porto, Portugal
Correspondance:
António Pedro Fonseca,
Alameda Prof. Hernâni
apfonseca09@gmail.com
Conflict of interest: None
10
Biofilms in wounds:
An unsolved problem?
ABSTRACT
Chronically infected wounds are very costly to
health care institutions and a significant cause of
suffering. The major failure associated to chronic
wounds is a delayed healing process due to the
presence of single or polymicrobial communities
that give protection to antimicrobials and host defenses.
These biofilm communities can be healthy
or pathogenic according to the predominant microorganism
so all the prophylactic and therapeutic
measures should consider the wound healing
process as a window of opportunity, ideally after
a sharp and regular debridement. The aim of this
review is to give an additional insight to health
practitioners of the importance of the biofilm
paradigm in explaining the delay in wound healing
and its relation to a diagnostic, prophylactic
and therapeutic management.
1. BIOFILMS
a. Introduction
The ability of a microorganism to establish an
infection is dependent on several factors, namely
those of the host and the pathogen. There is a balance
between the pathogen and the host concerning
the numbers of pathogens that are needed to
start colonization and advance an infection. This
balance is dependent on the host defense system
and the presence and expression of pathogenic
factors associated to the microorganism 1,2 .
References
1. Gardner SE, Frantz RA, Saltzman CL, Dodgson KJ. Staphylococcus aureus
is associated with high microbial load in chronic wounds. Wounds 2004:
16(8):251-7.
2. Jensen PØ, Bjarnsholt T, Phipps R, Rasmussen TB, Calum H, Christoffersen
L, Moser C, Williams P, Pressler T, Givskov M,, Høiby N. Rapid
necrotic killing of polymorphonuclear leukocytes is caused by quorumsensing-controlled
production of rhamnolipid by Pseudomonas aeruginosa.
Microbiology 2007: 153:1329-38.
3. Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a common
cause of persistent infections. Science 1999: 284:1318-22.
4. Donlan RM, Costerton JW. Biofilms: Survival mechanisms of clinically
relevant microorganisms. Clin Microbiol Rev 2002: 15(2):167-93.
5. Hall-Stoodley L, Costerton JW, Stoodley P. Bacterial biofilms: From the
natural environment to infectious diseases. Nat Rev Microbiol 2004:
2:95-108.
6. Jefferson KK. What drives bacteria to produce a biofilm? FEMS Microbiol
Lett 2004: 236(2):163-73.
b. Biofilm formation
Biofilm is a community of single or multiple microorganisms
that are surface attached and encased
within an extracellular matrix 3 . This community
is found attached to abiotic surfaces like industrial
waters systems and indwelling medical devices 4
or biotic like mucosal surfaces 5 .Biofilm formation
in the host is a strategy of the microorganism
to survive the host defenses and also to optimize
the use of the nutrient rich environment and the
cooperative work between the biofilm organisms 6 .
Biofilms can have either a positive effect such as
the biodegradation 7 in sewage treatment 8 or a
negative effect such as corrosion of pipes, infection
of indwelling medical devices and the persistent
infections in cystic fibrosis and chronic
wounds 9,10 .
Bacteria can grow in a free-living planktonic
state or in a sessile form, a complex process that
requires a sequence of coordinated activities 11 .
This complex sequence starts with the adhesion
of the microorganism. This adhesion can be reversible
at first and then becomes irreversible. Following
this there is the formation of microcolonies
with the intervention of the quorum sensing
(QS) molecules and afterwards the segregation of
mucopolyssacharides (the matrix that encase the
microcolonies in a biofilm) 10 .
7. Mor R, Sivan A. Biofilm formation and partial biodegradation of
polystyrene by the actinomycete Rhodococcus rubber. Biodegradation
2008: 19(6):851-8.
8. Oliver R, May E, Williams J. Microcosm investigations of phthalate
behaviour in sewage treatment biofilms. Sci Total Environ 2007:
372(2-3):605-14.
9. James GA, Swogger E, Wolcott R, Pulcini E, Secor P, Sestrich J,
Costerton JW, Stewart PS. Biofilms in chronic wounds. Wound Repair
Regener 2008: 16(1):37-44.
10. Fonseca AP, Sousa JC, Tenreiro R. Pseudomonas aeruginosa as a
nosocomial pathogen: Epidemiology, virulence, biofilm formation and
antimicrobial therapy. In: Pandalai SG, editor. Recent Research
Developments in Microbiology. Kerala, India: Research Signpost; 2006.
Volume 10. p. 97-132.
11. Davey ME, O’Toole GA. Microbial biofilms: from ecology to molecular
genetics. Microbiol Mol Biol Rev 2000: 64(4):847-67.
12. Oliveira DR, Azeredo J, Teixeira P, Fonseca AP. The role of hydrophobicity
in bacterial adhesion. In: Gilbert P, Allison D, Brading M, Verran
J, Walker J, editors. Biofilm Community Interactions: Chance or
Necessity? Cardiff: Bioline; 2001. p. 11-22.
EWMA Journal 2011 vol 11 no 2

i. Adhesion
Planktonic motile and non motile bacteria can become
sessile as they start the adhesion process to an abiotic
or biotic surface. For this initial step the presence and
functionality of several adhesins such as flagella and
fimbrae are needed 10,12 . There are two possible stages,
namely the reversible adhesion in which bacteria can
revert to the planktonic state and the irreversible adhesion
that is a really step to microcolony development
and biofilm formation (Figure 1).
13. Malic S, Hill KE, Hayes A, Percival SL, Thomas DW, Williams DW. Detection and
identification of specific bacteria in wound biofilms using peptide nucleic acid
fluorescent in situ hybridization (PNA FISH). Microbiology 2009: 155:2603-11.
14. Liu YC, Post JC. Biofilms in pediatric respiratory and related infections. Curr Allergy
Asthma Rep 2009: 9(6):449-55.
15. Sauer K, Camper AK, Ehrlich GD, Costerton JW, Davies DG. Pseudomonas
aeruginosa displays multiple phenotypes during development as a biofilm. J Bacteriol
2002: 184(4):1140-54.
16. Fux CA, Stoodley P, Hall-Stoodley L, Costerton JW. Bacterial biofilms: a diagnostic
and therapeutic challenge. Expert Rev Anti-infect Ther 2003: 1(4):667-83.
17. Flemming HC, Wingender J. Relevance of microbial extracellular polymeric
substances (EPSs)- Part I: Structural and ecological aspects. Water Sci Technol
2001: 43(6):1-8.
18. Barraud N, Hassett DJ, Hwang S, Rice RA, Kjelleberg S, Webb JS. Involvement of
nitric oxide in biofilm dispersal of Pseudomonas aeruginosa. J Bacteriol 2006:
188(21):7344-53.
19. Davis SC, Ricotti C, Cazzaniga A, Welsh E, Eaglstein WH, Mertz PM. Microscopic
and physiologic evidence for biofilm-associated wound colonization in vivo. Wound
Repair Regen 2008: 16(1):23-9.
Science, Practice and Education
Figure 1. Biofilm development in Pseudomonas aeruginosa.
This flowchart divides biofilm formation in different steps
involving specific events and bacterial properties.
Firstly, planktonic bacteria migrate to the surface and
adhere (A, B).
Once adhered, bacteria divide and twitch to form
microcolonies (C).
Then alginate production begins that helps to cement the
biofilm matrix in a three dimensional structure (D).
Some of singular or aggregate cells (also referred as “planktonic
biofilms”) are released from the biofilm and adhere to
the surface in a cyclic pathway (E).
LW-Lifshitz-Van der Waals forces;
EL: electrostatic forces;
AB: acid-base interactions;
OMP: outer membrane protein;
LPS: lipopolysaccharide
(Adapted from Fonseca et al 2006) (10) .
ii. Microcolonies and biofilm formation
After the initial irreversible adhesion, the cells start
to divide and form cell clusters called microcolonies.
The dividing cells produce quorum sensing molecules
that allow the aggregation of the microcolonies. These
structures are thus able to produce a matrix of extracellular
polymeric substances (EPS) that encases the
aggregating cells in a biofilm. These cells can have a
flagellum-drive movement within the biofilm thus they
are not evenly distributed in the biofilm 13 and in this
particular case they demand the existence of interstitial
water channels that also facilitate the exchange of
nutrients and wastes 10,14 .
Expression of genes was found to be different
in several steps of biofilm formation; in fact the av-
20. Wu J, Xi C. Evaluation of different methods for extracting extracellular DNA from the
biofilm matrix. Appl Environ Microbiol 2009: 75(16):5390-5.
21. De Beer D, Stoodley P. Relation between the structure of an aerobic biofilm and
transport phenomena. Water Sci Technol 1995: 32(8):11-18.
22. Barrett JF, Hoch JA. Two – component signal transduction as a target for microbial
anti-infective therapy. Antimicrob Agents Chemother 1998: 42:1529–36.
23. Yao W, Yue D, Yong Z, YangBo H, BaoYu Y, ShiYun C. Effects of quorum sensing
autoinducer degradation gene on virulence and biofilm formation of Pseudomonas
aeruginosa. Sci China C Life Sci 2007: 50(3):385-91.
24. Kaplan JB. Biofilm dispersal: mechanisms, clinical implications, and potential
therapeutic uses. J Dent Res 2010: 89(3):205-18.
25. Schaber JA,Triffo WJ, Suh SJ, Oliver JW, Hastert MC, Griswold JA, Auer M, Hamood
AN, Rumbaugh KP. Pseudomonas aeruginosa forms biofilms in acute infection
independent of cell-to-cell signaling. Infect Immun 2007: 75(8):3715-21.
26. Bjarnsholt T, Givskov M. Quorum-sensing blockade as a strategy for enhancing host
defences against bacterial pathogens. Philos Trans R Soc 2007: 362(1483):1213-22.
27. Rasmussen TB, Bjarnsholt T, Skindersoe ME, et al (2005) Screening for quorum
sensing inhibitors (QSI) by use of a novel genetic system, the QSI selector. J Bact
187(5): 1799–1814.
EWMA Journal 2011 vol 11 no 2 11
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Science, Practice and Education
erage difference in protein regulation was 35% 15 . If
planktonic cells are compared with biofilm cells, 800
proteins can be upregulated which demonstrates an
expression level over 50% of the proteome 15 .
The microcolonies and biofilm formation is a
complex process that involves multiple factors and a
variety of interactions, namely the adaptive responses
of the sessile microorganisms. In fact the eventual presence
of optimal amount of nutrients can be an inducing
factor for biofilm dispersal due to increased growth
of the microorganisms 16 . Some of the biofilm cells can
switch to a planktonic free-swimming phenothype or
can detach as aggregates (“planktonic biofilms”) 17 and
this process aids the spread of the infection by the restarting
of the biofilm formation in other locations 18 .
iii. Biofilm physiology
The knowledge of biofilm physiology is of utmost
importance to understand the activities of the microorganisms
within the biofilm. This information is essential
for any approach in order to control biofilm
formation. There are several methods that can give
some insights into biofilm morphophysiology such as
the use of light, epifluorescence, electron and confocal
laser microscopy 19 .
Biofilm architecture is an important factor that influences
the detachment process and is affected by the
amount of extracellular polymeric substances (EPS)
produced. EPS is often composed of polysaccharides,
lipids, proteins, nucleic acids and enzymes, and is an
aid to the bacterial adhesion process 20 . The bulk of
the biofilm is 75-90% of EPS with only 10-25% being
made up of cells. Additionally it is known that
biofilms from different species have their singular cellular
and non cellular arrangements. An example of
this are the water channels that are often dependent
on the degree of hydration of the biofilm and are of
utmost importance in the intake of the nutrients and
excretion of the wastes, and are thus essential for bio-
28. Lasaro MA, Salinger N, Zhang J, Wang Y, Zhong Z, Goulian M, Zhu J. F1C fimbriae
play an important role in biofilm formation and intestinal colonization by the
Escherichia coli commensal strain Nissle 1917. Appl Environ Microbiol 2009:
75(1):246-51.
29. O’Toole GA, Kolter R. Flagellar and twitching motility are necessary for Pseudomonas
aeruginosa biofilm development. Mol Microbiol 1998: 30:295-304.
30. Ammons MCB, Ward LS, Fisher ST, Wolcott RD, James GA. In vitro susceptibility of
established biofilms composed of a clinical wound isolate of Pseudomonas
aeruginosa treated with Lactoferrin and xylitol. Int J Antimicrob Agents 2009:
33(3):230-6.
31. Lee J, Jayaraman A, Wood TK. Indole is an inter-species biofilm signal mediated by
SdiA. BMC Microbiol 2007: 18(7):42.
32. Giladi M, Porat Y, Blatt A, Shmueli E, Wasserman Y, Kirson ED, Palti Y. Microbial
growth inhibition by alternating electric fields in mice with Pseudomonas aeruginosa
lung infection. Antimicrob Agents Chemother 2010: 54(8):3212-18.
33. Percival SL, Thomas JG, Williams DW. Biofilms and bacterial imbalances in chronic
wounds: anti-Koch. Int Wound J 2010: 7(3): 169-175.
34. Rusconi R, Lecuyer S, Guglielmini L, Stone HA. Laminar flow around corners triggers
the formation of biofilm streamers. J R Soc Interface 2010: 7:1293-9.
12
film survival 21 . There are also several differences in a
biofilm’s architecture due to the mono or poly specific
character of the biofilm. The microbial ecology can
also influence the production of virulence factors and
have an effect in the biofilm phenotype as a collective
virulence parameter and this may be caused by the
communication between the cells. The ability to adapt
and have adequate responses to the series of changes in
the environment is dependent on cell-cell signal transduction
systems 22,23 . Microorganisms can monitor and
respond to the presence of others by the production of
signaling molecules and this process is called quorum
sensing. It is known that this process controls biofilm
formation through the secretion of autoinducers, thus
representing a key role in the regulation of biofilm
architecture, the expression of virulence factors and in
the dispersion of organisms 24 . Nevertheless, there are
some strains of Pseudomonas aeruginosa that can form
biofilm independently of quorum sensing 25 . The inhibition
of cell communication has been shown lately as a
new treatment strategy, in particular in the prevention
of biofilm infections such as in the case of garlic that
inhibits quorum sensing in P. aeruginosa 26,27 .
c. Factors that interfere in Biofilm formation
The formation of biofilm is influenced by various factors
that range from the morphophysiology of the microorganisms
to the complexity of the environment in terms of
nutrients or the presence of chemical and physical agents.
The ability of the microorganisms to adhere to abiotic
or biotic surfaces as well as the adherence rate is known
to influence the formation of the biofilm28 . Bacterial adhesins
such as flagella or type IV fimbrae29 and the overall
hydrophobicity of the bacterial surface can determine if
the attachment to the surface is reversible or irreversible.
The availability of nutrients is another important factor
for the production of quorum sensing molecules, enzymes
or amino acids that are essential for adhesion and biofilm
formation16 .
�
35. Bryers JD. Medical Biofilms. Biotechnol Bioeng 2008: 100(1):1–18.
36. Kirketerp-Møller K, Jensen PØ, Fazli M, Madsen KG, Pedersen J, Moser C,
Tolker-Nielsen T, Høiby N, Givskov M, Bjarnsholt T. Distribution, organization and
ecology of bacteria in chronic wounds. J Clin Microbiol 2008: 46(8):2717-22.
37. Oh YJ, Lee NR, Jo W, Jung WK, Lim JS. Effects of substrates on biofilm formation
observed by atomic force microscopy. Ultramicroscopy 2009: 109(8):874-80.
38. Leid JG, Shirtliff ME, Costerton JW, Stoodley AP. Human leukocytes adhere to,
penetrate, and respond to Staphylococcus aureus biofilms. Infect Immun 2002:
70(11):6339-45.
39. Burmølle M, Webb JS, Rao D, Hansen LH, Sørensen SJ, Kjelleberg S. Enhanced
biofilm formation and increased resistance to antimicrobial agents and bacterial
invasion are caused by synergistic interactions in multispecies biofilms. Appl Environ
Microbiol 2006: 72(6):3916-23.
40. Wenzel RP. Health care-associated infections: major issues in the early years of the
21st century. Clin Infect Dis 2007: 15(45 Suppl 1):S85-8.
41. Fonseca AP, Granja PL, Nogueira JA, Oliveira DR, Barbosa MA. Staphylococcus
epidermidis RP62A adhesion to chemically modified cellulose derivatives. J Mat Sci:
Mat Med 2001: 12:543-8.
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Science, Practice and Education
i. Effect of chemical and physical agents on biofilm
The presence of specific substances during biofilm
growth can affect it either stimulating or inhibiting
formation. It is known that certain substances have
a chelating effect for iron, which is important in low
concentrations for sessile growth 30 . Another substance,
indole, which is secreted by several gram negative microorganisms,
such as Escherichia coli, increases biofilm
formation in Pseudomonas aeruginosa 31 . The application
of electric currents, however, can inhibit biofilm
development and have a synergetic activity with the antimicrobials
in the attack on biofilms 32 . This synergistic
activity may provide a competitive advantage to the
microorganisms and a real increase in the pathogenic
effect of a biofilm in several diseases and infections,
namely in chronic wounds, resulting in enhanced tissue
degradation or impairment of the host immune
response 33 . Another factor is the shear stress that affects
the adhesion and biofilm formation process. In fact,
the hydrodynamic conditions in which the biofilm occurs
can influence the architecture and strength of the
biofilm 4 . Additionally, biofilm formation can occur not
only in laminar but also in turbulent flow, although
it is known that for this case quorum sensing is less
effective 34 .
d. Biofilm detection methods
The early or even late detection of biofilms is of utmost importance.
There are several methods to determine the presence
of the biofilm in vitro and in vivo in wounds isolated
or in combination. Shape and size of the microorganisms
in a singular or mixed culture and the eventual presence of
polymorphonuclear neutrophils (PMN) in a tissue can be
assessed by light microscopy 35 . If the microscope also has a
fluorescent light it is possible to use fluorophores as stains,
which absorb light emitted at a specific wavelength. If the
fluorescence technique is used to stain specific components
such as the DNA using peptide nucleic acids it is called
Fluorescent in situ hybridization (FISH) 36 . It is possible,
with the use of confocal laser scanning microscopy, which
42. Extremina CI, Aguiar AI, Costa L, Peixe L, Fonseca AP. Optimization of processing
conditions for the quantification of enterococci biofilms using microtitre-plates. J
Microbiol Methods (in press).
43. Fonseca AP, Extremina C, Fonseca AF, Sousa JC. Effect of subinhibitory concentration
of piperacillin/tazobactam on Pseudomonas aeruginosa. J Med Microbiol 2004:
53:903-10.
44. Fonseca AP, Correia P, Sousa JC, Tenreiro R. Association patterns of Pseudomonas
aeruginosa clinical isolates as revealed by virulence traits, antibiotic resistance,
serotype and genotype. FEMS Immunol Med Microbiol 2007: 51:505-16.
45. Fonseca AP, Sousa JC. Effect of antibiotic-induced morphological changes on
surface properties, motility and adhesion of nosocomial Pseudomonas aeruginosa
strains under different physiological states. J Appl Microbiol 2007: 103:1828-37.
46. Fonseca AP, Sousa JC. Effect of shear stress on growth, adhesion and biofilm
formation of Pseudomonas aeruginosa with antibiotic-induced morphological
changes. Int J Antimicrob Agents 2007: 30:236-41.
47. Gaetti-Jardim Jr E, Nakano V, Wahasugui TC, Cabral FC, Gamba R, Avila-Campos
MJ. Occurrence of yeasts, enterococci and other enteric bacteria in subgingival
biofilm of HIV-positive patients with chronic gingivitis and necrotizing periodontitis.
Braz J Microbiol 2008: 39(2):257-61.
48. Douglas LJ. Candida biofilms and their role in infection. Trends Microbiol 2003:
11(1):30-6.
14
allows a 3D visualization of the biological sample, and if
coupled with a live/dead stain, to see the composition and
distribution of living cells within the biofilm structure in
vivo and in real time 35 . If necessary it is possible to have
detailed information in the arrangement of the biofilm
structures such as the type of adherence to the matrix or
to a specific matrix through assessment using scanning
electron microscopy (SEM), but, if available, it is also
possible to have the levels of resolution of the SEM using
“in vivo” conditions and studying real time effects of the
antimicrobials, using atomic force microscopy (AFM) 37 .
There is always the possibility to obtain the percentage of
colony forming units, but, in the main, planktonic cells
grow rather than biofilm cells. In this case special care must
be taken if the biofilm is polymicrobial such in the case
of wounds and if there is the possibility of the presence
of anaerobic bacteria.
e. Medical importance of Biofilms
Biofilms are resistance phenotypes for microorganisms
that give protection to the antimicrobials 35 and to the immune
system 38 , namely through the effect of EPS and the
slow growth rate of the microorganism within the biofilm.
This biofilm ability often results in chronic infections. The
close proximity of microorganisms within the biofilm creates
conditions for a better transference and acquisition of
resistance and virulence genes 35 . These biofilm resistance
strategies result in a huge resistance to antimicrobials as
compared to their planktonic counterparts 39 and under
certain circumstances the detached biofilm can lead to an
embolism when transported through the veins and this is
definitely life threatening 40 .
Biofilms are often the cause of indwelling medical device
associated infections. These devices, such as catheters,
prosthesis, contact lenses 4 etc serve as reservoirs for the
microorganisms and are a source of nosocomial infections.
Several species of bacteria can be biofilm forming microorganisms
such as Staphylococcus species 41 , Enterococcus spe-
49. Costerton JW, Lewandowski Z, Caldwell DE, Korber DR, Lappin-Scott HM. Microbial
biofilms. Annu Rev Microbiol 1995: 49:711-45.
50. Thomas JG, Nakaishi LA. Managing the complexity of a dynamic biofilm. J Am Dent
Assoc 2006: 137(3):10S-15S.
51. Dowd SE, Sun Y, Secor PR, Rhoads DD, Wolcott BM, James GA, Wolcott RD. Survey
of bacterial diversity in chronic wounds using pyrosequencing, DGGE, and full
ribosome shotgun sequencing. BMC Microbiol 2008: 8:43.
52. Anderson GG, O’Toole GA. Innate and induced resistance mechanisms of bacterial
biofilms. Curr Top Microbiol Immunol 2008; 322:85-105.53. Borriello G, Werner E,
Roe F, Kim AM, Ehrlich GD, Stewart PS. Oxygen limitation contributes to antibiotic
tolerance of Pseudomonas aeruginosa in biofilms. Antimicrob Agents Chemother
2004: 48(4):2659-64.
54. Driffield K, Miller K, Bostock JM, O’Neill AJ, Chopra I. Increased mutability of
Pseudomonas aeruginosa in biofilms. J Antimicrob Chemother 2008: 61(5):1053-6.
55. Phillips P, Sampson E, Yang Q, Antonelli P, Progulske-Fox A, Schultz G. Bacterial
biofilms in wounds. Wound Healing Southern Africa 2008: 1(2):10-2.
56. Karatuna O, Yagci A. Analysis of the quorum sensing-dependent virulence factor
production and its relationship with antimicrobial susceptibility in Pseudomonas
aeruginosa respiratory isolates. Clin Microbiol Infect 2010 (Epub ahead of print).
�
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Science, Practice and Education
cies 42 , Pseudomonas aeruginosa 10,41,43-46 , Enteric bacteria 47
and Candida albicans 48 , but most biofilms in wounds are
often polymicrobial and several synergistic or antagonistic
effects can occur between the virulence factors of the
present microorganisms. For example, the Candida species
produces a chemical substance that is inhibitory to quorum
sensing in Pseudomonas aeruginosa. It is known that
over 60% of chronic infections are biofilm related 49 . In
fact biofilms are implicated in several microbial infections
such as catheter infections 16 , ear and dental infections 50 ,
cystic fibrosis and human wounds 13,51 .
Biofilm composition and architecture represent key roles
in resistance to antimicrobials 52 . Besides the singular resistance
of each cell, the biofilm can be seen as a community
that has a resistance phenotype and this starts in the beginning
when adhesion occurs and increases with the biofilm
development 35 . There are several mechanisms that allow
the biofilm to work as a resistance phenotype: a) the oxygen
tension, the pH and the chemical substances within
can alter the activity of the antimicrobials 53 , b) the slow
growth as a result of the low oxygen tension makes the microorganisms
less susceptible to the antimicrobials that are
exponential growing cells, like the ß-lactams, c) the biotic
or abiotic surface and the hydrodynamics (shear stress) of
the biofilm formation process can select subpopulations
resulting in different architectures and compositions of
the biofilm, d) the close proximity of the microorganism
within the biofilm creates the perfect conditions to the
transfer/acquisition of genes. Additionally the microorganisms
seem to increase their ability to mutate and this can
affect the antimicrobial resistance 54 , e) quorum sensing
molecules can regulate resistance genes but their absence
does not necessarily mean a reduction in the susceptibility
to the antimicrobials 55,56 , and f) extracellular matrices
(EPS) work as a physical barrier that restricts the diffusion
of the antimicrobial agents into the biofilm.
57. Church D, Elsayed S, Reid O, Winston B, Lindsay R. Burn Wound Infections. Clin
Microbiol Rev 2006: 19(2):403-34.
58. Gariboldi S, Palazzo M, Zanobbio L, Selleri S, Sommariva M, Sfondrini L, Cavicchini
S, Balsari A, Rimui C. Low molecular weight hyaluronic acid increases the selfdefence
of skin epithelium by induction of β-Defensin 2 via TLR2 and TLR4. J
Immunol 2008: 181(3):2103-10.
59. Cooper R. Using honey to inhibit wound pathogens. Nurs Times 2008: 104(3):
46-9.
60. Davies CE, Hill KE, Newcombe RG, Stephens P, Wilson MJ, Harding KG, Thomas
DW. A prospective study of the microbiology of chronic venous ulcers to reevaluate
the clinical predictive value of tissue biopsies and swabs. Wound Repair Regen
2007: 15:17-22.
61. Bjarnsholt T, Kirketerp-Møller K, Jensen PØ, Madsen KG, Phipps R, Krogfelt K,
Høiby N, Givskov M. Why chronic wounds fail to heal: a new hypothesis. Wound
Repair Regen 2008: 16(1):2-10.
62. Burmølle M, Thomsen TR, Fazli M, Dige I, Christensen L, Homøe P, Tvede M,
Nyvad B, Tolker-Nielsen T, Givskov M, Moser C, Kirketerp-Møller K, Johansen HK,
Høiby N, Jensen PØ, Sørensen SJ, Bjarnsholt T. Biofilms in chronic infections – a
matter of opportunity – monospecies biofilms in multispecies infections. FEMS
Immunol Med Microbiol 2010: 59:324-36.
16
2. BIOFILMS IN WOUNDS
– WHY THEY ARE A PROBLEM?
a. Wound formation
In the human body the frontier to the external environment
is the skin. This multi-layered structure is an anatomical
barrier that also helps in the homeostatic preservation,
thermoregulation and protection against infection 57 .
An additional condition of the skin is its dryness, and
the ability to secrete antibodies and inhibitory substances.
The skin is also the surface for the proliferation for microbial
normal flora that has the function of preventing
the adhesion of pathogenic microorganisms 58 . A wound
is a discontinuity of the skin that can be in more than a
tissue or organ and have accidental or deliberate causes 55 .
b. Effect of Biofilm on wound healing
– the biofilm paradigm
The pathogenicity of the microorganisms is dependent
on their virulence ability within the wound. This capability
of most microorganisms results from their production
of toxins and enzymes, or from their biofilm production
abilities. In the case of a slow reaction of the host to the
biofilm, and in the particular case of an immunodeficient
host, it increases the possibility of the development
of chronic infections 9,59 . The PMN have little reaction
against the “community resistance phenotype” called biofilm
which in the case of wounds can be polymicrobial
and thus quite recalcitrant. Virulent organisms, such as
Pseudomonas aeruginosa and Staphylococcus aureus, when
forming biofilms in vivo, show less susceptibility to antimicrobials
compared to the planktonic culture 60 . There
are two main wound microbial biofilm hypotheses that
can explain why biofilms delay wound healing. The first
suggests that there are specific bacterial species, despite the
complexity of microbial populations within the biofilm,
which are responsible for the delay in wound healing and
in the overall infection process. The second argues that
there is no specific bacterial species but that all the microbial
community is responsible and the biofilm works as a
63. Thomsen TR, Aasholm MS, Rudkjøbing VB, Saunders AM, Bjarnsholt T, Givskov M,
Kirketerp-Møller K, Nielsen PH. The bacteriology of chronic venous leg ulcer
examined by culture-independent molecular methods. Wound Repair Regen 2010:
18(1):38-49.
64. Wolcott RD, Kennedy JP, Dowd SE. Regular debridement is the main tool for
maintaining a healthy wound bed in most chronic. J Wound Care 2009: 18(2):54-6.
65. Leake JL, Dowd SE, Wolcott RD, Zischkau AM. Identification of yeast in chronic
wounds using new pathogen-detection technologies. J Wound Care 2009:
18(3):103-4, 106, 108.
66. Fazli M, Bjarnsholt T, Kirketerp-Møller K, Jørgensen B, Andersen AS, Krogfelt KA,
Givskov M, Tolker-Nielsen T. Non-random distribution of Pseudomonas aeruginosa
and Staphylococcus aureus in chronic wounds. J Clin Microbiol 2009: 47(12):4084-9.
67. Prompers L, Schaper N, Apelqvist J, Edmonds M, Jude E, Mauricio D, Uccioli L,
Urbancic V, Bakker K, Holstein P, Jirkovska A, Piaggesi A, Ragnarson-Tennvall G,
Reike H, Spraul M, Van Acker K, Van Baal J, Van Merode F, Ferreira I, Huijberts M.
Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences
between individuals with and without peripheral arterial disease.
The EURODIALE study. Diabetologia 2008: 51(5):747-55.
�
EWMA Journal 2011 vol 11 no 2

