Biofilm występuje w większości ran trudno gojących się i stanowi poważną barierę w leczeniu. Bakterie obecne w biofilmie są oporne na działania zwalczające. W eliminacji biofilmu dużą rolę odgrywa więc dokładne stosowanie się do zaleceń medycznych polegających na wielkokierunkowym działaniu i korzystaniu ze specjalistycznych produktów.
Biofilm to złożone skupisko jednego lub wielu gatunków drobnoustrojów pokryte zewnątrzkomórkową polimerową substancją (macierzą EPS). Biofilm powstaje w wyniku wielowarstwowego lub jednowarstwowego wzrostu drobnoustrojów, które układają się w uporządkowane i skomplikowane struktury. Bakterie wytwarzają macierz ochronną, którą przytwierdzają do żywej lub martwej powierzchni. Macierz ta stanowi fizyczną barierę, która skutecznie chroni mikroorganizmy przed działaniem antybiotyków, antyseptyków, a także układu immunologicznego gospodarza.
Jak tworzy się biofilm?
Biofilm występuje w 60-100 proc. przypadków ran przewlekłych. Bakterie tworzące biofilm są oporne na działania zwalczające – dezynfekcję, antybiotyki, środki antyseptyczne, a także na zmiany temperatury i pH. Tworzeniu się biofilmu sprzyja wilgotne środowisko ran przewlekłych, a w szczególności zła kontrola wysięku z dużą ilością substancji odżywczych.
Biofilm kształtuje się w przeciągu kilku minut, ale dojrzałość osiąga po około 48-72 godzinach. W pierwszym etapie dochodzi do adhezji komórek do podłoża, a bezpośrednio po kontakcie z powierzchnią drobnoustroje rozpoczynają tworzyć mikrokolonie. W kolejnych etapach bakterie kolonizują łożysko rany, przywierając do niego w sposób nieodwracalny. Po etapie adhezji rozpoczyna się namnażanie drobnoustrojów i ich różnicowanie. Gdy biofilm osiąga dojrzałość, zaczyna emitować bakterie planktoniczne, kolonizujące skórę i tkanki, oraz abiotyczne (nieożywione).
Jak biofilm wpływa na gojenie ran?
Obecność biofilmu w ranie wpływa na zaburzenia gojenia, a także negatywnie oddziałuje na procesy immunologiczne gospodarza, ziarninowanie i naskórkowanie. Biofilm przyczynia się również do powiększenia obszaru rany oraz powoduje hipoksję tkanek, co prowadzi do powstawania martwicy trudnej do usunięcia. Ponadto tkanki są niedożywione, ponieważ biofilm nie przepuszcza do rany związków odżywczych, a wykorzystuje je dla własnych potrzeb.
Biofilm jest również bardzo groźny dla zdrowia i życia człowieka i może powodować zakażenie ogólnoustrojowe, np. sepsę.
Jak zdiagnozować biofilm?
W diagnostyce biofilmu złoty standard stanowi biopsja tkanek i wykonanie posiewu ilościowego z bioptatu. Wykrycie struktur biofilmu w badaniu laboratoryjnym często jest jednak utrudnione, ponieważ bakterie ukrywają się w matrycy. Ponadto drobnoustroje w biofilmie są trudne do hodowania i sztucznego rozwoju. Stąd ogromne znaczenie ma również obserwacja pacjenta i ocena objawów infekcji.
Biofilm nie jest widoczny gołym okiem i nie manifestuje się klinicznymi objawami infekcji (zaczerwienienie, obrzęk, zwiększona temperatura w ranie). Na jego obecność w ranie najczęściej wskazuje brak efektów leczenia pomimo prawidłowo dobranego postępowania miejscowego, a także grudkowa, twarda i lśniąca powierzchnia rany, nawroty infekcji oraz infekcja trwająca powyżej 7 dni. W ranie objętej biofilmem pojawia się znaczny wysięk i nieprzyjemny zapach, a także szybkie powiększanie się powierzchni rany i martwica trudna do eradykacji.
Jak walczyć z biofilmem?
Biofilm skutecznie chroni bakterie przed działaniem substancji przeciwdrobnoustrojowych – antybiotyków, a czasem również antyseptyków – dlatego leczenie nie jest łatwym zadaniem.
Jednym z elementów walki z biofilmem jest jego fizyczne usunięcie z rany – poprzez zdrapanie lub opracowanie chirurgiczne. Równie istotne jest dokładne i regularne oczyszczanie rany. Biofilm może się jednak odnawiać, dlatego w ciągu 24 godzin od usunięcia biofilmu lub naruszenia jego struktur zalecane jest zastosowanie odpowiednich do stanu rany, nowoczesnych antyseptyków. W celu kontroli biofilmu można również stosować specjalistyczne opatrunki o właściwościach antybakteryjnych oraz środki przeciwbiofilmowe.
Antybiotykoterapia ogólnoustrojowa w celu zwalczenia biofilmu może zostać wdrożona po uzyskaniu wyników badań mikrobiologicznych wskazujących na obecność infekcji. W praktyce klinicznej zaleca się jednak wyższą dawkę leków niż w przypadku klasycznego zakażenia rany. Nieprawidłowo stosowane antybiotyki mogą natomiast przyczynić się do odnawiania się struktury biofilmu. Z kolei zbyt krótka antybiotykoterapia prowadzi jedynie do opóźnienia powstawania biofilmu o 1-2 tygodnie, ale nie stanowi formy leczenia oraz profilaktyki zakażeń. W praktyce klinicznej stanowczo odradza się stosowanie antybiotyków miejscowych, nie tylko w przypadku obecności biofilmu, ale także podczas zwykłego zakażenia rany. Antybiotyk nie przedostaje się przez wiele warstw biofilmu, a więc nie ma możliwości, by osiągnąć w ranie terapeutyczne stężenie leku.
Więcej tematów związanych z zakażeniami będzie poruszanych na konferencji II Forum Zakażeń, która odbędzie się w dniach 12-14 maja w Jachrance. Serdecznie zapraszamy do rejestracji!
Źródła:
K. Karolewska, U. Wójcik, B. Sadowska, B. Różalska, „Przegląd nowoczesnych technik obrazowych i analitycznych w badaniu cech biofilmu” w: „Forum Zakażeń” 2018;9(2), str. 63-71
E. Szkiler, „Charakterystyka, diagnoza i leczenie biofilmu. Przegląd piśmiennictwa” w: „Forum Leczenia Ran” 2021;2(4), str. 169-174
I. Strużycka, I. Stępień, „Biofilm – nowy sposób rozumienia mikrobiologii” w: „Nowa Stomatologia” 3/2009, str. 85-89
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