An update on biofilms in acute and chronic wounds: Incidence, clinical evidence, diagnosis, prevention, and treatment.

Abstract

Pathogenic biofilms are a critical barrier to wound healing, driving infection persistence, delayed tissue repair, and antimicrobial resistance (AMR) and tolerance. This recognition has driven a paradigm shift from a traditional planktonic model of infection to a biofilm-mediated framework, where structured microbial communities are encased within a protective extracellular polymeric substance (EPS) matrix. These communities are highly prevalent in chronic wounds, with reported detection rates of 60%-100% across diabetic foot ulcers, venous leg ulcers, and pressure injuries. The establishment of biofilms fundamentally alters host-microbe interactions, promotes antimicrobial tolerance, and triggers therapeutic failure, prolonged inflammation, and wound chronicity. Despite their clinical relevance, management strategies remain limited. Crucially, a lack of rapid point-of-care diagnostics and standardized clinical endpoints hampers timely intervention. Conventional culture based methods frequently fail to detect sessile microbial populations, necessitating advanced techniques such as next-generation sequencing or confocal microscopy, which are largely unavailable in routine practice. A detailed understanding of the molecular and cellular mechanisms underpinning biofilm persistence is essential to translate knowledge into targeted clinical interventions. Effective management requires a biofilm centric, multimodal strategy that prioritizes regular mechanical debridement to disrupt the EPS matrix, supported by proactive exudate control and appropriate topical therapies. Looking forward, advances in diagnostic technologies, artificial intelligence (AI)-assisted analysis, and matrix disrupting or permeating agents offer significant potential. Furthermore, emerging biological therapies, including bacteriophages, promise to help transform wound management, reduce the burden of AMR, and potentially improve patient outcomes globally.