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Science, Practice and Education
unit. Both theories are important to explain the wound
healing process and need to be proven, so both may be
taken into account by practitioners considering wound
management strategies 33 .
The biofilm in the chronic wound is composed of a community
of microorganisms in which the overall effect in
the community unit is greater than the sum of its singular
or specific parts 33 , thus an important approach to promote
wound healing could be to enable an “ecological shift” that
increases growth of non-problematic bacteria. This could
be a prevention approach with the development of techniques
to continuously avoid the predominance of pathogenic
bacteria within the biofilm. This could involve the
use of probiotics and the idea of helpful biofilm in wound
healing 33 . It is therefore of utmost importance to control
the microbial progression during wound healing and to
maintain “healthy” biofilms, thus avoiding the development
of pathogenic biofilms. If the biofilm community
pathogenic effect exceeds host immune response, there is
a compromised wound healing process 33,61 .
3. HOW CAN BIOFILMS BE TREATED?
a. Diagnosis of biofilms in wounds
The diagnosis of wound infection is mainly done on the
basis of clinical symptoms but it was demonstrated that
the microbial load of wound samples can be higher than
1 x 10 5 microorganisms/g of tissue with no signs of clinical
infection, thus showing an urgent need for revision of
the established guidelines for wound infections diagnosis.
There are cases of chronic wound infections that progress
to septicemia or even death because they fail to show clinical
symptoms 55 . Recently, it has been shown that using
culture-dependent methods in the wound microorganisms
enable the isolation and identification of only 5% of the
bacterial species, thus biopsy samples are a better option
to have accurate information on the microbial diversity in
the biofilms 13 . Besides an improved sampling technique,
68. Yasuhara H, Hattori T, Shigeta O. Significance of phlebosclerosis in non-healing
ischaemic foot ulcers of end-stage renal disease. Eur J Vasc Endovasc Surg 2008:
36(3):346-52.
69. Hunt TK. Hyperbaric Oxygen and Wounds: A tale of two enzymes. EWMA J 2010:
10(2):7-9.
70. Rhoads DD, Wolcott RD, Percival SL. Biofilms in wounds: management strategies. J
Wound Care 2008: 17(11):502-8.
71. Wolcott RD, Ehrlich GD. Biofilms and chronic infections. J Am Med Assoc 2008:
299(22):2682-4.
72. Schultz GS, Barillo DJ, Mozingo DW, Chin GA. Wound bed preparation and a brief
history of TIME. Int Wound J 2004: 1(1):19-32.
73. Wolcott RD, Rumbaugh KP, James G, Schultz G, Phillips P, Yang Q, Watters C,
Stewart PS, Dowd SE. Biofilm maturity studies indicate sharp debridement opens a
time-dependent therapeutic window. J Wound Care 2010: 19(8):320-8.
74. Hofman D. The autolytic debridement of venous leg ulcers. Wound Essentials 2007:
2:68-73.
75. Armstrong DG, Salas P, Short B, Martin BR, Kimbriel HR, Nixon BP, Boulton AJM.
Maggot therapy in “lower-extremity hospice” wound care; fewer amputations and
more antibiotic-free days. J Am Podiatr Med Assoc 2005; 95(3):254-7.
18
there is the emergence of molecular biology methods 9,62 ,
but the best option is perhaps the combination of cultivation/molecular
methods 63 .
There are several microorganisms that are predominant in
the biofilms that cause chronic wounds and these include
fastidious or anaerobic biofilm growing bacteria such as
Staphylococcus, Pseudomonas, Serratia, Bacteroides, and
Corynebacterium 64 .
The identification of the biofilm bacteria in wounds
can be assessed using several molecular methods such as
fingerprinting, using 16S rRNA, fluorescence in situ hybridization
(FISH), pyrosequencing and quantitative PCR
(Q-PCR) 51,64 . This last method enables a characterization
within a few hours of the microorganisms present in
wounds and has already been used to demonstrate that
the numbers of certain bacteria such as P. aeruginosa and
S. aureus varies between samples which are taken in different
locations in the same wound 63 . But if detection of
the relative contribution of the bacteria or yeast is needed
in a chronic wound sample, pyrosequencing methods are
recommended, although they only give return results in
24 hours 65 . The use of rRNA gene based PCR techniques,
that is using Q-PCR and pyrosequencing, gives information
regarding presence of viable and nonviable bacteria,
prevalence and type of bacterial species, but there is no
information concerning the structural organization and
spatial distribution of the bacteria in the biofilm nor even
any information on the relative contribution of each bacteria
to the disease pathogenesis. This can be obtained by
visualization of the bacterial communities that exist in
the wound biofilms by using FISH with species-specific
peptide nucleic acid-PNA DNA probe plus a PNA probe
for all eubacterial species. Burmølle et al (2010) 62 describe
the use of a combination of PNA-FISH and confocal laser
scanning microscopy (CLSM) to assess the spatial distribution
and structural organization of biofilm bacteria
in chronic wounds 62,66 . The combined method demonstrated
that the microbial communities in chronic wounds
76. Andersen AS, Jøergensen B, Bjarnsholt T, Johansen H, Karlsmark T, Givskov M,
Krogfelt KA. Quorum-sensing-regulated virulence factors in Pseudomonas aeruginosa
are toxic to Lucilia sericata maggots. Microbiology 2009; 156:400-7.
77. Marazzi M, Stefani A, Chiaratti A, Ordanini MN, Falcone L, Rapisarda V. Effect of
enzymatic debridement with collagenase on acute and chronic hard-to-heal wounds.
J Wound Care 2006: 15(5):222-7.
78. Cowan T. Biofilms and their management: implications for the future of wound care.
J Wound Care 2010: 19(3):117-20.
79. Bratzler DW, Houck PM, Richards C, Steele L, Dellinger EP, Fry DE, Wright C, Ma A,
Carr K, Red L. Use of antimicrobial prophylaxis for major surgery: baseline results
from the national surgical infection prevention project. Arch Surg 2005: 140(2):
174-82.
80. Lipp C, Kirker K, Agostinho A, James G, Stewart P. Testing wound dressings using
an in vitro wound model. J Wound Care 2010: 19(6):220-6.
81. Presterl E, Suchomel M, Eder M, Reichmann S, Lassnigg A, Graninger W, Rotter M.
Effects of alcohols, povidone-iodine and hydrogen peroxide on biofilms of Staphylococcus
epidermidis. J Antimicrob Chemother 2007: 60:417-20.
82. Demling RH, Burrell RE. The beneficial effects of nanocrystalline silver as a topical
antimicrobial agent. Leadership Medica 2002: 16(7).
�
EWMA Journal 2011 vol 11 no 2

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Science, Practice and Education
are often polymicrobial but the bacterial aggregates are
mainly composed of a single bacterial species 62 . Fazli et al
(2009) 66 showed by using PNA- FISH and CLSM there is
a nonrandom distribution of the bacteria in wounds, for
example P. aeruginosa is primarily at the deepest part and
S. aureus is often near the surface. Dowd et al (2008) 51 described
some repeated patterns of coaggregation that have
the ability to work in synergy to produce chronic infection
as “functional equivalent pathogroups” (FEPs).The above
referred techniques are complex and limited to research
laboratories, thus there is a need to develop simpler means
of detecting biofilms in a routine microbiology diagnostic.
b. Biofilm Treatments for chronic wounds
Patient quality of life can be affected by a delayed wound
healing process, thus the wound treatment aims to achieve
its goal within a reasonable time frame. This is possible if
appropriate care is taken and attention paid to the condition
of the wound and of the patient 55 .
Some predisposing factors such as underlying diseases
67,68 and microbial infection with biofilm forming
organisms 51 can influence the healing process of infected
and chronic wounds. There are several strategies targeted
towards promoting wound healing in chronic wounds and
they must take into account the factors that are responsible
for the delay in the healing process. These factors should
be identified as soon as possible to prevent complications.
Nevertheless, if complications occur there are treatment
strategies that range from using ultrasounds, debridement,
negative pressure, hyperbaric oxygen 69 , and others 70 .
First of all, foreign bodies should be removed from the
wound because their presence interferes with the healing
process, thus a physical intervention is of utmost importance
for the management of biofilms 71 . This cleansing can
be done by mechanical, chemical or biological methods.
Additionally the presence of devitalized tissue serves as a
nutritional matrix for microbial development and proliferation,
thus removal of foreign bodies and devitalized
tissue must be done and the process is called debridement.
This technique cannot avoid the ability of the bio-
83. Russell AD, Hugo WB. Antimicrobial activity and action of silver. Prog Med Chem
1994: 31:351-70.
84. Knight GM, McIntyre JM, Craig GG, Mulyani, Zilm PS, Gully NJ. Inability to form a
biofilm of Streptococcus mutans on silver fluoride- and potassium iodide-treated
demineralised dentin. Quintessence Int 2009: 40(2):155-61.
85. Okhiria OA, Henriques AFM, Burton NF, Peters A, Cooper RA. Honey modulates
biofilms of Pseudomonas aeruginosa in a time and dose dependent manner. J
ApiProduct & ApiMedical Sci 2009: 1(1):6-10.
86. Molan PC. The evidence supporting the use of honey as a wound dressing. Int J Low
Extrem Wounds 2006: 5(1):40-54.
87. Merckoll P, Jonassen TØ, Vad ME, Jeansson SL, Melby KK. Bacteria, biofilm and
honey: A study of the effects of honey on ‘planktonic’ and biofilm-embedded chronic
wound bacteria. Scand J Infect Dis 2009: 41:341-7
88. Extremina CI, Freitas da Fonseca A, Granja PL, Fonseca AP. Anti-adhesion and
anti-proliferative cellulose triacetate membrane for prevention of biomaterial
centered infections associated to Staphylococcus epidermidis. Int J Antimicrob
Agents 2010: 35:164-8.
89. Thomas S, McCubbin P. A comparison of the antimicrobial effects of four silvercontaining
dressings on three organisms. J Wound Care 2003: 12(3):101-7.
20
film to reconstitute itself, thus topical antimicrobial and
antibiofilm strategies should be considered 72 , but during
this recovery process the biofilm is more vulnerable to
antimicrobials because it needs to reform its extracellular
polymeric substances, increase cell division and colony
activity 64 . Wolcott et al (2010) 73 showed that debridement
or post-debridement opens a time-dependent therapeutic
window of increased antibiotic sensitivity which is 24-48
hours for P. aeruginosa.
In the wounds there is an autolytic debridement when the
healing process is developing in the right timeframe and
this process only functions when the wound is moist and
the patient’s own enzymes can be used 74 . Debridement
can also be done by larvae which feed on the dead tissues
and excrete bactericidal products that help to reduce the
wound’s bioburden 75 , although Andersen et al (2009) 76
did describe the death of the larvae by P. aeruginosa quorum
sensing molecules. There is also the possibility of a
more selective debridement by using enzymes for the digestion
of the slough of a wound and they can be obtained
from microorganisms such as collagenase or fibrinolysin or
from urea and papain or even plants 77 . In particular cases
there is a need for removal of large amounts of necrotic
tissue and this demands a more extreme course of action
such as a surgical procedure 78 .
Treatment of biofilms in wounds often needs the use of
antimicrobials in a systemic and/or topical therapy. Antimicrobials
can also be used for prophylactics especially
in immunocompromised patients 79 , but the correct procedure
is to identify the microorganisms involved and
to determine antimicrobial susceptibility, although the
information is always reduced because they are determined
with planktonic, not sessile populations.
Antimicrobials can be administered topically as wound
dressings 80 , orally, or injected intravenously or subcutaneously
and the main objective is to reduce or even completely
remove the microbial load of wounds 78 . Several
90. Pietschmann S, Hoffmann K, Voget M, Pison U. Synergistic effects of Miconazole
and Polymyxin B on microbial pathogens. Vet Res Commun 2009: 33:489-505.
91. Stewart PS, Costerton JW. Antibiotic resistance of bacteria in biofilms. Lancet 2001:
358(9276):135-8.
92. Katsuyama M, Kobayashi Y, Ichikawa H, Mizuno A, Miyachi Y, Matsunaga K,
Kawashima M. A novel method to control the balance of skin microflora Part 2. A
study to assess the effect of a cream containing farnesol and xylitol on atopic dry
skin. J Dermatol Sci 2005: 38(3):207-13.
93. Kaneko Y, Thoendel M, Olakanmi O, Britigan BE, Singh PK. The transition metal
gallium disrupts Pseudomonas aeruginosa iron metabolism and has antimicrobial
and antibiofilm activity. J Clin Invest 2007: 117(4):877-88.
94. Martineau L, Dosch H-M. Biofilm reduction by a new burn gel that targets nociception.
J Appl Microbiol 2007: 103:297-304.
95. Itoh Y, Wang X, Hinnebusch BJ, Preston JF 3rd, Romeo T. Depolymerization of
beta-1,6-N-acetyl-D-glucosamine disrupts the integrity of diverse bacterial biofilms. J
Bacteriol 2005: 187(1):382-7.
96. Gill AL, Bell CNA. Hyperbaric oxygen: its uses, mechanisms of action and outcomes.
Q J Med 2004: 97:385-95.
�
EWMA Journal 2011 vol 11 no 2

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Science, Practice and Education
antiseptics, such as Povidone iodine, can be used alone
or in combination with the antibiotics in order to achieve
increased antimicrobial activities 81 . In fact one of the possible
advantages of using antiseptics is the reduced probability
of developing bacterial resistance since they have
several targets in the bacteria.
The use of silver as part of dressings has also proved to
be successful, and this is due to the bactericidal properties
of silver 82 , as already reported for silver catheters 83 .
Silver lethal activity works at much higher concentrations
for sessile bacteria as compared to planktonic bacteria 84 .
Another known antiseptic is honey, which is claimed to
have antibacterial activity through the action of its phytochemicals
and the ability to promote healing 85-87 .
Several works have demonstrated the importance of
drug release in the prevention of biofilm formation 88 and it
is known that the rate of antimicrobial release from a dressing
or catheter determines its efficacy 89 . Combinations of
antimicrobials with synergistic activity can be used as in
the case of bacitracin-polymyxin 90 because there are major
difficulties in having an effect on dormant cells within
the biofilm 91 . Another issue is that systematic antibiotics
have only 25-32% efficacy against biofilms 70 because they
only suppress rapidly growing cells at the outermost active
edges of the biofilm 91 .
It is of utmost importance to combine strategies, i.e.
combining the use of debridement and antibiotics, and
especially those with antibiofilm abilities. There are a
number of well-known antibiofilm agents, some of which
have already been referred to during this review, like Lactoferrin
and the use of phages and pulsed electric fields, but
there are others such as Xylitol, Gallium, EDTA, Dispersin
B, as well. 92 . Gallium can disrupt Fe-dependent processes
because many biological systems cannot distinguish
Ga3+ from Fe3+ and this is particularly important for P.
aeruginosa biofilm development 93 . Martineau and Dosch
(2007) 94 have recently described that EDTA in a wound
gel can have some efficacy against P. aeruginosa biofilms.
Dispersin B targets the EPS and degrades the community
structure of the biofilm 95 .
97. Percival SL, Cutting KF. Biofilms: possible strategies for suppression in chronic
wounds. Nurs Stand 2009: 23(32):64-72.
98. Badiavas EV, Falanga V. Treatment of chronic wounds with bone marrow -derived
cells. Arch Dermatol 2003; 139:510-6.
99. Branski LK, Gauglitz GG, Herndon DN, Jeschke MG. A review of gene and stem cell
therapy in cutaneous wound healing. Burns 2009: 35(2):171-80.
100. Sillankorva S, Neubauer P, Azeredo J. Pseudomonas fluorescens biofilms subjected
to phage phiIBB-PF7A. BMC Biotechnol 2008: 8:79.
101. Wakabayashi H, Yamauchi K, Kobayashi T, Yaeshima T, Iwatsuki K, Yoshie H.
Inhibitory effects of Lactoferrin on growth and biofilm formation of Porphyromonas
gingivalis and Prevotella intermedia. Antimicrob Agents Chemother 2009:
53(8):3308-16.
102. Bjarnsholt T, Jensen PØ, Rasmussen TB, Christophersen L, Calum H, Hentzer M,
Hougen H, Rygaard J, Moser C, Eberl L, Høiby N, Givskov M. Garlic blocks quorum
sensing and promotes rapid clearing of pulmonary Pseudomonas aeruginosa
infections. Microbiology 2005: 151:3873-80.
22
As a conclusion, in order to suppress and eliminate biofilms,
a triple strategy should be used incorporating topical
antiseptics and systemic antibiotics for damaging of cell
metabolism and integrity, using antibiofilm antimicrobials
that act in the biofilm as a microbial community that
works together in a “resistance phenotype” 70 and using
a strategy that augments the host’s defenses 95 . Alongside
the triangle of antimicrobial – pathogenic agent – host, we
must consider the environment in which all three work together
and this can be also used to enhance wound healing.
An example of this is the use of topical oxygen therapy that
involves the use of supersaturated oxygen delivered to the
wound over a certain time period which increases protein
production and cell homeostasis 60 . Another example is the
use of hyperbaric oxygen therapy that supplies adequate
tissue oxygenation 96 .
Prevention of biofilm should be the first and important
aim of any strategy for infection control. Nevertheless
with biofilm therapeutic measures, care should be taken
in order to reduce the quantity of the microorganisms as
well as the virulent factors they express allowing a better
and facilitated work for the immune system 97 .
Several studies show that there are pathogens that can
form biofilms within 10-16 h of culture 45 and this ability
has been reported in vivo in animal for 48-72 hours 35 . This
ability of some pathogens to easily form biofilm in wounds
should be stopped in the early step of the initial adhesion,
and this is particularly important in immunocompromised
hosts. In this case the use of natural substances
that stimulate cellular growth may promote enhancement
of regenerative process as is the case in the use of bone
marrow-derived cells 98 or stem cells 99 . Another strategy to
control biofilms is the use of phages to which particularly
the young biofilms seem to be more susceptible 100 . Lactoferrin
is a protein present in the gingival fluids and in saliva
that has iron-binding properties. This ability is particularly
important in the case of Pseudomonas aeruginosa wound
biofilms, since they need iron for their stability. The use
of Lactoferrin can interfere with normal biofilm formation
103. Alipour M, Suntres ZE, Lafrenie RM, Omri A. Attenuation of Pseudomonas
aeruginosa virulence factors and biofilms by co-encapsulation of bismuth–ethanedithiol
with tobramycin in liposomes. J Antimicrob Chemother 2010; 0:dkq036v1dkq036.
104. Cooper RA, Okhiria O. Biofilms, wound infection and the issue of control. Wounds
UK 2006: 2(3):52-61.
105. Uhlemann C, Heinig B, Wollina U. Therapeutic ultrasound in lower extremity wound
management. Int J Low Extrem Wounds 2003: 2(3):152-7.
106. Petrofsky JS, Lawson D, Berk L, Suh H. Enhanced healing of diabetic foot ulcers
using local heat and electrical stimulation for 30 min three times per week. J
Diabetes 2010: 2:41-6.
107. Charles CA, Ricotti CA, Davis SC, Mertz PM, Kirsner RS. Use of tissue-engineered
skin to study in vitro biofilms. Dermatol Surg 2009: 35(9):1334-41.
108. Kanno E, Toriyabe S, Zhang L, Imai Y, Tachi M. Biofilm formation on rat skin
wounds by Pseudomonas aeruginosa carrying the green fluorescent protein gene.
Exp Dermatol 2010: 19(2):154-6.
EWMA Journal 2011 vol 11 no 2

allowing improved efficacy in the antimicrobial action 101 .
Another biofilm control measure is to use substances that
can interfere in the cell to cell communication, namely
by quorum sensing attenuation 26 . Garlic has been used
for the rapid clearance of P. aeruginosa from the lungs
of mice models 102 . Synergistic activity has been reported
between tobramycin and bismuth against P. aeruginosa
quorum sensing, virulence factors and biofilm formation
ability 103 . Several studies have demonstrated in vitro that
the use of honey can influence biofilm formation 85 thereby
having the possibility of topical application in wound
management 104 . Another strategy is to disrupt the biofilm
in wounds by using ultrasound 105 , electric stimulation or
electromagnetic therapy 106 .
In order to evaluate potential biofilm interventions
there is a need for the development of biofilm models
13,107,108 , however before effective anti-biofilm interventions
are accepted there is a need for clinical evidence
of biofilm associated infections.
CONCLUSION REMARKS AND FUTURE WORK
The increased number of chronic wounds in ageing populations
is a major problem. The knowledge of the relation
between the concepts of wound chronicity and biofilm is
of utmost importance. It is therefore crucial to develop
means to diagnose biofilm infections, and there is a strong
need for effective treatment strategies. However it should
be stated that there are no routine biofilm detection methods
available yet and effective interventions depend on the
quality of the diagnosis.
It is certainly possible to explain, under a biofilm paradigm,
the delay in chronic wound healing, therefore the
biofilm communities must be identified as soon as possible
as well as their distribution within the biofilm, but
more information regarding their specific contribution
to the pathogenesis is fundamental for the selection of
adequate therapeutic methods. The debridement or postdebridement
of chronic wounds can induce a restart in
the biofilm formation and this can create a window of
opportunity that should be exploited using a combination
of methods, within an antibiofilm strategy. The relative
predominance of pathogens in the biofilm community can
also be avoided by promoting the shift to healthy biofilm
that can be an easier target for host defenses. m
Acknowledgements
I gratefully acknowledge to Dr. Clara Extremina from
REQUIMTE, Faculdade de Farmácia, Universidade do
Porto and to Professor A. Freitas da Fonseca, for the critical
review of the manuscript.
EWMA Journal 2011 vol 11 no 2
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Diabetic foot ulcer pain:
The hidden burden (Part two)
ABSTRACT
Background: Diabetic foot ulcers (DFU) are often
considered painless due to sensory peripheral neuropathy,
with pain only occurring with infection
or other complications (Sibbald et al., 2006). Recent
research suggests DFU pain is more prevalent
than expected and severely impacts on quality of
life (Ribu et al., 2006; Bengtsson et al., 2007).
Aim: To explore the effect of specific DFU pain
on life quality from the patient’s perspective.
Methods: Purposive sampling identified three
patients from a specialist DFU clinic. Data was
collected using semi-structured interviews. Interviews
were recorded, transcribed and analysed
using thematic content analysis.
Results: Four themes emerged: Experience of
Pain; Physical Effects of Pain; Coping, Support
and Social Impact; and Psychological Impact. Results
indicated that DFU pain affected patients
physically and psychologically, especially with regards
to sleep, mobility and social roles. Feelings
of depression, isolation and loss of independence
were expressed. Pressure from footwear and dressing
changes caused or worsened DFU pain.
Conclusions: DFU pain is an under-recognised
phenomenon which can be both severe and debilitating,
and also negatively impact on life quality
across physical and psychosocial domains. Further
qualitative work into the patients’ lived experiences
of DFU pain is needed to help clinicians
understand the relevance to holistic diabetic foot
care and service provision.
INTRODUCTION
Diabetic Foot Ulcer (DFU) pain is a phenomenon
which has been both under-estimated and underresearched.
The exploratory study published in
part one of this article on the presence and characteristics
of DFU pain found that patients can
experience specific DFU pain despite the presence
of neuropathy, and not always related to
Decorrelated complications. This supported the
findings of previous works1,2. A second phase
was therefore conducted within the same study
to investigate the impact of specific DFU pain
on quality of life (QoL).
Previous research has indicated that DFUs negatively
impact on QoL 3,4,5 , as does pain from various
causes 6,7,8,9 . DFU can significantly decrease
QoL for a variety of reasons, including decreased
mobility, diminished independence, loss of
employment, increased risk of amputation and
repetitive trips to clinicians for care 10 . Despite
this, there is relatively little research in this area.
Although pain is often raised as an issue in studies
on DFU and QoL, none have looked specifically
at DFU pain and QoL from the patient’s
perspective.
Ribu et al. 1 evaluated health-related quality of life
(HRQoL) as part of their research into DFU pain
using generic and disease-specific measurement
tools. Results found that patients experiencing
DFU pain had consistently low scores in both
physical and psychological domains.
A qualitative study on the patient’s perspective
of living with a DFU identified pain as one of
six commonly experienced problems 11 . Almost
all patients experienced pain at some time, with
most reporting ulcer pain woke them at night and
having to lie in certain positions to avoid pressure
on the ulcer. Pain was reported when walking
even short distances. Three patients avoided
taking analgesia due to fear of reliance. Pain was
mainly discussed in relation to painful neuropathy,
although direct relationship with the ulcer
or other causes was not considered. The effect of
the pain in causing sleep deprivation and fatigue
affecting overall QoL was highlighted.
Pain was raised as a significant factor in a phenomenological
study 12 to determine the QoL issues
of 21 patients with DFUs. Just under half of the
patients complained of ulcer pain impairing their
ability to walk, discomfort on lying down and
during dressing changes. The authors felt unable
�
Science, Practice and Education
Sarah E Bradbury, MSc
Research Nurse,
Cardiff University
Patricia E Price, PhD
Professor and Dean
of Healthcare Studies,
Cardiff University
Department of Dermato logy
and Wound Healing,
Cardiff University
Correspondence:
Sarah Bradbury
Research Nurse
Dept. of Dermatology
and Wound Healing
Room 13
Upper Ground Floor
School of Medicine
Heath Park
Cardiff
Conflict of interest: None
EWMA Journal 2011 vol 11 no 2 25

Science, Practice and Education
Table 1
Inclusion criteria Exclusion criteria
Over eighteen years of age Dementia or learning/communication difficulties
Experience of specific DFU pain
Willing to participate in an interview
Able to fully understand and give informed consent
to confirm that pain was definitely originating from the
ulcer rather than an underlying pathology, but it suggests
that patients feel they are experiencing ulcer pain which
is impairing their QoL. A comparable study by Watson-
Miller 13 yielded similar results.
Other studies also found patients with DFU experienced
pain, but did not further explore the nature of that
pain or its specific impact on QoL 4,14,15 .
Despite providing useful information on the effect of DFU
on HRQoL, studies generally have small sample sizes and
the subject would still benefit from further research. The
difficulty with measuring HRQoL with specific regard
to foot ulcers in diabetic patients is that they often do
not experience only one complication of the disease in
isolation. This can make it difficult to determine with
certainty that it is the ulcer that is affecting QoL, especially
in studies which do not exclude patients with other
diabetic complications. The lack of disease-specific tools
for DFU until relatively recently may also have hindered
progress within this field – as Vileikyte 16 stated, the effects
of DFU on HRQoL are distinct from those associated
with the disease itself and need to be addressed separately.
Overall, it is clear from the qualitative work undertaken,
which allows the patients to voice their individual
difficulties and experiences, that pain is an important
contributor to reduced QoL for patients with DFU. Unfortunately,
QoL studies related to DFU generally do
not provide enough detail on the effect of pain as this is
not their primary aim. Substantial conclusions cannot be
drawn from their results with relation to pain, but they
do provide a useful overview and some insight into the
nature and degree of the problem, thereby justifying the
need for more specific work.
The need for further research on the subject of pain
from DFU and QoL was thus identified to determine
the extent to which the problem needs consideration in
clinical practice.
METHODS
An exploratory research design was continued in this phase
using qualitative methods.
Participants were chosen using purposive sampling
from the same local specialist diabetic foot clinic as in
26
phase one. Basic inclusion/exclusion criteria were used to
assess if a participant was suitable (Table 1).
Face-to-face semi-structured interviews were considered
an appropriate method to collect qualitative data on
the effect of DFU pain on everyday life. An interview
schedule was developed to guide the conversation onto
relevant topics based on the study aims and issues identified
within the literature, but with a particular focus on
pain. The first interview acted as a pilot of the schedule
to determine if the questions were valid and easy to
understand, and to gain insight into how the questions
were interpreted by patients to try to improve reliability.
Following this the interview schedule was shortened and
revised to include broader topic areas.
The interviews were recorded and manually transcribed.
Reflective notes were also made shortly after completing
the interview recording any non-verbal communication,
the researcher’s thoughts on the topics covered and
the response of the participant to ensure the best quality
information was assembled for analysis.
The study protocol was approved by the Local Research
Ethics Committee. Confidentiality and anonymity
were maintained throughout the research process,
and written informed consent was taken. Identification
of suitable participants and completion of the interviews
occurred over a six month period. All participants chose
to be interviewed at home, and each interview lasted approximately
30 minutes.
The taped conversations were transcribed by the researcher
and then verified by a second researcher not involved
with the interviews. A copy was sent to the appropriate
participant for verification and to make any required
changes or additions. These processes were performed to
improve reliability and minimise bias within the study
findings. The transcribed and verified data was then analysed
using thematic content analysis, guided by elements
of the method published by Burnand 17 .
In an effort to demonstrate methodological rigour and
reduce researcher bias, the identified data categories were
checked by a second researcher to ensure the primary interpretation
fairly represented the data. The themes were then
examined to identify any associated relationships which
were discussed and compared.
�
EWMA Journal 2011 vol 11 no 2

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Science, Practice and Education
RESULTS
Three patients were recruited between September 2007
and January 2008. The intended sample was five patients
but, mainly due to the time delay while waiting for ethics
approval, a number of patients achieved ulcer healing
and were discharged, or no longer had pain in their ulcer.
Some patients refused to participate.
The study sample, again although small, presented views
from a male and female perspective (Table 2). The type
and duration of diabetes and ulcer aetiology and duration
were similar across the group. All the patients had complex
medical histories consisting of independent diseases and
diabetes-related complications, which could impact on
QoL. The interview data will be presented using the four
themes generated during analysis.
Experience of Pain
This theme was generated from the patient’s descriptions
of their pain, when it occurred, the factors that caused it
or made it worse and how they managed it.
Participants described their pain in various ways –
sharp, unexpected, variable in occurrence but of severe
intensity, intermittent, spontaneous, continuous and unrelenting.
One described it “...as if my foot were in a bed
of stinging nettles”, while another stated it was the worst
he’d ever had.
None of the patients seemed surprised to be experiencing
pain, despite having peripheral neuropathy. One felt
that pain could even be a good sign, while another was
more surprised at its severity.
The main issue consistently raised relating to factors
that increased or worsened pain was application of pressure
on the wound, especially during dressing changes and from
footwear. All patients described pain occurring in bed due
to pressure from bedclothes or moving to lie on the ulcer:
“…I can’t sleep in bed, I can’t stand blankets or anything
on the foot”.
Two patients having dressings changed by family members
stated it was not terribly painful, except during cleansing
and if the dressing had ‘dried out’.
28
Table 2: Sample Demographics
Study number P1 P2 P3
Gender M F M
Age 72 86 71
Type of Diabetes 2 2 2
Duration of Diabetes (Years) 30 21 10
DFU Aetiology NI NI NI
Duration of DFU (Months) 17 16 6
No. of Diabetes Related Complications 2 1 2
The patient having dressings changed by District Nurses
remarked that cleansing could be painful, but felt the
pain at was more dependent on the individual performing
it, describing some as ‘rough-handed’. He also experienced
pain during dressing application and for some time afterwards:
“If anybody touches it, it’s hell”.
Difficulty finding footwear that did not exert pressure
and cause pain was expressed by two patients. Both had
bought their own shoes or found solutions, but not always
ideal ones, such as wearing sandals throughout the winter.
One was particularly frustrated with the service provided
by the hospital:
“The shoes they make are too heavy and are no good to
me, but I can’t make them understand that”; “…they bruised
all my feet and aggravated the toe”.
Analgesia was used by all three participants for pain management.
Two took a codeine-based preparation which
helped decrease their pain most of the time, although one
felt the pain never went away entirely. This patient was
reluctant to take increased or further analgesia due to polypharmacy.
The third patient was taking multiple forms
of analgesia, including Morphine tablets and liquid, an
anti-epileptic for neuropathic pain and Paracetamol, but
still experienced uncontrolled ulcer pain:
“…the medicine I’m taking is not touching me…”; “… If
I could find a tablet or a medicine that could take it away
just for a few hours, I’d be more than happy”.
He had previously overdosed on Oramorph in desperation
to get rid of the pain, leaving him feeling ill for
several days. When discussing a previous possibility of
having the leg amputated due to a back condition and
reduced circulation, he felt that at times amputation would
be preferable to continuing in such pain from his ulcer:
“I suppose that’s the worst I can look forward to, but if
it can get rid of that [pointing at the ulcer]…I know it
sounds stupid…”.
He described restlessness at not getting any relief from
the pain, describing himself as like ‘an animal in a cage’,
stating he’d try anything to decrease the pain.
�
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Science, Practice and Education
Physical Effects of Pain
This theme was identified from patient comments regarding
the effects of DFU pain on physical aspects of their
daily life.
Problems with mobility due to pain were discussed by
all participants, leading to feelings of loss of independence.
One felt his pain was improving as his ulcer was beginning
to heal – he was using a walking stick rather than a Zimmer
frame, and commented that feelings of loss of control in
his life had diminished as his mobility improved.
Another felt decreased mobility had the biggest effect
on QoL. Already experiencing limited mobility, the
ulcer pain now forced her to use a wheelchair. Footwear
problems highlighted previously also had adverse effects.
Another participant identified walking as a dominant
factor in increasing his ulcer pain, requiring an electric
scooter outside the house and leaving him unable to drive.
Sleep was also altered due to DFU pain, particularly for
one. He slept in a chair as he couldn’t tolerate the pressure
of the duvet on his foot while in bed, but was awake
for long periods during the night. Sleeping tablets were
ineffective:
“I just move my foot like everybody else does in bed…and
that’s it, bang, it wakes me up”; “…about half hour and I
wake…”; “I’ve gone through the roof with smoking... every
time I wake up I’ve got to have something to do…”.
He thought lack of sleep made him feel much worse,
feeling he could cope much better generally if his sleep
improved.
Another commented that pain affected her sleep, finding
she needed daytime naps due to tiredness, but felt that
analgesia taken at night helped. One participant felt ulcer
pain did not specifically wake him during the night, but
took sleeping tablets with his bedtime analgesia.
Pain had also led to the loss of a previously healthy appetite
for one participant:
“Well, I’m not living, it’s as simple as that. I’ve got no
appetite, I eat like a pigeon. I used to love my Sunday dinners,
but the look of them makes me feel ill now”.
Coping, Support and Social Impact
This theme was derived from the patients’ accounts of the
impact ulcer pain had on their relationship with family,
friends and healthcare professionals, including the support
they received and coping strategies they adopted.
All participants remarked they were unable to perform
all their activities of daily living independently. This was
also due to other medical conditions which affected their
general health, such as cardiovascular disease, haemolytic
anaemia and previous back surgery, in addition to the
pain.
30
Help and support from family members also enabled them
to cope. One felt the support received from her daughter
made a big difference to her daily life and with coping with
the pain. She performed dressing changes, reminded her to
take analgesia and performed housework. This, however,
made the patient feel she was putting pressure on her
daughter’s time.
Feeling a burden on their family was also identified by
the other participants, with one commenting he and his
wife had no retirement. Another also depended greatly
on his wife, feeling that DFU pain and the limitations
it placed on his mobility was impacting on his family
relationships:
“I’ve got a daughter nearby… I hardly see her..”; “I’ve
got to the stage where I don’t want anybody…I mean I love
having the grandkids up here but they can be noisy, and it
makes me irritable”; “…as kids are, they don’t realise. I’m
frightened when one of them is behind me. All I need is a tap
on that and I’m up in the air”; “…it has changed my life,
without a doubt”.
He also felt unable to perform any household maintenance
or previously enjoyed social activities, especially as
there were steep steps outside his house:
“…I’m not in the mood, I just can’t be bothered. I’m sick
of being in but I don’t want to do anything else”.
Another participant stated:
“I’ve just been like a zombie. With no interest. Now I’m
beginning to get out a bit, I feel better. I want to go out more”.
All participants commented on the care received from
various clinicians for their DFU and related pain. Two
felt that healthcare professionals had provided them with
good care and support, which helped them cope.
“…There was one nurse… she sat with me and gave me
comfort. Now that is something that you cannot get with
swallowing a pill”.
One felt psychological support wouldn’t have helped, as
she felt she had adapted to living with pain.
Neither felt there was anything clinicians could have
done better.
Conversely, one participant was unhappy with the support
he had received from his general practitioner and
district nurses, in particular, feeling there was no encouragement
with progress of the wound and they were always
in a rush to leave. He did feel more supported by the DFU
clinic that had referred him to a Pain Specialist whose
interventions had provided some relief for a short while.
He was, however, frustrated with delays in treatment.
�
EWMA Journal 2011 vol 11 no 2

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Dr Paul Silverstein, Clinical Professor Plastic Surgery, University of
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Science, Practice and Education
Psychological Impact
This theme concerns the patient’s emotions, including
feelings of depression, isolation and loss of independence,
which overlapped considerably with the other themes due
to the wide impact of the pain overall.
Loss of motivation and feelings of depression due to
ulcer pain were expressed by two participants:
“…the worst time I’ve got at the moment is getting out
of bed in the morning. I need real willpower to go into the
bathroom and dress”.
“I look out there now and think spring is coming, but
what can I do? Nothing.”.
Feelings of isolation and loss of independence were also
raised. One participant felt frustrated with the lack of
relief from the pain and that the ulcer controlled his life.
Two participants did however express trying to cope
with things by thinking more positively, especially one
whose pain was slowly improving:
“There’s a light at the end of the tunnel now”.
DISCUSSION
A larger, more diverse sample would have provided a richer
data set and increased expression of views, but time constraints
made it difficult to address this issue. It would have
been interesting to learn the experience of patients with
purely neuropathic ulceration to determine any differences
in QoL issues. Data saturation was not achieved so the
collected data may be lacking in diversity or consistency.
However, the main aim was not to generate theory but to
gain information and perspective of the lived experience
of DFU pain.
Experience of Pain
The reported descriptions of pain are varied and intense
in nature, similar to the results of the Short-Form McGill
Pain Questionnaire 18 used in phase one. Despite the common
perception that neuropathy leads to painless ulcers,
the patients were not surprised to be experiencing pain.
Preconceptions often held by patients and clinicians regarding
the pain experience need addressing if DFU pain
is to be understood and adequately managed.
The causes of pain were similar to that reported by qualitative
studies relating to DFU as a whole 11,12 , with pressure
from footwear or bedding being recurrent themes. Pain
at dressing change has been noted by other QoL studies
into DFU 12 , and is a common finding with studies
related to wound pain 19,20,21 . As with one patient here,
leg ulcer studies have reported how individual clinicians’
technique and basic understanding can impact on the experience,
with patients feeling that they are not listened
to or cared about 22 . VLU were once considered painless
32
or not as painful as arterial ulcers which potentially caused
increased pain at dressing change due to a poor knowledge
base – a similar situation could occur with DFU due to
the preconception that the pain sensation is compromised.
Although pain at dressing change is becoming a more
prominent and researched area, more consideration needs
to be given to treatment of DFU with the awareness that
they can be painful.
Problems with footwear are commonly cited within the
QoL research relating to both DFU and VLU, although
not always necessarily related to pain. The dissatisfaction
or difficulties expressed by two patients regarding finding
appropriate footwear could be an important issue for
future care. Appropriate footwear for patients with DFU
is paramount due to the requirement for offloading to
improve healing 23,24,25 . Use of appropriate orthoses can
improve physical and mental functioning in diabetic patients
26 , reinforcing the requirements for an efficient and
effective orthotic service within diabetic foot clinics to
not only improve healing but also QoL. The adverse effect
of footwear on DFU pain is a significant issue for any
healthcare professional (HCP) involved in the management
of DFU, which again requires raised awareness and
consideration within service provision.
Participants reported varying efficacy of analgesia for controlling
DFU pain. Whereas previous literature is mainly
concerned with the under-use of analgesia or the fear of
dependence by patients 11,27 , some findings here suggest
DFU pain can be so severe and multi-factorial that oral
analgesia alone may not be sufficient. The only temporary
relief one patient experienced was following referral to a
chronic pain specialist, yet until clinicians acknowledge
that specific ulcer pain exists and is not necessarily of neuropathic
origin, there may be minimal referrals to specialist
services. Management of some DFU pain may require
treatment such as nerve blocks, psychological support or
complementary therapies. Further research into this area
alone is necessary if DFU pain assessment and management
is to become even adequate.
Physical Effects of Pain
The majority of research into chronic wounds and QoL
suggests they impact significantly on physical aspects of
daily life 4,11,12,22,28,29,30 . Qualitative work consistently
highlights issues with mobility and sleep, the consequences
of which appear far-reaching in terms of fatigue, loss of
independence and social isolation.
Similar reports were found here, particularly with regard
to mobility. Standing and walking even short distances
was found to increase pain, which concurred with
previous findings in both quantitative and qualitative
�
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Science, Practice and Education
studies 1,2,11,12 . Some patients with DFU report frustration
at the enforced decrease in mobility due to the need
to offload the foot, and state they would rather adopt risktaking
behaviours and accept the possible consequences to
their physical health for an increase in their QoL 11,12,30 .
If pain, however, is the cause of reduced mobility, then
this option may not be available, leaving patients feeling
completely restricted and isolated and with few coping
mechanisms on which to depend. Achieving ulcer healing
may be the only way of returning to a more normal physical
functioning, as described by one participant.
Sleep was an important issue for patients both in this
study and previous works, leading to extreme fatigue and
changes in mood 4,28 . The patients seem to become trapped
in a vicious circle whereby the consequence of one problem
exacerbates another. Increased fatigue due to sleep deprivation
leads to further decreased mobility, which increases
fatigue further due to patients becoming lonely, isolated
and lacking in energy and motivation.
The results reinforce the idea that the impact of physical
restrictions from DFU pain has the same widespread effect
on psychosocial well-being as other types of chronic
wound. This emphasises the need for a holistic approach in
order to facilitate a better understanding of patients’ needs.
Coping, Support and Social Impact
The accounts of DFU pain causing increased dependence
on others for assistance with simple daily activities
is in accordance with general QOL studies into patients
with DFU and VLU 11,13,30 . This causes feelings of loss of
control and loss of self, which can leave patients anxious,
depressed and vulnerable. While supportive families are a
common theme within this study and others, and recognised
as invaluable by patients, it is common for patients
to feel burdensome and guilty, placing unwanted restrictions
on their loved ones, especially if partners are elderly
and may not be in perfect health. These issues can affect
relationships whereby patients feel a loss of their previous
life and a change in their social role, as reflected by the
comments of one subject regarding not being able to play
with his grandchildren or wanting to socialise with other
family and friends. These comments are again a recurring
theme in other QoL literature on patients with chronic
wounds, where fear of others knocking their wound and
causing pain led to the avoidance of social or public situations
12,19,29,30,31,32 . Again, a perpetual cycle may develop
where decreased mobility and increased dependence
leads to social isolation, leaving patients depressed and
not wanting contact with others. One patient alluded to
such feelings, mentioning he could not perform tasks related
to the upkeep of his home, a restriction which may
have left him with feelings of low self-worth due to his
34
change of role within the family. These issues highlight
the extent to which DFU pain can restrict individuals and
compromise lives, so clinicians need to be aware of these
feelings if they are to address all the needs of the patient.
Varying positive and negative relationships with HCPs
were reported by participants. The literature suggests
many patients with chronic wounds become disillusioned
with their HCPs, feeling their personal experience is not
being recognised, thus inhibiting freedom of expression 13 ,
and that they are not provided with enough education or
involvement in decision-making regarding their care 31 .
Others get frustrated with the inconsistency of treatment
and develop a lack of confidence in their HCP’s 32 . It has
been suggested that clinicians become focused on treating
illnesses rather than people, or on curing rather than helping
patients to live and cope with chronic illness 29,33 – this
may be the case with the patient who felt ignored and that
his clinicians never offered him encouragement or reassurance,
but seemed only concerned with completing the
task in hand (redressing the ulcer) as quickly as possible.
The ulcer and its healing can become the sole focus of
all interventions, and the clinician loses sight of the personal
experience and caring perspective. This underlines
the need for clinicians to develop effective interpersonal
skills and consider psychosocial aspects to recognise individual
needs. The aim should be to prevent or lessen the
psychosocial implications of DFU pain in the same way
as physical treatment. Support in the form of allowing
patients to talk, providing comfort and information-giving
were the factors which participants felt fostered good relationships
with their HCPs and helped them to cope.
Psychological Impact
The psychological impact of DFU pain is a common
thread running through all the themes already discussed
– the experience of pain, physical restrictions and changes
in relationships all led to feelings which created a change
in psychosocial well-being. Several comments dealt solely
with feelings of depression, loss of motivation and resignation
at their situation and the effect it was having on
their lives.
Increased anxiety and depression in patients with diabetes
and foot ulcers has been documented 3,414,34 . These feelings
can be enhanced due to concern that ulcers will never heal
and a fear for the future at the loss of hope over regaining
any control over their lives. One patient commented that
the ulcer and pain controlled him, leaving him without
positive thoughts. Another expressed a loss of motivation
to even get up and wash and dress, yet was concerned
about being a burden on his carer and frustrated at his
lack of independence. Fear of amputation and its link to
�
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Science, Practice and Education
depression is often mentioned within the literature 11,13 , yet
the desperation and anxiety felt by one patient regarding
the lack of relief from his DFU pain had led him to question
if amputation would be the more preferable option.
These issues underline the importance for clinicians to pay
more than lip service to holistic and psychological care,
especially with regard to patients experiencing DFU pain,
if prevention and management of such severe emotions
is to be achieved.
Some patients coped with the feelings surrounding their
DFU pain and its impact on their lives by either resigning
themselves to its existence and their need to adapt to it,
or by trying to think positively rather than succumbing
to negative feelings. Husband 29 suggested after a period
of adaptation and endurance of long-term ulceration patients
may learn to shift the focus of their life away from
the ulcer in order to cope with it. Small improvements
in one patient’s ulcer pain may have enabled him to see a
future without pain and a return to his old feelings of self.
Either way, clinicians need to consider helping the patient
to cope and adapt to potentially chronic conditions while
also trying to address physical needs and ulcer healing.
Limitations to the study are acknowledged, such as the
potential for poor external validity. Smaller than expected
sample sizes were obtained, and were chosen from a specialist
environment dealing with complex and chronically
ill patients. Therefore, similar findings may not occur with
a larger, less complex population, and it is possible observed
effects were not independent of natural variation
within the clinic. However, the study was purely exploratory
and filled a void by providing interesting and valuable
information on an under-researched area. The results act
References
1. Ribu L, Rustoen T, Birkeland K, Hanestad BR, Paul SM, Miaskowski C (2006) The
Prevalence and Occurrence of Diabetic Foot Ulcer Pain and its Impact on Health-
Related Quality of Life The Journal of Pain 7 (4) 290-299
2. Bengtsson L, Jonsson M, Apelqvist J (2008) Wound-Related Pain is Underestimated
in Patients with Diabetic foot Ulcers Journal of Wound Care 17 (10) 433
3. Carrington AL, Mawdsley SKV, Morley M, Kincey J, Boulton AJM (1996) Psychological
Status of Diabetic People with or without Lower Limb Disability Diabetes
Research and Clinical Practice 32: 19-25
4. Brod M (1998) Quality of Life Issues in Patients with Diabetes and Lower Extremity
Ulcers: Patients and Care Givers Quality of Life Research 7: 365 – 372
5. Meijer JWG, Trip J, Jaegers SMHJ, Links TP, Smits AJ, Groothoff JW, Eisma WH
(2001) Quality of Life in Patients with Diabetic Foot Ulcers Disability and Rehabilitation
23 (8) 336-340
6. Paul SM, Zelman DC, Smith M, Miaskowski C (2005) Categorizing the Severity of
Cancer Pain: Further Exploration of the Establishments of Cutpoints Pain 113: 37-44
7. Zelman DC, Dukes E, Brandenburg N, Bostrom A, Gore M (2005) Identification of
Cut-points for Mild, Moderate and Severe Pain due to Diabetic Peripheral Neuropathy
Pain 115: 29-36
8. Benbow M (2006) Holistic Assessment of Pain and Chronic Wounds Journal of
Community Nursing 20 (5) 24-28
9. Flanagan M (2006) Managing Chronic Wound Pain in Primary Care Practice Nurse
31 (2) 34-37
10. Goodridge D, Trepman E, Embil, JM (2005) Health-Related Quality of Life in
Diabetic Patients with Foot Ulcers Journal of Wound, Ostomy and Continence
Nursing 32 (6) 368-377
11. Ribu L, Wahl A (2004) Living with Diabetic Foot Ulcers: a Life of Fear, Restrictions,
and Pain Ostomy/Wound Management 50 (2) 57-67
36
as a basis for future research and highlight the requirement
for this work to be performed.
The presence of complications related to diabetes and
other medical conditions within the sample could also
raise the question as to the extent to which the views and
experiences expressed were solely attributable to DFU
pain. They could also incorporate the difficulties of living
with foot ulcers or diabetes itself, or even just general
ill-health. Attempts were made to overcome this through
reading of a statement at the commencement of each interview
reiterating the specific subject matter and study aims.
CONCLUSION
Overall, the results of the qualitative component of this
study into DFU pain have confirmed that this underrecognised
phenomenon can have detrimental physical
and psychosocial effects. This has major implications for
clinical practice in that it challenges current assessment
practices and accentuates the need for clinicians to improve
their understanding of DFU pain and its consequences
in order to increase quality of care provision and
ensure the holistic needs of patients are met.
Lloyd and Orchard 35 considered that improvements in
QoL have become a more accepted goal of medical care,
in addition to the alleviation of physical symptoms, but it
is still evident that advancements can be made with regard
to psychosocial issues. External pressures such as limited
time and resources within diabetic foot clinics may lead to
QoL issues related to pain and other aspects of living with
a foot ulcer being overlooked, as the physical challenge of
the ulcer itself is prioritised. Clinicians need to consider
12. Ashford RL, McGee P, Kinmond K (2000) Perception of Quality Of Life by Patients
with Diabetic Foot Ulcers the Diabetic Foot 3 (4) 150-155
13. Watson-Miller S (2006) Living with a Diabetic Foot Ulcer: A Phenomenological
Study Journal of Clinical Nursing 15: 1336-1337
14. Tennvall GR, Apelqvist, J (2000) Health-Related Quality of Life in Patients with
Diabetes Mellitus and Foot Ulcers Journal of Diabetes and Its Complications 14:
235-241
15. Ribu L, Hanestad BR, Moum T, Birkeland K, Rustoen T (2007) A Comparison of the
Health-Related Quality of Life in Patients with Diabetic Foot Ulcers, with a Diabetes
Group and a Nondiabetes Group from the General Population Quality of Life
Research 16: 179-189
16. Vileikyte L (2001) Diabetic Foot Ulcers: A Quality of Life Issue Diabetes/Metabolism
Research and Reviews 17: 246-249
17. Burnand P (1991) A Method of Analysing Interview Transcripts in Qualitative
Research Nurse Education Today 11: 461-466
18. Melzack R (1987) The Short-Form McGill Pain Questionnaire Pain 30: 191-197
19. Mudge E, Holloway S, Simmonds W, Price P (2006) Living with Venous Leg
Ulceration: Issues Concerning Adherence British Journal of Nursing 15 (21)
1166-1171
20. White R (2008) A Multinational Survey of the Assessment of Pain when Removing
Dressings Wounds UK 4 (1) 14-24
21. Price P, Fagervik-Morton H, Mudge EJ, Beele H, Ruiz JC, Nystrom TH, Lindholm C,
Maume S, Melby-Ostergaard B, Peter Y, Romanelli M, Seppanen S, Serena TE,
Sibbald G, Soriano JV, White W, Wollina U, Woo KY, Wyndham-White C, Harding
KG (2008) Dressing-Related Pain in Patients with Chronic Wounds: An International
Perspective International Wound Journal 5 (2) 159-171
22. Charles H (1995) The Impact of Leg Ulcers on Patients’ Quality of Life Professional
Nurse 10 (9) 571-574
EWMA Journal 2011 vol 11 no 2

increased QoL as a measure of success as well as objective
physical outcome measures, because while these are
important, dealing with a chronic and progressive disease
such as diabetes may mean that patients have to cope with
such problems for long periods of time. More work into
the effect of DFU pain on QoL may help to raise awareness
and aid clinicians in the provision of holistic care
that facilitates both physical and psychological well-being.
Implications for clinical practice
n Clinicians need to be more aware of the importance
of providing psychosocial care in addition to focusing
on ulcer healing.
n Collaborative working between diabetic foot specialists,
wound care specialists, pain specialists and
primary care teams could promote better assessment
and management of DFU pain and its impact on QoL.
n Patients should be involved in decision-making
regarding their treatment.
Further research
n Further qualitative work into the patient’s perspective
on DFU pain could help clinicians to understand
the relevance to diabetic foot care and to their
own practice, and aid in meeting patient needs more
completely.
n Quantitative work using formal HRQoL tools could
provide interesting information and comparative
data with other patient populations.
n The development of a tool incorporating the physical
assessment of DFU pain in conjunction with
a review of psychosocial issues might be a useful
method of increasing awareness and improving
dissemination of information. m
23. Krasner D (1998) Diabetic Ulcers of the Lower Extremity: A Review of Comprehensive
Management Ostomy/Wound Management 44 (4) 56-75
24. Frykberg RG (2002) Diabetic Foot Ulcers: Pathogenesis and Management American
Family Physician 66 (9) 1655-1662
25. Jeffcoate WJ, Harding KG (2003) Diabetic Foot Ulcers The Lancet 361: 1545-1551
26 Davies S, Gibby O, Phillips C, Price P, Tyrrell W (2000) The Health Status of Diabetic
Patients Receiving Orthotic Therapy Quality of Life Research 9: 233-240
27. Persoon A, Heinen MM, van der Vleuten CJM, de Rooij MJ, van de Kerkhof PCM,
van Achterberg T (2004) Leg Ulcers: A Review of their Impact on Daily Life Journal
of Clinical Nursing 13: 341-354
28. Douglas V (2001) Living with a Chronic Leg Ulcer: An Insight into Patients’
Experiences and Feelings Journal of Wound Care 10 (9) 355-360
29. Husband LL (2001) Shaping the Trajectory of Patients with Venous Ulceration in
Primary Care Health Expectations 4: 189-198
30. Kinmond K, McGee P, Gough S, Ashford R (2003) ‘Loss of Self’: A Psychosocial
Study of the Quality of Life of Adults with Diabetic Foot Ulceration Journal of Tissue
Viability 13 (1) 6-16
31. McPherson MV, Binning J (2002) Chronic Foot Ulcers Associated with Diabetes:
Patient’s Views The Diabetic Foot 5: 198-204
32. Rich A, McLachlen L (2003) How Living with a Leg Ulcer Affects People’s Daily Life:
A Nurse-Led Study Journal of Wound Care 12 (2) 51-54
33. Pott E (1992) Health Promotion and Chronic Illness: Discovering a New Quality of
Health Geneva: World Health Organisation
34. Anderson RJ, Clouse RE, Freedland KE, Lustman PJ (2001) The Prevalence of
Comorbid Depression in Adults with Diabetes: A Meta Analysis Diabetes Care 24 (6)
1069-1078
35. Lloyd CE, Orchard TJ (1999) Physical and Psychological Well-Being in Adults with
Type 1 Diabetes Diabetes Research and Clinical Practice 44: 9-19
EWMA Journal 2011 vol 11 no 2
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1 Martin Šimek, MD,PhD
1 Martin Kaláb, MD,
2 Martin Molitor, MD,PhD
1 Roman Hájek, MD,PhD
1 Jana Grulichová
1 Patrick Tobbia, MD
2 Bohumil Zálešák, MD,PhD
1 Vladimír Lonský, MD,PhD
Short paper
1 Department of Cardiac
Surgery
2 Department of Plastic
and Aesthetic Surgery
University Hospital and
Palacky University Faculty
of Medicine, Olomouc,
Czech Republic
Correspondence:
Martin Šimek
martin.simek@c-mail.cz
The authors have no
financial relationship
with KCI Company
San Antonio, TX, USA
38
Topical negative pressure
in the treatment of deep
sternal infection following
cardiac surgery:
Five year results of first-line
application protocol
ABSTRACT
Aim: We sought to evaluate a five year single
centre experience for the application of
topical negative pressure therapy (TNP) as
the first-line therapy in the treatment of deep
sternal wound infection (DSWI) following
cardiac surgery.
Methods: Prospective analysis of 50 consecutive
patients (27 men, 23 women, mean age
67.8±9.2 years) who underwent first-line
application of topical negative pressure for
the treatment of deep sternal wound infection
within a five year period (from September
2004 to September 2009). Clinical and
wound care outcomes were evaluated, therapeutic
failure rates, in-hospital and as well as
the one year mortality of unified application
protocol.
Results: During follow-up 4% of 30-day
mortality, 8% of in-hospital mortality, and
14% of one year mortality (10% DSWI-related
complication adjusted) were observed.
The mean length of overall therapy reached
12.6±8.0 days including the mean of 5.4±2.5
revision/dressing changes within 38.1±14.6
days of the mean in-hospital stay. The sternal
bone was stabilized in 94% of cases; various
flaps were employed in covering of the residual
soft tissue defect in 70% of patients.
Treatment failed in 6% of all cases, 4% due
to DSWI recurrence, and 2% due to necrosis
of the advanced muscle flap. The risk of
wire-related fistula was 14% during whole
follow-up period.
Conclusion: TNP therapy is a reliable method
for the treatment of DSWI following
cardiac surgery. The primary application of
TNP demonstrated a low risk of failure and
a significant decrease in short- and mid-term
mortality was observed.
Presented at
the 20th Conference of the
European Wound Management
Association, 26-28 May,
Geneva, Switzerland.
INTRODUCTION
Deep sternal wound infection (DSWI) is one of the
most serious complications of cardiac surgery performed
through median sternotomy with predicted
mortality ranging between 5 to 30% 1 . Despite welldescribed
risk-related factors, improved antibiotic
prophylaxis and aseptic methods, the incidence remains
unchanged, varying from 1% to 5% 2 . The treatment
strategies of DSWI is still challenging; it differs
from one country to another, from one institution to
another and even from one surgeon to another at the
same department 2 .
METHODS
Between March 2002 to September 2009, 6009 median
sternotomies were performed at our department
as a primary access for heart surgery. DSWIs were
diagnosed according to the guidelines of the Centre
for Disease Control and Prevention (CDC, 3), DSWI
occurred in 84 patients which represented an incidence
rate of 1.39%. Fifty consecutive patients (59%)
were primarily scheduled for the first-line application
of topical negative pressure therapy (TNP) between
September 2004 and September 2009. The detailed
unified therapeutic protocol has been described previously
4,5,6 . The median sternotomy was completely
released and all suture material removed during primary
revision. After bacterial sampling, when two to
three swabs were taken (subticular, and mediastinal
tissue, sternal bone), the wound was repeatedly flushed
out with tepid saline solution. Inherent surgical debridement
included removing only clearly necrotic
tissue and was performed with aid of a scalpel, surgical
spoon, and low-voltage electrocautery. Hydrosurgical
debridement using saline jet-powered device
(Versajet, Smith and Nephew, UK) has not been
employed. Moreover, debridement on the mediastinal
structures was done extremely gently to avoid the
risk of severe bleeding from grafts or the right ventri-
EWMA Journal 2011 vol 11 no 2

Figure 1. Therapeutic protocol
cle. If the bone mass was affected with osteomyelitis, it
was removed with adherent sternocostal joints and costal
cartilages. Emphasis was put on meticulous haemostasis
throughout each debridement. Bleeding from the bone
marrow was controlled with temporally placed bone wax,
which was removed within next dressing changes. Surgical
debridement with repetitive application of TNP (Vacuumassisted
closure, KCI San Antonio, Tx, USA) was carried
out every 48 hours until the wound bed was found to
be free of infection, then the wound was covered by wellvascularised
granulation tissue. When C-reactive protein
levels dropped below 30 mg/l, then the chest was reclosed
(Figure 1). Peri-procedural, wound care characteristics and
clinical outcomes were recorded in a prospective manner.
All patients had a one year follow-up for the evaluation
of long-term morbidity and mortality, Kaplan-Meier actuarial
analysis of survival was plotted. Approval of the
local ethics committee was obtained for the protocol of
the application of TNP to the open chest wound in 2004.
RESULTS
There were 27 males (54%) and 23 females (47%) with an
average age 67.8±9.2, and BMI 29.9±5.3 kg/m 2 . Detailed
peri-operative characteristics including co-morbidities,
surgical procedures and post-operative complications related
to DSWI are summarized in Table 1. A total of 45
patients underwent coronary artery bypass grafting either
as single procedure or in combination with valve surgery.
In this subgroup of patients, 28 (63%) had diabetes and
the internal thoracic artery (IMA) was taken down in 40
(89%). Unilateral IMA harvesting (80%) was done in
pedicled fashion, whereas bilateral IMA harvesting (20%)
was always performed without surrounding tissue as a skeletonized
graft with maximal effort to spare the chest bone
blood supply. The presentation of DSWI was delayed
in average 16.1±14.2 days after the primary surgery, and
twenty-three (46%) patients were re-admitted to the hospital
due to DSWI despite an uneventful wound healing
progress at the time of discharge. Gram positive strains
Table 1. Perioperative characteristics
Science, Practice and Education
TNP (n=50)
Age (years) 67.8±9.2
BMI (kg/m2 ) 29.9±5.3
Male/female ration (%) 54.0/46.0
DM (%) 58.0
COPD (%) 34.0
Immunosuppressive therapy (%) 18.0
Renal impairment (kreatinin>120 mmol/l) (%) 28.0
LVEF (%) 40.8±13.6
EuroSCORE log 6.9±6.2
CABG/valve/combined procedure (%) 60/10/30
Mean operation time (min) 230.5±44.8
Mean XC time (min) 62.8±45.6
Mean ECC time (min) 90.7±40.1
Emergency surgery (%) 24.0
Postoperative blood loss (ml) 910±540.3
Mean artificial pulmonary ventilation (hours) 19.4±28.1
Mean ICU stay (hours) 61.1±34.8
Revision for bleeding/tamponade (%) 18.0
Revision for sternal instability (%) 40.0
Prolonged mechanical ventilation/tracheostomy (%) 8.0
BMI – body mass index
DM – diabetes mellitus
COPD – chronic obstructive pulmonary disease
LVEF – left ventricle ejection fraction
CABG – coronary artery bypass grafting
XC – cross clamp
ECC – extracorporeal circulation
ICU – intensive care unit
were dominantly cultivated from swabs obtained from the
infected wound site, particularly staphylococcal aureus and
coagulase-negative staphylococcus (Graph 1). There was
no significant difference in outcome based on etiological
causative agent. Based on the protocol, mean length of
primary therapy reached 10.8±7.9 days including mean of
5.0±2.1 number of dressing changes in average until the
wound bed was free of infection. All dressing changes were
performed in the operating theatre, every patient was given
a general anaesthetic and relaxed to avoid right ventricle
or graft injury caused by the sternal lamella margins. The
cost of each surgical debridement and dressing changes
were analysed. The expenditure was approximately 2000
CZK (77 €) for general anaesthesia, 900 CZK (35 €) for
surgical debridement, and 2500 CZK (96 €) for dressing
material and collecting canister. A calculated total cost per
one dressing change reached 5400 CZK (208 €).Changes
in laboratory inflammatory parameters characteristics
Graph 1. Predominant wound microorganisms
EWMA Journal 2011 vol 11 no 2 39
�

Graph 2. Laboratory inflammatory parameters characteristics Graph 3. Flap employment
(C-reactive protein, white blood count) throughout the
therapy are displayed in Graph 2. The sternum was approximated
in 47 patients (94%), and residual soft tissue
defect needed to be covered with local flaps in 45 patients
(70%). Detail of employed flaps is showed in Graph 3.
Primary treatment failed in three patients (6%); in two
patients (4%) due to DSWI recurrence, and in one (2%)
due to necrosis of bipedicle muscle flap owing to the technical
failure. All those patients underwent TNP therapy
according to the therapeutic protocol similar to primary
application (rescue therapy), and the necrotic flap was
removed. Furthermore, superficial sternal wound infection
(SSWI) or soft tissue dehiscence occurred in four patients
(8%) which was treated with moist healing therapy and/or
was surgically closed. Mean overall length of TNP therapy
reached 12.6±8.0 days including 5.4±2.5 dressing changes
on average, mean in-hospital time was 38.1±14.6 days.
Focusing on the mortality, 4% of 30-day mortality (two
patients), and 8% of in-hospital mortality (four patients)
was recorded ranging between the 9th-94th post-operative
day. Three patients (6%) died of multiple organ failure
and one (2%) of intractable bleeding from a right ventricle
rupture that occurred shortly after the primary revision.
Detailed therapy characteristics and clinical outcomes are
recorded in table 2. During the one year follow-up, a total
of seven patients (14%) were lost, five of whom (10%)
were an immediate consequence of DSWI (DSWI adjusted
mortality), another seven patients (14%) underwent
treatment for wire-related fistula. The one year plotted
survival analysis using Kaplan-Meier analysis is displayed
in Figure 2.
DISCUSSION
The treatment of DSWI poses an ongoing challenge for
cardiac surgeons; thus far there is no consensus about the
standard of care covering this issue 2 . TNP therapy has
been used in cardiac surgery since 1997. Despite growing
and encouraging experience, evidence that TNP is better
than conventional therapy is still lacking 4 . Several studies
comparing TNP versus conventional therapy showed superiority
of TNP in terms of reduction of primary therapy
failure, short- and long-term mortality and morbidity, and
40
better quality of life, however, all had retrospective design
and were conducted on a limited number of patients 5,6,7,8 .
Recently initial data showed the cost-effectiveness of this
therapy 9 . Even though the cost of TNP was comparable
with other treatment strategies of DSWI, this treatment
brought a significant reduction in mortality and in-hospital
stay 9 . Thus, there is still essential need for further
investigations including larger prospective multi-centre
study, and randomized trials 4 . From a surgical point of
view, TNP combines advantages of the open therapy
which enables repetitive debridement and wound drainage
with the closed therapy, because even in the absence
of sternal closure, applied negative pressure of 125 mm
Hg effectively stabilizes the chest. It allows immediate
postoperative extubation and mobilization of the patient.
Moreover, sealing the sternal wound minimizes the risk
of secondary contamination and facilitates handling with
patients, particularly if they need to be hospitalized in
the ICU 10 .
The exact mechanism of TNP action on wound healing
has not been fully explained as yet 10 . It has been shown
to accelerate granulation tissue building, reduce wound
surface area, decrease local and interstitial tissue oedema,
and increase perfusion of the peri- and wound area 10,11,12
even when the left internal mammary artery has been harvested
for bypass grafting 13 . Moreover, diminished bacterial
load or modulation of bacterial species together with
the reduction of the amount of metalloproteinase detected
in the wound bed strongly suggest that the effect of TNP
on wound healing processes is rather more fundamental
than adjunct 14,15 .
A new negative pressure therapy (V.A.C – Instillation,
KCI, San Antonio, TX, USA) has been recently
introduced. It combines the positive effect of sub atmospheric
pressure with intermittent instillation of antiseptic
solution. This therapy demonstrated its effectiveness in
the treatment of chronic-infected wounds such as pelvic
and leg post-traumatic osteomyelitis. Applied negative
pressures together with intermittent instillation of polyhexanide
solution significantly reduced total in-hospital
stay (36 vs. 73 days, p

Table 2. Therapy characteristics and outcomes
TNP (n=50)
Primary therapy
No. of revisions/dressing changes 5.0±2.1
Length of primary therapy (days) 10.8±7.9
Failure of primary therapy (%) 6.0
Complications after the chest closure
DSWI (%) 4.0
Flap necrosis (%) 2.0
SSWI/dehiscence (%) 8.0
Fistula (%) 14.0
Overall therapy
Overall length of therapy (days) 12.6±8.0
Overall No. of revision/dressing changes 5.4±2.5
In-ICU stay (hours) 204.4±320.1
In-hospital stay (days) 38.1±14.6
Mortality
30-day mortality (%) 4.0
In-hospital mortality (%) 8.0
Multiple organ failure (%) 6.0
Intractable bleeding (%) 2.0
1-year mortality (%) 14.0
ICU – intensive care unit
Although the manufacturer’s recommended negative
pressure setting is 125 mmHg for polyurethane foam,
and 150 mmHg for polyvinyl alcohol foam, some of the
studies that focused on cutaneous blood flow suggested
that further increase in sub atmospheric pressure, even up
to 300 mmHg, leads to a three times increase of cutaneous
blood flow for polyvinyl alcohol and five times for
polyurethane foam 17 .
The aim of this prospective study was to evaluate
the clinical outcome of first-line application of TNP for
DSWI as a standard of care. The results suggested that
TNP therapy is associated with low rates of therapy failure,
and reduction in short- and mid-term mortality. Uniform
treatment protocol allowed for equivalent outcomes to be
achieved among all surgeons at one unit.
Literature
1. Lepelletier D, Perron S, Bizouarn P, et al. Surgicalsite
infection after cardiac surgery: Incidence,
microbiology, and risk factors. Infect Control Hosp
Epidemiol 2005;26:466-72.
2. Schimmer C, Sommer P, Bensch M, Elert M, Leyh R.
Management of poststernotomy mediastinitis:
experience and results of different therapy modalities.
Thorac Cardiovasc Surg 2008;56:200-4.
3. Mangram AJ, Horan TC, Pearson ML, Silver LC,
Jarvis WR. The hospital infection control practise
advisory committee. Guidelines for prevention of
surgical site infection. Infect Control Hosp Epidemiol
2002;20:247-78.
4. Raja SG, Berg GA. Should vacuum-assisted closure
therapy be routinely used for management of deep
sternal wound infection after cardiac surgery.
Interactive Cardiovasc Thorac Surg 2007;6:523–27.
5. Sjögren J, Gustafsson R, Nilsson J, Malmsjö M,
Ingemansson R. Clinical outcome after poststernotomy
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6. Simek M, Hajek R, Fluger I, et al. Topical negative
pressure versus conventional treatment of deep
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Figure 2. Kaplan-Meier survival analysis
7. De Feo M, Vicchio M, Nappi G, Contrufo M. Role of
Vacuum in Meticillin-Resistant Deep Sternal Wound
Infection. Asian Cardiovasc Thorac Ann
2010;18:360-363.
8. Petzina R, Hoffman J, Navasardyan A, Mamsjoe S,
Ubenhaun A, Hetzer R. Negative pressure wound
therapy for post-sternotomy mediastinitis reduces
mortality rate and sternal re-infection rate compared
to conventional treatment. Eur J Cadiothoracic Surg
2010;38:110-113
9. Mokhari A, Sjögren J, Nilsson J, Gustafsson R,
Malmsjö M, Ingemansson R. The cost of vacuumassisted
closure in treatment of deep sternal wound
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10. Banwell PE, Musgrave M. Topical negative pressure
therapy: mechanisms and indications. Int Wound J
2004;1:95-106.
11. Ubbink DT, Westerbos SJ, Nelson EA, Vermeulen H.
A systematic review of topical negative pressure
therapy for acute and chronic wounds. Brit J Surg
2008;95:685-692.
12. Argenta LC, Morykvas MJ, Marks MW, DeFranzo AJ,
Molnar JA, David LR. Vacuum-assisted closure: State
of art. Plast Reconstruct Surg 2006;117: 127-42S.
Science, Practice and Education
CONCLUSION
TNP therapy is a safe method for the treatment of DSWI
following cardiac surgery. The first-line application protocol
of TNP demonstrated a low risk of failure and a
significant decrease in short- and mid-term mortality was
observed.
Implications for Clinical Practice
n TNP is an effective treatment for deep sternal infection
after cardiac surgery
n TNP is associated with low failure rate, and reduced
short- and mid-term mortality
n TNP should be widely accepted as a first-line treatment
strategy for DSWI in cardiac surgery
Further Research
n Multi-centre prospective randomized trials comparing
TNP with the conventional therapy need to be
undertaken
n Influences of individual wound-healing risk factors
and microbiological agents on the effectiveness of
TNP therapy need to be examined m
13. Petzina R, Gustafsson L, Mokhtari A, Ingemansson
R, Malmsjö M. Effect of vacuum-assisted closure on
blood flow in the peristernal thoracic wall after
internal mammary artery harvesting. Eur J Cardiothorac
Surg 2006;30:85-9.
14. Mouës CM, Vos MC, van den Bemd GJ, Stijnen T,
Hovius SE. Bacterial load in relation to vacuumassisted
closure wound therapy: a prospective
randomized trial. Wound Repair Regen 2004;12:11-
7.
15. Mouës CM, van Toorenenbergen AW, Heule F, Hop
WC, Hovius SE. The role of topical negative pressure
in wound repair: expression of biochemical markers
in wound fluid during wound healing. Wound Repair
Regen 2008;6:488-94.
16. Timmers MS, Steenvoorde P, Bernards AT, van Dissel
JT, Jukema GN. Negative pressure wound treatment
with polyvinyl alcohol foam and polyhexanide
antiseptic solution instillation in posttraumatic
osteomyelitis.Wound Repair Regen. 2009;17:278-
86.
17. Timmers MS, Le Cessie S, Banwell P, Jukema GN:
The effects of varying degrees of pressure delivered
by negative pressure wound therapy on skin/tissue
perfusion. Ann Plast Surg 2005:55:665-671.
EWMA Journal 2011 vol 11 no 2 41

Phytoceuticals Ltd. | 8008 Zurich | Switzerland
SIMPLE.
NATURAL.
EFFECTIVE.
WWW.1WOUND.INFO

Wounds Research for Patient Benefit:
A five year programme
of research in wound care
BACKGROUND
The Wounds Research for Patient Benefit
(WRPB) programme commenced in 2008
and will receive £1.75 million of funding from
the Programme Grants for Applied Research
funding stream of the National Institute for
Health Research (NIHR), over five years. The
research programme is a multidisciplinary collaboration
between NHS Leeds Community
Healthcare and the University of York. The
large and diverse population of Leeds offers an
ideal laboratory for research, ensuring the delivery
of useful and valid information regarding
complex wound care and the University of
York is home to the Wounds Research Group
which has an international reputation for its
expertise in a range of research methodologies
applied to wound care.
The WRPB programme is specifically focused
on researching complex wounds which
we define as wounds which involve superficial,
partial or full thickness skin loss and which are
healing by secondary intention. They are wounds
with an underlying cause or which occur in patients
where underlying disease may impact upon
healing e.g. pressure ulcers, leg ulcers and dehisced
surgical wounds. Currently good information
regarding the nature, treatment, costs and
outcomes for people with complex wounds
is very limited and this research programme
will plug some of these knowledge gaps, reduce
clinical uncertainty and enable decision
makers to prioritise future research and areas
for service development. We wanted to take
this opportunity to provide an overview of the
work that is being carried out as part of this
programme and to invite you to share your
clinical uncertainties with us.
The research programme is split into three
distinct, but integrated workstreams which we
will describe in turn.
WORKSTREAM 1:
Data capture and epidemiology
Workstream 1 is focused on collecting high quality
information about complex wounds and their
care. There is a real lack of basic, yet important,
information about the treatment of complex wounds
in the UK; a fact we have confirmed in a recently
completed literature review of wound prevalence
surveys/audits. Whilst we included fifty studies in
the review, problems of study design meant that
many of these studies were at high risk of bias and
likely to under- or over-estimate wound prevalence.
These biases result in large differences in the published
estimates of complex wound prevalence. Our
literature review helped inform the design of a new
large and comprehensive survey of people with complex
wounds in Leeds. The survey took place over
a two-week period in March 2011 and included all
settings in which people with complex wounds are
treated including health clinics for people with no
fixed abode and prisons. This comprehensive data
collection and the inclusion of hard-to-reach groups
such as IV drug users mean that we are confident
in the results and the estimate of wound prevalence
this study will bring. This survey also recorded who
is delivering health care, how often and what treatments
are being provided so we will have important
new insights into the impact of wounds on all health
care services. Data are currently being analysed and
will be published late 2011.
�
Scientific Communication
Karen Lamb 1
Nikki Stubbs 1
Jo Dumville 2
Nicky Cullum 2
Dr Susan O’Meara 2
1 NHS Leeds Community
Healthcare,
St. Marys Hospital,
Leeds, LS12 3QE
2 Department of Health
Sciences,
University of York, York,
YO10 5DD
Conflict of interest: None
EWMA Journal 2011 vol 11 no 2 43

Scientific Communication
Finally, within this workstream we are exploring whether
we can routinely collect high quality data about people
with complex wounds, for use in both service planning and
research. Such a system, a type of register, would record
the number of patients affected; the ongoing impact of
wounds on quality of life; actual treatments received and
healing rates achieved. Additionally, such a system could
facilitate on-going assessment of costs and benefits, as well
as monitoring the diffusion of new-to-market medical devices
into practice. Such data will contribute to health
technology assessment via the tentative application of advance
methodologies that may generate information on
the clinical and cost effectiveness of wound treatments.
This work is on-going and more information about this
and all aspects of workstream 1 can be found at: www.
york.ac.uk/healthsciences/wounds-patientbenefit/wone/
WORKSTREAM 2:
Understanding what matters most to patients, carers
and health professionals in complex wound care
Workstream two acknowledges that those researching
and delivering wound care should fully understand what
outcomes matters most to patients and carers. Wound
healing is frequently reported in trials, whilst some have
argued for alternative outcomes 1 , so we are asking patients
and clinicians. Other possible outcomes of interest could
include debridement, the number of dressing changes,
resource use, exudate, odour, pain, dressing comfort and
product durability. To find out we are undertaking indepth
interviews with patients, carers and healthcare staff
about the relative importance of different wound treat-
44
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ment outcomes to them. The study includes patients who
have leg ulcers, diabetic foot ulcers, pressure ulcers and
dehisced surgical wounds and the findings will provide
missing information for researchers and health care staff
on what matters most to different patients experiencing
wound care. Additionally, in collaboration with the James
Lind alliance (JLA) 2 , we are convening groups of patients,
carers and citizens who are interested in helping to set the
research agenda for the treatment specific wounds.
The JLA was established in 2004 to encourage patients,
carers and clinicians to work together to identify and
prioritise important healthcare uncertainties that can be
translated into research priorities. Where there is no clear
evidence about the effectiveness of treatments, clinicians
and patients are left with uncertainty and are reliant on the
opinions of health care professionals which can be flawed.
In our experience public involvement in, and awareness
of, wounds research is minimal. Given the lack of patient
involvement in research agenda setting and the limited evidence-base
informing clinical decisions in wound care 3-5 ,
the JLA is supporting the development of a partnership of
patients, carers and clinicians to identify research priorities
in the prevention and management of pressure ulcers. The
objective is to discover the research questions that matter
most to stakeholders. The initial meeting of the James
Lind Alliance Pressure Ulcer Partnership (JLAPUP) took
place in York in Spring 2011 and was participated in with
much enthusiasm by delegates. Further information on the
JLAPUP can be found at www.york.ac.uk/healthsciences/
wounds-patientbenefit/jla-pressureulcerpartnership/
EWMA Secretariat
Nordre Fasanvej 113,
2000 Frederiksberg,
Denmark
Tel: +45 7020 0305
Fax: +45 7020 0315
ewma@ewma.org
www.ewma.org
�
EWMA Journal 2011 vol 11 no 2

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Scientific Communication
WORKSTREAM 3:
Evidence synthesis
Workstream 3 brings together existing research to answer
questions about which wound treatments work best. In order
that our reviews tackle questions of high priority to the
NHS, we consulted with clinicians, including nurses and
podiatrists and compiled a list of 27 potential questions
which can be viewed on our website (www.york.ac.uk/
healthsciences/wounds-patientbenefit/wthree ). Questions
included: What is the relationship between debridement and
healing in foot ulcers and other complex/chronic wounds? and
What is the best way to diagnose osteomyelitis?
For each topic we have scoped the literature in order to
identify existing summaries of research and we have noted
those topics that seem ‘ripe’ for further investigation. It
is important to note that this list is not closed and we
welcome further suggestions from readers of this journal
(please submit suggestions via our Programme website or
by contacting Susan O’Meara, susan.omeara@york.ac.uk).
The main focus here is clinical effectiveness questions (i.e.,
those that explore how well an intervention works) or what
the most accurate method of diagnosis is.
Our consultation with clinicians has resulted in us initiating
a new review on dressings for healing diabetic foot
ulcers where we are using a more sophisticated method
of evidence synthesis (mixed treatment comparison) to
make the most of existing published data. 6-8 We are also
working on updating existing Cochrane reviews in wound
care. We have completed one update (Antibiotics and antiseptics
for venous leg ulcers 9 ) and another (Compression
for venous leg ulcers) is underway. We also have a new
review in progress which explores the influence of the type
of research funding on the quality of wound treatment
trials. Additional new reviews and review updates will be
undertaken as the research programme progresses. A further
component of this Workstream will investigate how
we might best present the results of evidence synthesis,
including quantitative information and uncertainty, to
make them most useful for health professionals.
46
CONCLUSIONS
Good clinical management of complex wounds promotes
positive outcomes and reduces wound recurrence. The lack
of good quality research evidence for wound treatments
should concern us all — only approximately 10% of recommendations
in National institute of Health and Clinical
Excellence and the Royal Collage of Nursing wound
care guidelines are supported by Level 1 evidence. The
Wound Research for Patient Benefit research programme
is encouraging the production of more relevant and better
quality research evidence on the effectiveness and costeffectiveness
of wound prevention and treatment. This
evidence has the potential to improve the quality of care,
patient outcomes and reduce costs. If you wish to contribute
to discussion on treatment uncertainties or have any
other wound care-related research questions please contact
us via our website: www.york.ac.uk/healthsciences/
wounds-patientbenefit/research-question/ m
Disclaimer
All authors receive funding from the National Institute for
Health Research (NIHR) under its Programme Grants for
Applied Research funding scheme (RP-PG-0407-10428).
The views expressed in this review are those of the author(s)
and not necessarily those of the NHS, the NIHR or the
Department of Health.
References
1. Gottrup F. Debridement: another evidence problem in wound healing. Wound Repair
and Regeneration 2009; 17:294-95.
2. The James Lind Alliance. www.lindalliance.org/ Accessed 19th April 2011
3. NICE (2005) The management of pressure ulcers in primary and secondary care: A
Clinical Practice Guideline. Available at http://guidance.nice.org.uk/CG29/Guidance/
pdf/English . (Accessed 06/01/2010).
4. NPUAP-EPUAP Guidelines for Pressure Ulcer Prevention and Treatment (2009).
Available at www.npuap.org (accessed 20 April 2011).
5. Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon PA (2008) Treatment of
Pressure Ulcers: A Systematic Review JAMA 300 22: 2647-2662
6. Sutton A, Ades AE, Cooper N, Abrams K. Use of indirect and mixed treatment
comparisons for technology assessment. Pharmacoeconomics. 2008;26(9):753-67.
7. Lu G, Ades AE. Combination of direct and indirect evidence in mixed treatment
comparisons. Stat Med. 2004 Oct 30;23(20):3105-24
8. Glenny AM, Altman DG, Song F, Sakarovitch C, Deeks JJ, D’Amico R, Bradburn M,
Eastwood AJ; International Stroke Trial Collaborative Group. Indirect comparisonsof
competing interventions. Health Technol Assess. 2005 Jul;9(26):1-134, iii-iv.
9. O’Meara S, Al-Kurdi D, Ologun Y, Ovington LG. Antibiotics and antiseptics for venous
leg ulcers. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.:
CD003557. DOI: 10.1002/14651858.CD003557.pub3. Available from www.mrw.
interscience.wiley.com/cochrane/clsysrev/articles/CD003557/frame.html
Are you interested in submitting an article or paper for EWMA Journal?
Read our author guidelines at www.ewma.org/english/authorguide
EWMA Journal 2011 vol 11 no 2

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EWMA2011
Brussels · Belgium
www.ewma2011.org

EWMA Journal
Previous Issues
The EWMA Journals can be downloaded free of charge from www.ewma.org
48
Volume 1, no 1, January 2011
Who will take on
Ali Barutcu, Aydin O. Enver, Top Husamettin, Violeta Zatrigi
Diabetic foot ulcer pain: The hidden burden
Sarah E Bradbury, Patricia E Price
The reconstructive clockwork as a 21st century concept in
wound surgery
Karsten Knobloch, Peter M. Vogt
Anaemia in patients with chronic wounds
Lotte M. Vestergaard, Isa Jensen, Knud Yderstraede
A survey of the provision of education in wound management
to undergraduate nursing students
Zena Moore, Eric Clarke
Caring for Patients with Hard-to-Heal Wounds – Homecare
Nurses’ Narratives
Camilla Eskilsson
Volume 10, no 3, October 2010
Rationale for compression in leg ulcers with mixed, arterial and
venous aetiology
Hugo Partsch
Pressure ulcers in Belgian hospitals:
What do nurses know and how do they feel about prevention?
D. Beeckman, T. Defloor, L. Schoonhoven, K. Vanderwee
Nutritional Supplement is Associated with a Reduction in Healing
Time and Improvement of Fat Free Body Mass in Patients with
Diabetic Foot Ulcers
P. Tatti, A.E. Barber, P. di Mauro, L. Masselli
Chronic wounds, non-healing wounds or a possible alternative?
M. Briggs
Silver-impregnated dressings reduce wound closure time in
marsupialized pilonidal sinus
A. Koyuncu, H. Karadaˇ, A. Kurt, C. Aydin, O. Topcu
Venous leg ulcer patients with low ABPIs: How much pressure is
safe and tolerable?
J. Schuren, A. Vos, J.O. Allen,
Adherence to leg ulcer treatment: Changes associated with
a nursing intervention for community care settings
A. Van Hecke, M. Grypdonck, H. Beele, K. Vanderwee, T. Defloor
A Social Model for Lower Limb Care: The Lindsay Leg Club Model
M. Clark
Volume 10, no 2, May 2010
Hyperbaric Oxygen and Wounds: A tale of two enzymes
Thomas K. Hunt
HBOT in evidence-based wound healing
Maarten J. Lubbers
Comparative analysis of two types of gelatin microcarrier beads
Mohamed A Eldardiri et al.
Evidence based guidelines – how to channel relevant knowledge
into the hands of nurses and carers
Susan F. Jørgensen, Rie Nygaard
Lack of due diligence in the prophylaxis of pressure ulcers?
Dr. Beate Weber, Hans-Joachim Castrup
Six prevalence studies for pressure ulcers – Snapshots from
Danish Hospitals
Susan Bermark et al.
The Ransart Boot – An offloading device for every type of
Diabetic Foot Ulcer?
I.J.Dumont et al.
The Haitian Earthquake, January 2010
John M Macdonald
Volume 10, no 1, January 2010
Systematic review of Repositioning for
the Treatment of Pressure Ulcers
Zena Moore, Seamus Cowman
Analysis of wound care in nursing care homes as part of a
district-wide wound care audit
Peter Vowden, Kathryn Vowden
Chronic leg ulcers among the Icelandic population
Guðbjörg Pálsdóttir, Ásta Thoroddsen
Cross-sectional Survey of the Occurrence of Chronic Wounds
within Capital Region in Finland
Anita Mäkelä
The EWMA Teach the Teacher Project
Zena Moore
Other Journals
The section on International Journals is part of
EWMA’s attempt to exchange information on
wound healing in a broad perspective.
Italian
English
Finnish
Spanish
English
Acta Vulnologica, vol. 9, no 1, 2011
www.vulnologia.it
Daptomycin in the disinfection of complicated infected skin
ulcers of the lower limbs in geriatric patients and candidates
for reconstructive and/or regenerative surgery
Campitiello F., et al.
Foam adhesive dressing in the treatment of leg skin ulcers
Bucalossi M., et al.
Classification of peristomal skin changes:
multicentric observational study
Pisani F., et al.
Chronic infected skin lesions, micro-organisms
and bacterial resistance
Nebbioso G., et al.
Chronic skin ulcers in elderly patients: What are the outcomes?
Peruzza S., et al.
Advances in Skin & Woundcare, vol. 24, no 5, 2011
www.aswcjournal.com
A Morphological and Biochemical Analysis Comparative
Study of Collagen Products
Jeffrey C. Karr, Anna Rita Taddei, Simona Picchietti,
Gabriella Gambellini, Anna Maria Fausto, Franco Giorgi
A Case of Refractory Pyoderma Gangrenosum Treated with
a Combination of Apligraf and Systemic Immunosuppressive
Agents
Giacomo Duchini, Peter Itin, Andreas Arnold
Overcoming Lower-Extremity Wound Defects Using
Hydrocolloid Framing
Bruce M. Goldstein
Haava, no. 4, 2010
www.shhy.fi
Thema: Burns
Burns – Classification and treatment
Leena Berg
Operative treatment of burns
Heli Kukko
Electricity damages – What they are?
Leena Berg
Treatment of burns in history and today in HYK burn center
Sari Ilmarinen
Paavo’s 1. day in intensive care unit
Liisa Sikkilä
Helcos, vol. 22, no. 1, 2011
Pressure ulcers risk assessment scales for children
FP García-Fernandez, PL Pancorbo-Hidalgo,
JJ Soldevilla-Agreda
Measue healing in perssure ulcers. What do we have?
JC Restrepo-Medrano, J Verdú
The skin has a symbolic characteristic because
it is where the body and the spirit unite
JA Marina
Journal of Wound Care, vol. 20, no 4, 2011
www.journalofwoundcare.com
A clinical evaluation of the efficacy and safety of singlet
oxygen in cleansing and disinfecting stagnating wounds
G. Kammerlander, O. Assadian, T. Eberlein, P. Zweimeller,
S. Luchsinger, A. Andriessen
Role of oxygen in wound healing: A review of the evidence
A.C. Chambers, D.J. Leaper
Wound healing following combined radiation and cetuximab
therapy in head and neck cancer patients
N.R. Dean, L. Sweeny, P.M. Harari, J.A. Bonner, V. Jones,
L. Clemons, H. Geye, E.L. Rosenthal
EWMA Journal 2011 vol 11 no 2

English
English
English
Int. Journal of Lower Extremity Wounds vol. 10, no, 3, 2011
http://ijlew.sagepub.com
Diabetic Foot Amputations in Greece: Where Do We Go From
Here?
N. Papanas,M.K. Lazarides
Impact of Diabetic Foot Related Complications on the Health
Related Quality of Life
(HRQol) of Patients – A Regional Study in Spain
E. García-Morales, et al.
A Chronic, Destructive Mycetoma Infection in a Diabetic Foot in
Saudi Arabia
M. Malone, Al Gannass, F. Bowling
Review: The Diabetic Bone: A Cellular and Molecular Perspective
Robert Blakytny, Maximilian Spraul, Edward B. Jude
Seminar Review: A Review of the Basis of Surgical Treatment of
Diabetic Foot Infections
Javier Aragón-Sánchez
Lietuvos chirurgija, vol. 8, no 4, 2010
www.chirurgija.lt
Anal fistula plug for the treatment of complex fistula-in-ano
Palubinskas E, Samalavicius NE, Gudelyte L
Aloplasty in inguinal hernia repair in Lithuania
Narmontas D, Gradauskas A
Comparative analysis of chronic hemorrhoids surgical
treatment
Denisenko VL
Injection of methylene blue solution into the inferior
mesenteric artery of resected rectal specimens for rectal
cancer as a method to increase lymph node harvest
Klepsyte E, Samalavicius NE
Early results of incarcerated abdominal wall hernia repair
Stanaitis J, Saltanavicius R, Povilavicius J, Stasinskas A
Acute mesenteric ischemia following cardiac surgery
Andrejaitiene J
Incarcerated obturator hernia in 49 year old women:
A case report and review of the literature
Markevicius M, Lunevicius R, Markovas V, Stanaitis J
Phlebologie, no 2, 2011
www.schattauer.de
Outpatient varicose vein surgery
Neller
5-year results for 980 nm endovenous laser obliteration of
Beinvarizen. First comparisons with 1470 nm laser and laser
radial probe.
Pinzetta et al.
Caliber reduction of the great saphenous vein and the femoral
artery after CHIVA
Mendoza et al.
Analgesic effect of topical sevoflurane on venous leg ulcer with
intractable pain
Geronimo-Pardo et al.
The CALISTO-study
Bauersachs
Differential diagnoses of venous leg ulcers
Gallenkemper, Schimmelpfennig, Dissemond
EWMA values your opinion
and would like to invite all readers to
participate in shaping the organisation.
Please submit possible topics for
future conference sessions.
EWMA is also interested in receiving
book reviews, articles etc.
Please contact the Journal Secretariat at
ewma@ewma.org
English
German
Scandinavian
EWMA
Leczenie Ran, Issue 1, Volume 8, 2011
Osteoprotegerin – a new marker of atherosclerosis helpful in
selecting patients at amputation risk?
Aleksandra Rumianowska, et al.
The Doreen Norton scale for assessing risk of pressure ulcers
Katarzyna Cierzniakowska, et al.
Risk factors of lower limb amputation in diabetic foot
syndrome
Beata Mrozikiewicz-Rakowska, et al.
The efficacy of selected antiseptics against CNS isolated from
chronic wound infections examined in in vitro conditions and in
conditions imitating the wound environment
Marzenna Bartoszewicz, et al.
Wound Repair and Regeneration, vol. 19, no 3, 2011
www.wiley.com
Time course of the angiogenic response during normotrophic
and hypertrophic scar formation in humans
Willem M. van der Veer, et al.
Formulated collagen gel accelerates healing rate immediately
after application in patients with diabetic neuropathic foot
ulcers
Peter Blume, et al.
Development of the DESIGN-R with an observational study:
An absolute evaluation tool for monitoring pressure ulcer
wound healing
Yuko Matsui, et.al
How to assess scar hypertrophy – A comparison of subjective
scales and Spectrocutometry: A new objective method
Ilkka S. Kaartinen, et al.
A novel noncontact method to assess the biomechanical
properties of wound tissue
Clare Y. L. Chao, et al.
Evaluation of effects of nutrition intervention on healing of
pressure ulcers and nutritional states (randomized controlled
trial)
Takehiko Ohura, et al.
Wund Management, vol. 5, no 2, 2011
English abstracts are available from www.mhp-verlag.de
Classification of wounds at risk (W.A.R. score) and their antimicrobial
treatment with polihexanide ó A practice-oriented
expert recommendation
J. Dissemond, O. Assadian, V. Gerber, A. Kingsley, A. Kramer,
D. J. Leaper, G. Mosti, A. Piatkowski, G. Riepe, A. Risse,
M. Romanelli, R. Strohal, J. Traber, A. Vasel-Biergans,T. Wild,
T. Eberlein
Electrotherapy of chronic wounds: Evidence of clinical
effectiveness and benefit
K. Herberger, T. Kornek, E. S. Debus, H. Diener, M. Augustin
Wounds (SÅR) vol. 19, no 1, 2011
www.saar.dk
Will systematic actions for improvement of wound bed
preparation, edema control and treatment of malnutrition lead
to a better wound healing? A review of 33 treatment cases
Arne Langøen, Tove Sandvoll Vee
Dressings: Super absorbents in the treatment of wounds
Anne Hindhede
Soap is not recommended in the treatment of wounds
Jette Skiveren, Britta ÿstergaard Melby, Lis Kirkedal Bunder,
Heidi Nordahl Larsen, Katja Safin Gudmundsen, Susan Bermark
Wound Management for Diabetic Patients: a Holistic Approach
Sanne Wichmann
EWMA Journal 2011 vol 11 no 2 49

Brigitte Crispin
President of AfiScep
and Befewo
Luc Gryson
President of C.N.C.
and Befewo
50
INTRODUCING
The Belgian Federation
The Belgian Federation
of Woundcare (BEFE-
WO) was established in
2004 as the umbrella organisation of two
major wound management associations in
Belgium. Belgium is a bilingual country
where both French and Flemish (Dutch) are
spoken. The two wound management associations
existing at that time were CNC Wound
Management Association and AFISCeP. An
outcome of this joint partnership was the Belgian
National Bilingual wound management
conference in 2006 in Brussels. The success
of this initiative has now resulted in an annual
BEFEWO conference with over 450 participants
each year. In 2011 the BEFEWO
conference will be held during the EWMA
conference at the SQUARE in Brussels. It is
a great privilege in 2011 for BEFEWO to host
EWMA’s conference in Brussels, the European
Capital, as it is also the fifth anniversary
of the Belgian Bilingual National Conference.
The organisations not only collaborate with
conferences but also in relation to liaising with
the Belgian Government. Here the organisations
undertake common initiatives and represent
each other as BEFEWO members in
diverse international organisations as EWMA,
ECET, EPUAP and ETRS. BEFEWO is a
joint organisation representing the strength,
multilingualism and unity of Belgium and
its wound management associations. Besides
the interest in wound management both organisations
have a specific interest in ostomy
care which is closely combined with wound
management in Belgium.
CNC Wound Management
Association
(CNC WMA)
Fifteen years ago CNC
WMA was established as a charity. The founding
members of CNC WMA were Jan Vandeputte and
Luc Gryson, both masters in Nursing Sciences and
still active in wound management. Today CNC
WMA has a board of managers, a council and
an executive to fulfil all activities now delivered
by CNC WMA. CNC WMA started as a very
small specialised wound care nurses’ association
but gradually healthcare professionals of different
specialities also became interested in membership.
Nowadays the healthcare professionals offer a valuable
contribution in the society’s activities and
nurses of all specialities with an interest in wound
management are becoming members.
The main purpose of CNC WMA is to promote
education in wound care among doctors, nurses
and other health care professionals. To this end,
CNC WMA has a strong and firm collaboration
with several University colleges making it possible
to organise more than six basic wound management
courses and two postgraduate courses for
nurses each year. As a result of this CNC WMA
has contributed to the education of over 3,000
nurses in modern wound care.
In addition, CNC WMA, together with partners,
offers over 25 different educational specialised programs
in wound management for nurses and doctors
in Flanders. Since 1999 CNC WMA, together
with The HUB University College of Brussels,
has organised the post graduate course in wound
management. In 2004 the same collaboration was
set up with the KATHO University College. Another
joint activity with HUB University College
Brussels will be the master class being launched in
EWMA Journal 2011 vol 11 no 2

of Woundcare
April 2011. This is a new initiative on which
there hopefully will be a lot of focus in the future.
Since 2000 an annual Flemish wound symposium
has been organised and in 2008 the symposium
became the Flemish Wound Management
Conference. Held in Kortrijk with its mirror
symposium in Hasselt –Genk the conference
annually attracts over 700 doctors and nurses
to attend.
Besides education and promotion of wound
management, CNC WMA believes in collaboration
between organisations to promote wound
care issues. CNC WMA collaborates with
NVKVV (Nationaal Verbond van Katholieke
Vlaamse Verpleegkundigen) Flanders, a major
Nurses organisation, regarding a joint membership
at reduced annual fee opportunity; with
VLAS, the Flemish ostomy organisation, regarding
educational activities and also with a
steering committee of 21 local wound management
companies to establish better education
and awareness towards wound-care in Belgium.
In 2001, CNC WMA started a preliminary
UCM (University Conference Model) concept
at the EWMA conference for its postgraduate
students. Since then CNC WMA has been
proud to be able to send students to the conference
each year.
In 2011 the updated website, www.woundcare.
be, will be launched which is a reference for
Flemish students and nurses seeking comprehensive
and accessible information concerning
wound management. Together with the paper
version wondzorg.be this is the major reference
source for the Flemish nurses and doctors.
EWMA2011
25-27 May
Brussels · Belgium
EWMA
AFISCeP.be – Association
Francophone d’Infirmiers(ères)
en Stomathérapie,
Cicatrisation et Plaies Belgique
Nearly twenty years ago an association named ARIAS was
established. This association handled the distribution of information
regarding ostomised patients to nurses and attending
doctors etc. for the more professional treatment of ostomised
patients.
Five years later ABISCEP was established with the intention
to train stoma therapy nurses in Belgium. Over time, this
association expanded into wound care and healing.
In 2007, these two francophone associations joined together
under one name: AFISCeP.be.
This association is very active. It organizes an annual conference
and roundtable meeting. In addition, some members
are responsible for informing home care providers and future
nurses in schools. It participates in the INAMI (Institut National
Assurance Maladie Invalidité – National Institute for
Disability Health Insurance) work group and defends patients
for the reimbursement of equipment used in stoma care. The
association works for the recognition of stoma therapy nurses
and nurses specializing in wound care. In addition, AFISCeP.
be also organises supplementary training events for certified
stoma therapy nurses.
An additional project was a 900 hour stoma therapy and
wound care training course that was organised to meet the
Belgian legislation in the field. Our association works with
CNC WMA to organise the BEFEWO conference which
bring together the French and Flemish communities.
To support and complement its activities the AFISCeP.be
publishes a quality journal twice a year that is respected and
valued by all professionals. Its website, www.afiscep.be, also
keeps members up-to-date on the latest news in the field. These
projects all contribute to the dissemination of information and
training to maintain a high skill level of caregivers in patient
support and care. m
EWMA Journal 2011 vol 11 no 2 51

·PATIENT OUTCOME GROUP·
EUROPEAN · WOUND · MANAGEMENT· ASSOCI
Patricia Price
PhD, CHPsychol,
Chair of
the EWMA Patient
Outcome Group
Dean and Head of
School of Healthcare
Studies
52
EWMA
ATION
EWMA update
EWMA Patient Outcome Group
Patient Outcome Group (POG) is currently
working on disseminating the messages formulated
in the POG document “Outcomes
in controlled and comparative studies on non-healing
wounds – Recommendations to improve quality of
evidence in wound management”.
POG is currently initiating several projects to
meet the general objectives:
1. Identify barriers:
n With a starting point in the current debate
on evidence in wound healing and the Cochrane
levels of evidence, the group will define
the primary barriers (as experienced by
clinicians and companies) related to the creation
and implementation of evidence-based
guidelines in wound healing.
2. Propose guidelines for clinical
data collection:
n The objective will be to define how existing
guidelines for clinical trials (e.g. RCTs
or more “practical” studies (real life studies
etc.)) can be adapted to wound management,
by including, for example, other end
points such as number of dressing changes,
health economics, QOL, education of staff
and structure of treatment.
3. Participate in the public debate /
policy making:
n The working group should present a common
viewpoint on clinical trials of wound
management products in relation to the debate
on both national and European levels.
A primary goal will be to influence the decision
making processes concerning approval
and reimbursement of wound management
products. EWMA will act as shareholder and
work to influence the national agendas in
order to put chronic wounds on the agenda.
n A central European HTA unit is assumed to
be established. The working group should
approach involved institutions in order to
present the work and conclusions of the
group in relation to evidence in HTA of
wound management products.
4. Create and implement consensus:
n Other interested parties (clinicians, companies,
reimbursement authorities, European
collaborative groups and institutions) should
be involved in order to establish consensus
within the area. A pan-European consensus
with a national implementation strategy has
been proposed.
POG conducted a Health Economics Course in
Copenhagen which can be read about elsewhere
in this Journal edition. Furthermore, the group is
currently preparing EWMA Industry Course to
be held on October 13-14th, 2011 in Budapest.
The group is also working on translating the essential
document into German and French in
order to spread the messages of the work. Currently
there is a Polish translation of the document,
which is available on the website.
Furthermore, the group is continuing to disseminate
the messages of the POG document by
addressing relevant concerns to the authorities in
the EU and member states in order to enhance
research in wound care and, in turn, create a better
treatment of wounds for patients all over Europe.
POG currently consists of:
Clinical:
Patricia Price, Chair (EWMA Council)
Jan Apelqvist (EWMA Council)
Finn Gottrup
Luc Gryson (EWMA Council)
Hugo Partsch
Robert Strohal (EWMA Council)
Industry:
Abbott Nutrition, B Braun, Convatec
Lohmann and Rauscher, Mölnlycke
For further information about EWMA Patient
Outcome Group, please visit ewma.org/english/
patient-outcome-group.html. Any questions concerning
Patient Outcome Group or the document
can be sent to EWMA Secretariat:
ewma@ewma.org m
EWMA Journal 2011 vol 11 no 2

Bionect ® Start
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faster heal!
Hyaluronic acid + Collagenase
BIONECT ® START is the bioactive solution
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Fidia’s collagenase, developed from
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wound environment and promotes
wound healing.

·PATIENT OUTCOME GROUP·
EUROPEAN · WOUND · MANAGEMENT· ASSOCI
ATION
EWMA INDUSTRY COURSES
13 -14 October 2011 · Budapest, Hungary
EWMA and the EWMA Patient Outcome Group introduce
the EWMA Industry Courses 2011.
The two courses are held over two days. One course focuses on
Evidence and Outcome and the other focuses on Health Economics.
The courses are primarily targeted at industry representatives,
but will also be of relevance to clinicians and others interested
in research and wound care economics.
13-14 October 2011
Generating Evidence in wound care
The course aims to give an introduction to clinical
trials in addition to the use of alternative end points
and outcomes in wound care. The course will provide
the participants with an understanding of what the
essential considerations and limitations are when
conducting research in wound care. Furthermore,
the participants will be provided with the necessary
information on how to conduct evidence based
research in wound care, taking the right measures
into consideration.
13-14 October 2011
Health Economics
This course aims to give an introduction to health
economics and evaluation as applied to wound
care. The course will provide the participants with
an understanding of how to evaluate the economic
benefits and challenges in prevention, diagnosis
and treatment. The participants will aquire basic
knowledge about economic analysis and training in
the tools of how to conduct economic evaluation.
The entry point is wound care, but the principles
are general.
For more information and registration please visit www.ewma.org/industrycourse

1st EWMA Health Economics Course
organised by the EWMA Patient Outcome Group
Facilitated by the internationally recognised
health economist John Posnett, the course
took place on 7-8 April 2011 in Copenhagen,
Denmark. The course was considered a pilot
for future similar courses with the next EWMA
Health Economics Course scheduled to take place
in Budapest on 13-14 October 2011.
The main objective of the course is to provide
training in health economics principles and
health economics analysis applied in wound care.
Participants are, among other things, introduced
to methods of how to elaborate and present arguments
on modern wound care products and the
organization of the treatment.
Learning objectives:
n To understand why an economic approach
to wound care is essential for both clinicians
and for the industry in the face of demographic
and technological trends;
n To understand how to demonstrate the
value of good treatment to senior managers
and other decision-makers, through audit
and other forms of observational research;
n To learn how to undertake or to interpret
the results of economic evaluations of
healthcare interventions.
Feedback and evaluation by course participants
The course attracted a mixed group of 30 participants
including international clinicians (physicians
and nurses), industry representatives and
EWMA Council members.
The following feedback is based on the responses
to an online evaluation questionnaire after the
course.
n 100% of the respondents expressed that the
course had met their expectations
n 100% of the respondents would recommend
the course to others.
n The social & networking aspects of participation
in the course were considered relevant
by all participants.
Background for the course and content
The EWMA Health Economics Course is a new
activity under the auspices of the EWMA Patient
Outcome Group (POG).
Meeting the objectives of EWMA POG, focus
on the need for knowledge about health economics
is increasing due to the changing demographics
and the continuing rise in the cost of health care
provision across Europe.
Health Economics is based on the concept
of scarcity, which suggests that there will never
be sufficient resources to meet the ever growing
need for health care by society. Thus, the underlying
premise is that the delivery of health care
should be founded on equity and efficiency; in
other words, making the best use of the resources
available (Phillips 2005).
EWMA wants to contribute to maintain focus on
the severe costs of wounds, thereby strengthening
the importance of wound care investments in
order to improve conditions for patients.
Further information about the next EWMA
Health Economy Course is available at:
www.ewma.org/industrycourse m
References
Phillips CJ (2005); Introduction; In Health Economics an Introduction for
Health Professionals (Phillips CJ ed.). British Medical Journal, Oxford, pp.
1-17.
Participants at the 1st EWMA Health Economics Course
in Copenhagen, April 2011.
EWMA
·PATIENT OUTCOME GROUP·
EUROPEAN · WOUND · MANAGEMENT· ASSOCI
ATION
Finn Gottrup
MD, DMSci
Professor of Surgery,
Former Chair of the EWMA
Patient Outcome Group
EWMA Journal 2011 vol 11 no 2 55

Hans Lundgren
Chair of the Eucomed
Advanced Wound Care
Sector Group
Patient Safety in the EU
By Zena Moore
I am happy to announce that EWMA
and the Eucomed based Advanced
Wound Care Sector Group (AWCS)
got a unique opportunity to be heard
prior the European Commission
Questionnaire to be send to all
Member States on Patient safety.
EWMA recommended together with
AWCS to the European Commission
that the following questions be incorporated
into the planned questionnaire
sent to member states.
56
Advanced
Wound Care Sector (AWCS)
Status Report
INTRODUCTION
The Eucomed AWCS group (www.eucomed.org)
was founded back in June 2007, and since then we
have had sixteen regular meetings. At present there
are eight companies in the group: B. Braun, Covidien,
ConvaTec, KCI, Mölnlycke Health Care,
Paul Hartmann, Smith & Nephew and 3M. In
addition, we also work in active partnership with
EWMA and Policy Action.
The purpose of this paper is to give an update
of our activities during the latest nine months,
from July 2010 to March 2011.
STATUS REPORT
Questionnaire about Patient Safety
sent out by the European Commission
to the Member States
With short notice, the AWCS group together with
EWMA was offered an opportunity to contribute
to a questionnaire that was being finalized by the
European Commission. This questionnaire, about
Patient Safety, was sent by the Commission to
the Member States by the end of March 2011.
The purpose of the exercise was to support the
European Commission in its review of the Council
Recommendation on Patient Safety (approved
June 2009). Our recommendation ended up in
EC Patient Safety Questionnaire
to Member States
The European Wound Management Association
(EWMA) and the Eucomed based Advanced
Wound Care Sector Group (AWCS) recommends
to the European Commission that the following
questions be incorporated into the planned
questionnaire sent to member states on Patient
safety.
1. Does the member state have in place guidelines
for diagnosis and effective treatment
of chronic/non-healing wounds?
Yes/no: ___
If yes, which programmes/policies/performance
para meters/quality measures are in place (homecare
or hospital targeted)? ___
nine distinct questions. Please see below for a list
of the questions posed. While it is not certain
that any questions submitted to the EC will in
fact be used in the questionnaire for the Member
States, the engagement alerts the Commission
to AWCS/EWMA’s interest in this dossier and
provides an avenue for future discussions with
the Commission – particularly regarding the use
of adequate wound care treatment to increase the
patient safety.
Eucomed AWCS
(Advanced Wound Care Sector)
The 16th Eucomed AWCS meeting took place
on 17-18 January 2011 at the B.Braun offices in
Paris, commensurate with the CPC. This was a
1½ day session with a goal & strategy meeting
followed by a normal meeting. The budget for the
year 2011 will be €30,000 which means €5,000
per company. The priorities of the group during
2011 will be:
n The European Commission AHAIP (Active
and Healthy Ageing Innovation Partnership),
knowing that diabetes is a chronic disease
with a hidden potential for DFUs and
thus a public health issue.
2. Do national targets exist for the prevention of wounds?
Yes/no: ___ • Pressure ulcers (tic x): __
• Leg ulcers: __ • Diabetic foot ulcers: __
• Healthcare associated infections in wounds: __
If yes, which programmes/policies/performance parameters/
quality measures are in place? (please elaborate below):
homecare or hospital targeted? ___
3. Do national targets exist for education and training
specific to wound care and prevention with regards
to adverse events, hereunder health care workers
specialisation in wound prevention and treatment?
Yes/no: ___ • Pressure ulcers (tic x): __
• Leg ulcers: __ • Diabetic foot ulcers: __
• Healthcare associated infections in wounds: __
If yes, which programmes/policies/performance parameters/
quality measures are in place? (please elaborate below):
homecare or hospital targeted? ___
EWMA Journal 2011 vol 11 no 2

n “Patient Safety”, continue to be involved with this
campaign through the risk of wound infections.
n “Continue the dialogue with national associations:
SDMA and ABHI (UK), BvMed (Germany),
Appamed (France), Assobiomedica (Italy) and
Fenin (Spain).
n Work in active partnership with Policy Action and
EWMA including the POG (Patient Outcomes
Group).
Wound Care contribution to the European Commission
campaign on ‘Active and Healthy Ageing’
Based on the EU2020 strategy for a smart, sustainable
and inclusive Europe, the European Commission (EC) in
October 2010 launched the Innovation Union Strategy. A
key pillar of that strategy is the pilot Innovation Partnership
on Active and Healthy Ageing. Eucomed answered to
the EU public consultation by providing four proposals to
the ‘Active and Healthy Ageing Partnership’ which revolve
around:
1. Developing procurement systems that focus on procuring
innovation. The UK and Sweden have developed
new approaches around this objective.
2. Facilitating research on the parameters that influence
national and local procurement decisions.
3. Reducing risks and hospitalisation of people with
cardiac problems. Raising awareness of the benefits
of remote monitoring of cardiac devices and develop
appropriate funding schemes.
4. Avoiding hospitalisation of people through effective
community care in the areas of stoma, wounds and
incontinence, conditions that have high prevalence
in people with any chronic conditions.
Today, the medical technology industry is faced with a
number of innovation hurdles which limit its potential
4. Do national targets exist for the multidisciplinary approach
to treatment and prevention of wounds?
Yes/no: ___ • Pressure ulcers (tic x): __
• Leg ulcers: __ • Diabetic foot ulcers: __
• Healthcare associated infections in wounds: __
If yes, which programmes/policies/performance parameters/quality
measures are in place? (please elaborate below): homecare or hospital
targeted? ___
5. Does national targets/procedures/regulation exist for
avoiding delay for patient treatment, hereunder organisation
of treatments (e.g. clinical pathways)?
Yes/no: ___ • Pressure ulcers (tic x): __
• Leg ulcers: __ • Diabetic foot ulcers: __
• Healthcare associated infections in wounds: __
If yes, which programmes/policies/performance parameters/quality
measures are in place? (please elaborate below): homecare or hospital
targeted? ___
to contribute to a smart, sustainable and inclusive economy,
ranging from limited end-user involvement, through
patchy adoption of novel technology, to a lack of harmonisation
in funding and reimbursement practices across
the member states. Eucomed is of the opinion that, in
partnership with other stakeholders, these innovation barriers
can be overcome, thus contributing to the three goals
the EC has set out for itself with this pilot partnership:
1. Enabling EU citizens to lead healthy, active and independent
lives while ageing;
2. Improving the sustainability and efficiency of social
and health care systems;
3. Boosting and improving the competitiveness of
the markets for innovative products and services,
responding to the ageing challenge at both EU and
global level, thus creating new opportunities for
businesses.
Eucomed MedTech Forum
On 12-14 October 2010, the annual Eucomed MedTech
Forum, organized under the patronage of Mr John Dalli,
EU Health Commissionaire, took place in Brussels. The
theme this year was “Europe 2020: Driving the innovation
agenda” and the highlight of the event was a CEO Summit.
The forum attracted over 350 leaders from policy and
scientific communities, along with the medical technology
industry. The mission of Eucomed (www.eucomed.
be) is to improve patient and clinician access to modern,
innovative and reliable medical technology.
The CEO Summit welcomed representatives from
both global and European industry leaders. In the first
panel we saw:
n Alex Gorski, Worldwide Chairman, Medical Devices
and Diagnostics Group, Johnson & Johnson
n Pierre Guyot, CEO Mölnlycke Health Care
�
n Srini Seshadri, President, Smiths Medical
EWMA
6. Does national standardisation exist for wound care,
hereunder national quality measures?
Yes/no: ___ • Pressure ulcers (tic x): __
• Leg ulcers: __ • Diabetic foot ulcers: __
• Healthcare associated infections in wounds: __
If yes, which programmes/policies/performance parameters/quality
measures are in place? (please elaborate below): homecare or
hospital targeted? ___
7a. If data collection on wounds are in place which is collected
and how is it reported?
• Incidence: __ • Prevalence: __ • Costs: __
If yes, how is it reported? Which measures for exhaustive collection
has been taken and how is it reported (e.g. clinical and/or research
based collection, national/local)?
�
EWMA Journal 2011 vol 11 no 2 57

EWMA
The speakers gave a description of what they think the
world will look like in five years and what it means for
the industry and for its customers in terms of change. In
his speech, Pierre Guyot started with an introduction of
Mölnlycke Health Care, then continued with describing
today’s challenges for the medtech industry in general, and
finally asked how Europe can help to create a more innovative
industry climate. The focal point of his presentation
was on the coming shift from hospital care to community
& homecare, and how government policy could help or
hinder this change.
The complete presentations from the MedTech Forum
can be found here, (www.eucomed.be/Home/portal/mtf2010_presentations/mtf_presentations.aspx)
IHE Forum (Swedish Institute of Health Economics)
This year’s annual conference took place in Lund on 2-3
September 2010, with the theme “How can we promote
innovations in healthcare? ”. There were many interesting
speeches from different angles including “Innovation –
what is that and how does it influence economic growth?”,
“Purchase of innovations”, and “Value Based Pricing – To
set the price on value or cost?”
Everyone agreed that innovations are necessary for society
to grow and develop, but still public payers (government,
county councils and municipalities) are reluctant to buy
new innovative products. The reason for that is the care
providers’ conservative idea of seeing their main goal as
the care of patients and not as bringing in innovations in
the healthcare process. Therefore we must apply a holistic
view of health and social care. In the end it is all about
customer benefits, in terms of utility for the patients, caregivers
and relatives, but also in services and efficiency in
the process and organization around the patient. m
8. Do national targets exist for research support on chronic/
non-healing wounds?
Yes/no: ___ • Pressure ulcers (tic x): __
• Leg ulcers: __ • Diabetic foot ulcers: __
• Healthcare associated infections in wounds: __
If yes, which programmes/policies/performance parameters/quality
measures are in place? (please elaborate below): homecare or
hospital targeted? ___
9. Does national targets/procedures/regulation exist for patient
rights to choose between treatment regimes, hereunder
reimbursement of services (e.g. prevention tools)?
Yes/no: ___ • Pressure ulcers (tic x): __
• Leg ulcers: __ • Diabetic foot ulcers: __
• Healthcare associated infections in wounds: __
If yes, which programmes/policies/performance parameters/quality
measures are in place? (please elaborate below): homecare or
hospital targeted? ___
58
Management of
the Diabetic Foot
Theory & Practice
4 Day Course, 3 - 6 October 2011
Pisa, Italy
This 4 day theoretical course & practical
training gives participants a thorough introduction
to all aspects of diagnosis, management
and treatment of the diabetic foot.
Lectures will be combined with practical
sessions held in the afternoon at the diabetic
foot clinic at the Pisa University Hospital.
Lectures will be in agreement with the
International Consensus on the Diabetic Foot
& Practical Guideline on the Management
and Prevention on the Diabetic Foot.
· COURSE ENDORSED BY ·
EUROPEAN · WOUND · MANAGEMENT· ASSOCI
ATION
This course is endorsed by EWMA.
www.diabeticfootcourses.org
EWMA Journal 2011 vol 11 no 2

Finn Gottrup
MD, DMSci
Professor of Surgery,
Former Chair of the EWMA
Patient Outcome Group
60
EWMA Wound Surveys
Resource consumption for wound care
BACKGROUND
Research within wound care is fragmented and
it is difficult to find validated data on the prevalence
and costs of wounds. The EWMA Patient
Outcome Group has for some time been working
for creating better evidence in wound care and
spreading the understanding of the complex approach
to wound care research.
The purpose of the EWMA Wound Survey is to
uncover the true resource costs of wounds to hospital
and community care health care providers
in different countries in Europe. Uncovering the
prevalence of wounds, the hours and time consumption
of health care professionals, and the
costs of treatment materials and wound-related
hospitalisation in specific health care providers’
organisations, serves to raise awareness of the true
significance of good wound care.
Specifically the surveys will focus on:
1) The prevalence of all types of wounds, in
both hospitals and in municipalities/community
service.
2) The costs of wound treatment in hospitals
and in municipalities/community care.
3) Convey publications and discussion papers/
arguments that can serve as a political tool to
increase awareness among politicians of the
actual prevalence of wounds and to reveal
the actual resources being used to treat the
wounds.
METHODS
The studies are part of a EWMA project, which
will cover several European countries. The first
study using this methodology was done in Hull
in the UK, published in the International Wound
Journal, 20081 and this methodology has been
adapted for the EWMA studies.
The study is intended to be made as a “point
prevalence” study. For practical reasons, data will
1 ”Drew P, Posnett J, Rusling L. The Costs of wound Care for a local
population in England. International Wound Journal 2007; 4(2): 149-155
be was collected over 2 days in hospitals and over
1 week in communities. Data are collected by going
through all patient files in all hospital wards
and in all community nursing centres as well as
in all nursing homes.
The researchers all take an active role in gathering
the data and in obtaining approval for the
study with the hospital management and with the
community nursing service.
The data are collected for each patient are categorised
and represent some of the following:
n Number of wounds
n Condition of the wound
n Type of wound
n Place of origin
The nursing staff collecting the data will access
the wounds and record the time consumption for
each patient per dressing change, for travelling
time and for documentation. Combining the time
consumption with the average cost of a nursing
hour, and extrapolating the data to the entire
country, the total cost for the nursing time consumption
for wound treatment can be calculated.
Similarly, the total cost for dressings and
wound-related hospitalisation can be calculated,
and adding these two costs together a total cost
of wound care can be measured.
The data collected in a database from where
the statistical analysis is taken from and thus calculated
the costs of the wound treatment.
RESULTS
The results of the survey are presented in tables
with written analysis and the following is essential
to prospects of the idea behind the survey.
EWMA Journal 2011 vol 11 no 2

The prevalence of the wound collected in both hospital
and municipalities/community care is presented, hereunder
the following parameters are covered:
n No. of Citizens covered (population)
n Percentage of inhabitants
n No. of Patients with wound(s)
n Prevalence per 1000 population
n Percentage of hospital patients with wounds
n Calculated total no. of patients with wound(s)
The different types of wounds are presented:
n Acute/surgical wound
n Pressure Ulcers
n Leg Ulcers
n Diabetic Foot Ulcers
n Other
n Total no
Furthermore, the types of wounds are correlated with the
resource consumption of the treatment of the wound. The
results presented are:
n Nursing time (minutes) per dressing change
n Travelling time Documentation time (minutes)
n Total, cost of nursing time
n Total cost of dressings
n Total cost nursing time and dressings
n Total cost of wound-related hospitalisation
As a member of EWMA, you already receive
numerous bene� ts in terms of access to information
and advice on the latest trends in wound care
practice. We would like to offer you one more.
Journal of Wound Care is a leading monthly
international MEDLINE-listed wound care journal,
with a loyal global audience and contributors
from every continent. JWC provides a truly global
perspective on wound care, from the latest in
evidence-based practice to cutting-edge research
from the US, Europe and elsewhere.
SUBSCRIBE TODAY
and receive special rates online by visiting
www.journalofwoundcare.com/EWMA
EWMA
CONCLUSION
The purpose of the surveys is to present the costs in the
individual country of wound care. The results of the survey
will convey the ability to hospital and municipalities/
community care givers to view their actual cost. This will
facilitate a dialogue with policy makers and other administrators
and result in saved money and improvement of
the quality of life for the patients.
Currently the surveys of this kind have been conducted
in England and Denmark and the results are presently
being processed in Denmark. Further surveys are planned
in Germany, Italy and Portugal and later in France and
Spain. m
The Danish Wound Survey
Nina Bækmark, MSc
Finn Gottrup, Professor, MD, DMSci.
Eskild W. Henneberg, MD
John Posnett, BA (Hons), DPhil (Econ). Heron Health
Jan Sørensen, MD
Rikke Trangbæk, MSc
j o u rnal of w o u nd ca r e W C
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?
j o u rnal l of f w o u nd d ca r e W C
v o l u m e 1 9 . n u m b e r 1 2 . d e c e m b e r 2 0 1 0
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j o u rnal of w o u nd ca r e W C
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v o l u m e 1 9 . n u m b e r 1 1 . n o v e m b e r 2 0 1 0
Effect of elasticity on sub-bandage pressure in two bandaging systems: a RCT
Why do wound dressings have a potential analgesic effect?
Predicting which organisms might cause infection in a resource-poor setting
Potential effects of honey on angiogenesis: an animal study
A bizarre presentation of necrotising fasciitis Pilonidal in the cervicofacial sinus region disease: a review
Severe hidradenitis suppurativa: a case report
Psychological profile of patients with neglected malignant wounds
Marjolin’s ulcer in the natal cleft mimics anal canal carcinoma
Reconstruction of a chronic late post-nephrectomy wound
Clinical and cost effectiveness evaluation of low friction and shear garments
NPWT: a systematic review
International organisations update
Venous reflux in delayed leg ulcer healing
A review of pilonidal sinus disease: part one
Clinical report: a new negative pressure wound therapy system
COVER.indd 1 03/12/2010 12:25
Can thermography predict delayed healing in pressure ulcers?
C
Using electrical stimulation to treat scars
JWC_19_10_frontcover.indd 1 07/10/2010 16:18
VISIT NOW:
www.journalofwoundcare.com/EWMA

Hugo Partsch
ICC President
Finn Gottrup
Former chair of
the EWMA Patient
Outcome Group
AWA
Austrian Wound Association
www.a-w-a.at
No. of members: 240
President: Franz Trautinger
Activities:
– Annual Congress
– Foster education and
research in wound care
62
EWMA
National collaboration for
the Leg Ulcer & Compression
Seminars 2011
Together with the wound management
associations in the Slovak Republic,
Austria and Hungary, the International
Compression Club (ICC) and EWMA arrange a
sequence of 3 Leg Ulcer & Compression seminars
in Bratislava, Vienna and Budapest on the 10th,
11th and 13th of October 2011.
The national wound management associations
involved are the Austrian Wound Association
(AWA), the Slovak Wound Care Association
(SSOOR), the Hungarian Association for the
Improvement in Care of Chronic Wounds and
Incontinence (SEBINKO) and the Hungarian
Wound Care Society (MSKT).
The program draws on the existing ICC consensus
documents on compression therapy as well
as results and experiences gained through the implementation
of the EWMA Central & Eastern
European Leg Ulcer Project (LUP) carried out
by the wound associations and project teams in
Slovenia, Poland and the Czech Republic.
The overall objective of the Leg Ulcer & Compression
seminars is to discuss and plan for the
establishment of national consensus on prevention
and treatment of leg ulceration using compression
therapy. In each country the seminar program is
MSKT
Hungarian Wound Care Society
www.euuzlet.hu/mskt/
President: Dr. Hunyadi János
Activities:
– Annual congress every year
in October
– Publishes the journal Sebkezelés
Sebgyógyulás
– Aims at spreading of practical
and scientific knowledge regarding
wound healing between
MD’s and health care workers.
based on the current national situation with regards
to the treatment of leg ulceration.
Further information and preliminary programme
for the Leg Ulcer & Compression seminars
is available at www.ewma.org/icc-ewmaseminar/
The role of the national wound associations
In order to achieve the objectives of the Leg
Ulcer & Compression seminars a close collaboration
between the local wound associations, the
ICC and EWMA is essential.
Apart from chairing the Leg Ulcer & Compression
seminars together, the national associations
play a key role in facilitating the involvement
of national stakeholders in the seminars and the
follow-up activities which may prove to be the
most important result of the seminars.
In Hungary, the annual meetings of MSKT
and SEBINKO will take place in connection with
the Leg Ulcer & Compression seminars. The two
Hungarian associations will hold their meetings
with a joint exhibition on 12 October at the same
venue where the seminars will take place on 13
October.
For more information about the national
wound associations please see below. m
SEBINKO
Hungarian Association for the
Improvement in Care of Chronic
Wounds and Incontinence
www.sebinko.hu
No. of members: 198
President: Fokiné Karap Zsuzsanna
Activities:
– Annual congress every year
in October
– Publishes the SEBINKO Journal
twice a year
SSOOR
Slovak Wound Care Association
www.ssoor.sk
No. of members: 31
President: Jozefa Košková
Activities:
– Cooperation with teaching
institutions and wound care
specialists
– Review the wound situation
in Slovakia
EWMA Journal 2011 vol 11 no 2

BRATISLAVA 10 OCTOBER
VIENNA 11 OCTOBER
BUDAPEST 13 OCTOBER
For information about the programme,
registration etc. please visit the website
www.ewma.org/icc-ewma-seminar
The seminars will be held in local
languages and English with
simultaneous translation.
LEG ULCER &
COMPRESSION
SEMINARS 2011
SEMINARS 2011
COMPRESSION
LEG ULCER &
Organised by: EWMA & International Compression Club (ICC)

Corporate A
Abbott Nutrition
200 Abbott Park Road
Abbott Park
Illinois 60064
USA
Tel: +1 (614) 624-7485
Fax: +1 (614) 624-7899
www.abbottnutrition.com
ConvaTec Europe
Harrington House
Milton Road, Ickenham, Uxbridge
UB10 8PU
United Kingdom
Tel: +44 0 1895 62 8300
Fax: +44 0 1895 62 8362
www.convatec.com
Covidien
154, Fareham Road
PO13 0AS Gosport
United Kingdom
Tel: +44 1329 224479
Fax: +44 1329 224107
www.covidien.com
Paul Hartmann AG
Paul-Hartmann-Strasse
D-89522 Heidenheim
Germany
Tel: +49 0 7321 / 36-0
Fax: +49 0 7321 / 36-3636
www.hartmann.info
64
Corporate Sponsor Contact Data
KCI Europe Holding B.V.
Parktoren, 6th floor
van Heuven Goedhartlaan 11
1181 LE Amstelveen
The Netherlands.
Tel: +31 0 20 426 0000
Fax: +31 0 20 426 0097
www.kci-medical.com
Lohmann & Rauscher
P.O. BOX 23 43 Neuwied
D-56513
Germany
Tel: +49 0 2634 99-6205
Fax: +49 0 2634 99-1205
www.lohmann-rauscher.com
Mölnlycke Health Care Ab
Box 13080
402 52 Göteborg,
Sweden
Tel: +46 31 722 30 00
Fax: +46 31 722 34 01
www.molnlycke.com
Ferris Mfg. Corp.
16W300 83rd Street
Burr Ridge,
Illinois 60527-5848 U.S.A.
Tel: +1 (630) 887-9797
Toll-Free: +1 (630) 800 765-9636
Fax: +1 (630) 887-1008
www.PolyMem.eu
Wound Management
Smith & Nephew Medical Ltd
101 Hessle Road
Hull, HU3 2BN
United Kingdom
Tel: +44 (0) 1482 225181
Fax: +44 (0) 1482 328326
www.smith-nephew.com/wound
Sorbion AG
Im Suedfeld 11
48308 Senden
Germany
Tel.: +49 (0) 2536 34 400 400
Fax: +49 (0) 2536 34 400 410
www.sorbion.com
Systagenix Wound Management
Gargrave
North Yorkshire
BD23 3RX
United Kingdom
Tel: +44 1756 747200
Fax: +44 1756 747590
www.systagenix.com
Use
the EWMA Journal
to profile your company
Deadline for advertising
in the October 2011 issue is
1 September 2011
EWMA Journal 2011 vol 11 no 2

Corporate B
3M Health Care
Morley Street, Loughborough
LE11 1EP Leicestershire
United Kingdom
Tel: +44 1509 260 869
Fax: +44 1 509 613326
www.mmm.com
Advanced BioHealing, Inc.
10933 N. Torrey Pines Road,
Suite 200
La Jolla, CA 92037
Tel: 858.754.3705
Fax: 858.754.3710
www.AdvancedBioHealing.com
AOTI Ltd.
Qualtech House
Parkmore Business Park West
Galway, Ireland
Tel: +353 91 660 310
Fax: +353 1 684 9936
www.aotinc.net
ArjoHuntleigh
310-312 Dallow Road
Luton
LU1 1TD
United Kingdom
Tel: +44 1582 413104
Fax: +44 1582 745778
www.ArjoHuntleigh.com
B. Braun Medical
204 avenue du Maréchal Juin
92107 Boulogne Billancourt
France
Tel: +33 1 41 10 75 66
Fax: +33 1 41 10 75 69
www.bbraun.com
BSN medical GmbH
Quickbornstrasse 24
20253 Hamburg
Tel: +49 40/4909-909
Fax: +49 40/4909-6666
www.bsnmedical.com
www.cutimed.com
Curea Medical GmbH
Münsterstraße 61-65
48565 Steinfurt
Germany
Tel: +49 36071 9009500
Fax: +49 36071 9009599
www.curea-medical.de
Flen pharma NV
Blauwesteenstraat 87
2550 Kontich
Belgium
Tel.: +32 3 825 70 63
Fax: +32 3 226 46 58
www.flenpharma.com
HILL-ROM
83, Boulevard du Montparnasse
75006 Paris
France
Tel: +33 (0) 1 53 63 53 73
Fax: +33 (0) 1 53 63 53 70
www.hill-rom.com
Life Wave
9 Hashiloach St.
P.O.B. 7242
Petach Tikvah 49514
Israel
Tel: +972-3-6095630
Fax: +972-3-6095640
www.life-wave.com
Nutricia Advanced Medical
Nutrition
Schiphol Boulevard 105
1118 BG Schiphol Airport
The Netherlands
www.nutricia.com
Organogenesis Switzerland
GmbH
Baarerstrasse 2
CH-6304 Zug
Switzerland
Tel: +41 41 727 67 89
www.organogenesis.com
Phytoceuticals
Zollikerstrasse 44
8008 Zurich
Switzerland
Tel: +41 58 800 58 58
www.1wound.info
EWMA
Argentum Medical LLC
Silver Antimicrobial Dressings
2571 Kaneville Court
Geneva, Illinois 60134
U.S.A.
Tel: +1 630-232-2507
Fax: +1 630-232-8005
www.silverlon.com
TEVA
5 Basel St.
Petach Tikva 49131
Israel
Tel: +972 8 932 4000
Fax: +972 8 932 4001
www.polyheal.co.il
Laboratoires Urgo
42 rue de Longvic
B.P. 157
21304 Chenôve
France
Tel: +33 3 80 54 50 00
Fax: +33 3 80 44 74 52
www.urgo.com
Welcare Industries SPA
Via dei Falegnami, 7
05010 Orvieto ( TR )
Italia
Tel: +39 0763-316353
Fax +39 0763-315210
www.welcaremedical.com
EWMA Journal 2011 vol 11 no 2 65

Organisations
Conference Calendar
Conferences Theme 2011 Days City Country
Annual Meeting of the Chronic Wounds Initiative (ICW) May 11-12 Bremen Germany
Annual Meeting of the Italian Nurses’ Cutaneous
Wounds Association (AISLeC)
21st Conference of the European Wound
Management Association
For web addresses please visit www.ewma.org
May 12-14 Bologna Italy
Common Voice – Common Rights May 25-27 Brussels Belgium
12th EFORT Congress Jun 1-4 Copenhagen Denmark
International Lymphoedema Framework Conference Towards Global implementation of Best Practice
– Opportunities and Challenges
Annual Meeting of German Society of Wound Healing
and Wound Treatment (DGfW)
Guidelines and quality standards of Fascinating
Biotechnology
14th Annual European Pressure Ulcer Meeting (EPUAP) Pressure Ulcer Research Achievements Translated
to Clinial Guidelines
30th Annual meeting of the European Bone
and Joint Infection Society
Annual meeting of Italian Association for the Study
of Cutaneous Ulcers (AIUC)
Biofilm and Health Economics in
Bone and Joint Infections
Jun 16-18 Toronto Canada
Jun 23-25 Hannover Germany
Aug
Sep
31-2 Oporto Portugal
Sep 15-17 Copenhagen Denmark
Sep 21-24 Ancona Italy
Pisa International Diabetic Foot Courses Oct 3-6 Pisa Italy
Bi-Annual Conference of the Wound Management
Association of Ireland
Oct 4-5 Galway Ireland
21st Annual European Tissue Repair Society Oct 5-7 Amsterdam Netherlands
EWMA Leg Ulcer and Compression Seminars Oct 10 Bratislava Slovakia
EWMA Leg Ulcer and Compression Seminars Oct 11 Vienna Austria
EWMA Leg Ulcer and Compression Seminars Oct 13 Budapest Hungary
4th Latin American Conference on Ulcers Oct 11-14 Rio de Janeiro Brazil
EWMA Master Course 2011 Is Oedema a Challenge in Wound Healing? Oct 13-14 Budapest Hungary
EWMA Industry Course 2011 Health Economics and Generating Evidence in
wound healing – clinical trials, alternative end
points and outcome
The Annual Fall Symposium on Advanced Wound care
(SAWC/WHS)
Oct 13-14 Budapest Hungary
Oct 13-15 Las Vegas USA
First International Pediatric Wound Care Symposium Oct 27-29 Rome Italy
Biannual meeting of the Woundcare Consultant Society Nov 22-23 Utrecht Netherlands
Annual Meeting of the Danish Wound Healing Society Nov 24-25 Kolding Denmark
16th National Conference of wound healing of CPC Jan 15-17 Paris France
10th National Australian Wound Management Association
Conference
2012
Mar 18-22 Sydney Australia
World Council of Enterostomal Therapists Conference Apr 19-23 Adelaide Australia
22nd Conference of the European Wound Management
Association
4th Congress of the World Union of Wound
Healing Societies
10th Scientific Meeting of Diabetic Foot Study Group
(DFSG)
66
May 23-25 Vienna Austria
Better care – Better Life Sep 7-12 Yokohama Japan
Sep 28-30 Potsdam Germany
EWMA Journal 2011 vol 11 no 2

FUNDRAISING CAMPAIGN
DURING THE EWMA BRUSSELS
CONFERENCE
Support the
WAWLC Podoconiosis
Eradication Project
in Ethiopia
AIMS OF THE WAWLC INITIATIVE:
n Training for 200 health care providers from
50 different hospitals, clinics and organisations
n Training to Health Extension Workers and local
non-medical community agents, especially women
n Provision of kit (education material and supplies)
for each participant to teach & treat patients
n Meeting with Ethiopian Ministry of Health in
August 2011
About Podoconiosis:
EWMA2011
25-27 May
Brussels · Belgium
Donations are welcomed at the EWMA Conference or at
http://wawlc.org/donation.html
n An endemic non-filarial elephantiasis,
commonly known as “Mossy Foot”.
n Affects > 1 million people in rural villages of Ethiopia.
n Listed by WHO as neglected tropical disease in 2010.
EWMA has since 2009 been part of
the WAWLC initiative.

22 nd Conference of the European Wound Management Association
22. Kongress der European Wound Management Association
EWMA 2012
23-25 May / Mai · 2012
WOUND HEALING – DIFFERENT PERSPECTIVES, ONE GOAL
WUNDHEILUNG – UNTERSCHIEDLICHE PERSPEKTIVEN, EIN ZIEL
ienna · Austria · Österreich
Organised by the European Wound Management Association
in cooperation with Die Österreichische Gesellschaft für
Wundbehandlung AWA (Austrian Wound Association)
Organisiert von: der Europäischen Wound Management Organisation
in Zusammenarbeit mit der Österreichische Gesellschaft für
Wundbehandlung, AWA
WWW.EWMA.ORG / EWMA2012
Bilingual:
English & German
Zweisprachig:
Englisch & Deutsch

ETRS
European
Tissue Repair
Society
Prof.dr. Gerrolt N. Jukema
Member of the
EWMA council,
board member of
the ETRS
Head Office : Riyadh
P.O Box 88552 Zip Code 11672
Kingdom of Saudi Arabia
Conference Report ETRS
EWMA Session, 20th Annual European
Tissue Repair Society Congress
Gent, 15-17 September 2010
Building on the long standing tradition and the relationship
between EWMA and the European Tissue
Repair Society, the interaction between both societies
has become even more intense during the last two
years. To continue their established relationship and
develop an even closer collaboration, a combined
session was scheduled during the 20th European
Tissue Repair Society Congress in Gent Belgium,
15-17 September 2010.
The local host of the meeting was the University of
Gent. The congress venue was an historical building
of the University (‘het Pand’) in the historical part of
the old city. The congress was attended by numerous
delegates from all over Europe and the United States
of America.
The topic of the combined EWMA / ETRS session was
‘Management of Acute Wounds.’ This session was
chaired by Finn Gottrup and Gerrolt Jukema
(a member of the EWMA council and a board member
of the ETRS).
Martin Koschnik highlighted in his presentation the
clinical relevance of antiseptic treatment of contaminated
and infected wounds with polyhexanid (PHMB)
solution.
16 Billions Approx.
Health Care Budget for the year 2011
An invitation to expand and invest in the biggest market among Gulf Region
Comate Ltd.,
is fully equipped with all necessary infrastructure to launch your product in Saudi Arabia.
Comate Ltd., is successfully representing many world renowned manufacturers.
Comate Ltd., is one of the leading companies in the field of
Medical Equipments, Wound Care Management & Dental materials in
Kingdom of Saudi Arabia
dealing with more than 100 potential customers in
Governmental & Private Sectors since 1989.
eyjarrar@comate.com
info@comate.com
Organisations
Gerrolt Jukema presented experimental clinical data
on infected trauma and orthopedic wounds. In addition,
new modalities for treatment of acute and
infected wounds were presented, including topical
negative wound therapy and the installation technique
with polyhexanid solution. Maggot therapy for
treatment of infected wounds, including data from
his experimental research, was also presented.
Finn Gottrup, as the current chair of the EWMA
Patient Outcome Group, shared his thoughts with
the audience about problems with evidence and
outcomes in wound healing studies. This session
was very well attended by congress participants and
featured an interactive discussion with the presenters,
reflecting the close relationship between the lab and
the clinician. Experimental research, based on clinical
problems studied in relation with patients’ carerelated
infections, can be a map guiding us to improved
and quality-related patient care.
A new combined, clinical-orientated session of both
societies is scheduled at the 21st Annual European
Tissue Repair Society Congress in Amsterdam,
The Netherlands, on October 5th-7th 2011. It is sure
to be both interesting and informative, and further
develop the close relations between these two wound
societies. m

Organisations
FWCS
Finnish Wound
Care Society
Anna Hjerppe
MD, Clinical teacher,
President
Department of Dermatology,
Tampere University Hospital,
Finland
www.suomenhaavan
hoitoyhdistys.fi
70
The 14th national wound healing
congress in Helsinki, Finland
In February this year, The Finnish Wound Care
Society organized its fourteenth, national, two day
congress on wound healing. The theme was:
Challenging and uncommon wounds
The theme was selected according to suggestions
from the field. Although these wounds are rare
and more seldom diagnosed than wounds such as
venous leg ulcers, they pose real challenges both
for the patient and for the health care system.
The theme was split into four main sessions.
The first session focused on malignant fungating
wounds. We had a leading Finnish dermatopathologist
to give an introductory lecture on the
different manifestations of skin cancers and cancer
metastasis to the skin. This was followed by
the different treatments and finally there was a
nurse-led lecture on the special wound care of
these extremely hard-to-heal or non-healing
wounds. Caring for a patient with a malignant
fungating wound is a challenge for any nurse or
doctor regardless of their years of experience in
wound care. The wounds cause huge distress for
the patient including pain, malodour, haemorrhage,
excessive exudate and infection, altered
body image and social isolation. Neglect may also
play its role with patients with advanced malignant
wounds. The patient and his family may fail to
seek medical help even if the wound is clearly visible.
The stories about the patients with malignant
fungating wounds were listened to attentively by
our audience. The informative lecture improved
both their knowledge and clinical understanding of
patients with malignant fungating wounds.
The second session focused on acute traumatic
wounds, especially on wounds in fragile elderly
skin or traumatic amputations. This lecture was
very appropriate as, at the same time as our conference,
the Fair Centre was also hosting a big
motorcycle event and many of those traumatic
amputations discussed seemed to have happened
to motorcyclists!
The third session about pressure ulcers (PU) was
held the next morning. This theme was chosen to
cover the new EPUAP and NPUAP Guidelines.
The session included the presentation of the new
Guidelines which the Finnish Wound Care Society
has had translated into Finnish to enable healthcare
professionals in Finland to fully understand
them; no more excuses for not preventing PUs!
Our fourth session concentrated on various types
of skin vasculitis, from the diagnosis to the treatment
and to local wound care.
Along with the main sessions, we had organised
practical workshops. The workshops focussed on
five common wound care themes:
debridement,
ABI- measuring,
compression therapy,
how to choose a right wound care product and
how to dress a difficult wound.
There were 96 participants at these workshops
(fully booked). And the participants had a chance
to learn “hands on” about the themes. Each workshop
included about 20 minutes introduction and
20 minutes of practical experience. Organizing
workshops requires strenuous efforts from our
organizing committee and is not financially
profitable, but we included them as they offer a
very beneficial way of learning.
The venue was in the Helsinki Fair Centre, in the
congress area. We have chosen this same venue
for four years now, because it is very easy to get
there from all over Finland. Also the personnel of
the Fair Centre are very professional and have
become almost “friends” to us which made the
hard work of organizing such an event easier for
us all.
On the first night of the congress we always have
a ‘get together’ evening party which also takes
place in the Fair Centre. The event is free of
charge and has a free buffet for participants. This
year’s theme was “TexMex” and featured not only
a buffet of food chosen to go with the theme, but
also some Tequila girls who danced and served
tequila for those who wanted to enjoy tequila
slammers; some participants had quite a headache
the next morning!
EWMA Journal 2011 vol 11 no 2

The objective of the evening party is to make
social contacts with other delegates and to meet
friends. The company members can also attend,
so it is also a good marketing possibility for
them. The party has always been very successful
and popular with the participants; this year we
had there almost 300 partygoers!
Over all we had around 650 participants at this
year’s congress. This was only about 100 fewer
than the year before, so our fears about the
theme were unnecessary. We had a marketing
area of 280m 2 for wound care companies and
37 companies attended. We are very strict
about what kinds of companies are allowed to
participate; only those companies that are genuinely
involved in wound care are welcomed.
This is because we want to preserve our status
as professionals. We also reward our lecturers
well for presenting the lectures; that way we can
ensure very high standard specialist lectures and
we can be sure the knowledge is always up to
date and evidence based.
In all, our congress was, once again, a very
successful event: the lectures were brilliant and
kept to schedule, the food was good, the exhibition
looked very impressive and the feedback
that we had was mainly positive. Next year is
our 15th national congress. The planning and
organizing has already started, the theme has
been chosen and marketing has begun.
The congress will be built around the theme of
acute wounds, so that it can serve as many
healthcare professionals as possible. This theme
was last presented six years ago and the event
was the biggest success we’ve ever had. That
time there were over 1100 participants and we
are hoping to have the same amount of participants
next year or even more; that will be a
really huge challenge for us! However, with a
good program, top lecturers and the good reputation
that we have gained over the years, the
challenge will not be an impossible one! m
THE EWMA
UNIVERSITY CONFERENCE
MODEL (UCM)
in Brussels
Since 2007, EWMA has successfully offered students
of wound management from institutes of higher
education across Europe the opportunity to take part
of academic studies whilst participating in the EWMA
Conference. In 2011 it is expected that students from
the institutes listed below will participate in the
EWMA UCM in Brussels.
The opportunity of participating in the EWMA UCM
is available to all teaching institutions with wound
management courses for health professionals.
EWMA strongly encourages teaching institutions and
students from all countries to benefit from the
possibilities of international networking and access to
lectures by many of the most experienced wound
management experts in the world.
Yours sincerely
Zena Moore,
Chair of the EWMA Education Committee, EWMA President
Participating institutions:
Haute École de Santé
Geneva, Switzerland
HUB Brussels
Belgium
KATHO university
college Roeselare
Belgium
Escola Superior de Enfermagem de Lisboa
Portugal
University of Hertfordshire
United Kingdom
Universidade Católica Portuguesa
Porto, Portugal
For further information about the EWMA UCM, please visit
the Education section of the EWMA website www.ewma.org
or contact the EWMA Secretariat at ewma@ewma.org
EWMA Journal 2011 vol 11 no 2 71
EWMA2011
25-27 May
Brussels · Belgium

Organisations
Rytis Rimdeika
Member of EWMA Council,
President of LWMA
Wound Treatment Organisation
established in Ukraine
On November 25-26th, 2010, in Kiev, the capital
of Ukraine, the conference “Wounds, Wound
Infections and Wound Closure” was organised by
the newly established Ukrainian Wound Treatment
Organization (UWTO).
This association is the first in the Ukraine that
focuses on wound treatment. The instigators of
UWTO have worked tremendously hard establishing
local sections in 15 regions of the Ukraine.
In the beginning the Ukrainian association was
mainly based on the initiative of doctors from various
specialties but there is a clear determination
for the association to become open to healthcare
professionals from multiple disciplines.
UWTO has a very strong council of well-known
Ukrainian physicians who have been elected to the
main positions. The council is represented by
Professor B. M. Datsenko as President, and
Professors E.J. Fistal, G. P. Kozynets and
T. Tamm as vice presidents.
During the process of establishment, several consultations
took place with EWMA Council and
EWMA Secretariat. The close co-operation with
EWMA is due to the fact that EWMA supports
local initiatives of establishment of national wound
management societies in countries across Eastern
Europe.
To date Ukrainian delegates have visited the
annual EWMA conference in Geneva and have
also participated in national meetings in Lithuania
and Belarus. The exchange of experiences with
neighbouring countries regarding the establishment
of their own associations greatly helped the
Ukrainian founders during the organising process
Chairing persons at the opening ceremony, from the left
UWTO President Prof. B. M. Datsenko,
chairman of the organizing committee Prof. G. P. Kozynets, and
EWMA representative Prof. R. Rimdeika
72
for UWTO. More information about UWTO can be
found on their web-site www.uwto.org.ua.
The conference “Wounds, Wound Infections and
Wound Closure” was organised in the Academy
for Postgraduate Studies of Ukraine. The procedure
of registration was finalised in the late
autumn after a long arrangement process.
The conference program included three thematic
sessions: Wound Care and Debridement, Surgical
Wound Reconstruction, and Modern Trends in
Management of Wound and Wound Infections.
EWMA was represented by the Council Member
Rytis Rimdeika, who had the privilege of opening
the conference with an introductory presentation
on EWMA.
The conference attracted more than 200 participants
from various regions of the Ukraine, and
neighbouring Belarus and Russia. Participants
from numerous regions of the Ukraine presented
papers and case reports from their clinical practices.
In addition, round table discussions on diabetic
foot issues were held by prominent lecturers from
the Ukraine. The conference also featured separate
poster sessions which were held in the exhibition
area.
During the conference there were exhibitions of
wound dressings, wound care equipment, medical
devices and pharmaceutical products. Representatives
of well-known international medical companies
as well as local manufacturers participated
actively in the exhibition and also organised concurrent
sessions and workshops. The conference
was followed by a welcome party for all participants.
m
The Exhibition
EWMA Journal 2011 vol 11 no 2

EUROPEAN · WOUND · MANAGEMENT· ASSOCI
· EWMA MASTER COURSE·
ATION
EWMA MASTER COURSE
Advanced theoretical and practical sessions
related to oedema and wound healing.
13-14 October 2011 · Budapest, Hungary
IS OEDEMA
A CHALLENGE IN
WOUND HEALING?
Through a mixture of lectures, workshops and interactive sessions the course
will bridge theory and practice, addressing a broad range of topics including:
n Oedema as a problem in different types of wounds and
what impact it has
n The pathophysiology of oedema
n Psycho-social impact of oedema
n Methods for diagnosing different types of oedema
n Prevention and management
n Development of evidence based outcome measurement
of oedema in wound healing
n Infection
n Associated skin complications
Credits for Continuing Medical Education (CME)
will be awarded by the European Union of Medical Specialists.
For more information about the programme, registration etc.
please visit
www.ewma.org/woundcourse

74
Cooperating Organisations
Danish Wound
Healing Society
AFIScep.be
Francophone Nurses’ Association in Stoma
Therapy, Wound Healing and Wounds
www.afiscep.be
AISLeC
Italian Nurses’ Association
for the Study of Cutaneous Wounds
www.aislec.it
AIUC
Italian Association for the study
of Cutaneous Ulcers
www.aiuc.it
APTFeridas
Portuguese Association
for the Treatment of Wounds
www.aptferidas.com
AWA
Austrian Wound Association
www.a-w-a.at
BEFEWO
Belgian Federation of Woundcare
www.befewo.org
BWA
Bulgarian Wound Association
www.woundbulgaria.org
CNC
Clinical Nursing Consulting – Wondzorg
www.wondzorg.be
CSLR
Czech Wound Management Society
www.cslr.cz
CWA
Croatian Wound Association
www.huzr.hr
DGfW
German Wound Healing Society
www.dgfw.de
DSFS
Danish Wound Healing Society
www.saar.dk
FWCS
Finnish Wound Care Society
www.suomenhaavanhoitoyhdistys.fi
GAIF
Associated Group of Research in Wounds
www.gaif.net
GNEAUPP
National Advisory Group for the Study of
Pressure Ulcers and Chronic Wounds
www.gneaupp.org
ICW
Chronic Wounds Initiative
www.ic-wunden.de
LBAA
Latvian Wound Treating Organisation
LUF
The Leg Ulcer Forum
www.legulcerforum.org
LWMA
Lithuanian Wound
Management Association
www.lzga.lt
MASC
Maltese Association of Skin and Wound Care
www.mwcf.madv.org.mt/
MSKT
Hungarian Wound Care Society
www.euuzlet.hu/mskt/
MWMA
Macedonian Wound
Management Association
NATVNS
National Association of Tissue Viability
Nurses, Scotland
NIFS
Norwegian Wound Healing Association
www.nifs-saar.no
NOVW
Dutch Organisation of
Wound Care Nurses
www.novw.org
PWMA
Polish Wound Management Association
www.ptlr.pl
ROWMA
Romanian Wound Management
Association
www.artmp.ro
EWMA Journal 2011 vol 11 no 2

SAfW
Swiss Association for Wound Care
(German section)
www.safw.ch
SAfW
Swiss Association for Wound Care
(French section)
www.safw-romande.ch
SAWMA
Serbian Advanced Wound Management
Association
www.serbiawound.org
SEBINKO
Hungarian Association for the
Improvement in Care of Chronic Wounds and
Incontinentia
www.sebinko.hu
SFFPC
The French and Francophone
Society of Wounds and Wound Healing
www.sffpc.org
SSiS
Swedish Wound Care Nurses Association
www.sarsjukskoterskor.se
SSOOR
Slovak Wound Care Association
www.ssoor.sk
SUMS
Icelandic Wound Healing Society
www.sums-is.org
International Partner Organisations
AWMA
Australian Wound
Management Association
www.awma.com.au
AAWC
Association for the
Advancement of Wound Care
www.aawconline.org
Associated Organisations
Leg Club
Lindsay Leg Club Foundation
www.legclub.org
Debra International
www.debra-international.org
ILF
International Lymphoedema
Framework
www.lympho.org
LSN
The Lymphoedema
Support Network
www.lymphoedema.org/lsn
SWHS
Serbian Wound Healing Society
www.lecenjerana.com
SWHS
Swedish Wound Healing Society
www.sarlakning.se
TVS
Tissue Viability Society
www.tvs.org.uk
URuBiH
Association for Wound Management of
Bosnia and Herzegovina
www.urubih.ba
V&VN
Decubitus and Wound Consultants,
Netherlands
www.venvn.nl
WMAK
Wound Management Association of Kosova
WMAOI
Wound Management Association of Ireland
www.wmaoi.ie
WMAS
Wound Management Association Slovenia
www.dors.si
WMAT
Wound Management Association Turkey
www.yaradernegi.net
WMS (Belarus)
Wound Management Society
NZWCS
New Zealand Wound
Care Society
www.nzwcs.org.nz
Organisations
SOBENFeE
Brazilian Wound
Management Association
www.sobenfee.org.br
For more information about
EWMA’s Cooperating Organisations
please visit www.ewma.org
EWMA Journal 2011 vol 11 no 2 75

5 Editorial
Carol Dealey
Science, Practice and Education
7 The fight against biofilm infections:
Do we have the knowledge and means?
Klaus Kirketerp-Møller, Thomas Bjarnsholt,
Trine Rolighed Thomsen
10 Biofilms in wounds: An unsolved problem?
António Pedro Fonseca
25 Diabetic foot ulcer pain: The hidden burden
Sarah E Bradbury, Patricia E Price
38 Topical negative pressure in the treatment of
deep sternal infection following cardiac surgery:
Five year results of first-line application protocol
Martin Šimek
Scientific Communication
43 Wounds Research for Patient Benefit: A five
year programme of research in wound care
Karen Lamb, Nikki Stubbs, Jo Dumville, Nicky Cullum
EWMA
48 EWMA Journal Previous Issues and
Other Journals
50 Introducing the Belgian Federation
of Woundcare
Brigitte Crispin, Luc Gryson
52 EWMA Patient Outcome Group
Patricia Price
55 1st EWMA Health Economics Course organised
by the EWMA Patient Outcome Group
Finn Gottrup
56 Advanced Wound Care Sector (AWCS)
Status Report
Hans Lundgren
60 EWMA Wound Surveys – Resource consumption
for wound care
Finn Gottrup
62 National collaboration for the Leg Ulcer
& Compression Seminars 2011
Hugo Partsch, Finn Gottrup
64 EWMA Corporate Sponsors Contact Data
Organisations
66 Conference Calendar
69 Conference Report: EWMA Session, 20th Annual
European Tissue Repair Society Congress
Gerrolt N. Jukema
70 FWCS: The 14th national wound healing
congress in Helsinki, Finland
Anna Hjerppe
72 Wound Treatment Organisation established
in Ukraine
Rytis Rimdeika
74 EWMA Cooperating Organisations
75 International Partner Organisations
75 Associated Organisations