Diabetic Foot Ulcer (DFU) Biofilm Infection and Recurrence (DFU Biofilm)

  • End date
    Jun 30, 2024
  • participants needed
  • sponsor
    Indiana University
Updated on 11 April 2023
wound infection
wound care
diabetic foot
imaging techniques
foot ulcer
laser speckle contrast imaging


Diabetic foot ulcers (DFU) are one of the most common reasons for hospitalization of diabetic patients and frequently results in amputation of lower limbs. Of the one million people who undergo non-traumatic leg amputations annually worldwide, 75% are performed on people who have type 2 diabetes (T2DM). The risk of death at 10 years for a diabetic with DFU is twice as high as the risk for a patient without a DFU. The rate of amputation in patients with DFU is 38.4%4. Infection is a common (>50%) complication of DFU. Emerging evidence underscores the significant risk that biofilm infection poses to the non-healing DFU. Biofilms are estimated to account for 60% of chronic wound infections. In the biofilm form, bacteria are in a dormant metabolic state. Thus, standard clinical techniques like the colony forming unit (CFU) assay to detect infection may not detect biofilm infection. Thus, biofilm infection may be viewed as a silent maleficent threat in wound care.


In the current standard of care (SoC), wound closure is defined (FDA) by wound area re-epithelialization without drainage. The investigators' pre-clinical large animal work demonstrates that wounds with a history of biofilm infection may meet above criteria but the repaired wound-site skin is deficient in barrier function. This has led to the concept of functional wound closure wherein the current clinical definition of wound closure is supplemented with a functional parameter - restoration of skin barrier function as measured by low trans-epidermal water loss (TEWL).

This study rests on DFU-patient based findings from a NIDDK-DIACOMP funded pilot study (Sen/Gurtner) showing that closed DFU with deficient barrier function are more likely to recur. Biofilm infection as assessed through Scanning electron microscopy and wheat germ aggluttin assay performed on debrided tissue causes faulty re-epithelialization, compromising skin barrier function at the closed wound site. Such defects are caused by biofilm-inducible miRs which silence junctional proteins necessary for skin barrier function. The IRB protocol associated with this study, rests on our novel patient-based observation that in wound-edge tissue catenin delta1/p120 catenin (CTNND1) is suppressed as measured through immunohistochemistry. CTNND1 is an essential regulator of E-cadherin stability which is regarded as a master organizer in epithelial phenotype and plays a critical role in maintaining the barrier integrity of skin. The investigators' prior study identified miR-9 is a biofilm induced microRNA that targets adherens junction protein E-cadherin. The investigators propose that miR-9 can target CTNND1. The validation of miR targeting will be performed quantitative real time PCR, Western blot analyses, Argonaute 2 pull down assay and on bead assay. Thus this proposal, fully based on the study of DFU patients, seeks to conduct a fully powered clinical study testing whether DFU with a history of biofilm infection closes with deficient barrier function (Aim 2). Aim 3 tests whether such functionally deficient wound closure, manifested as high TEWL, is associated with greater wound recurrence. Per FDA, the significance of association studies is heightened by support of a well-founded biological rationale provided by mechanistic studies. This proposal rests on such mechanisms that have been reported by us in pre-clinical large animal studies.

A chronic hyperglycemic diabetes increases the risk of developing Alzheimer's disease (AD) and vascular dementia (VaD), both in general and elderly population. With the age-related changes of the skin, there is an increased risk of adverse skin barrier function that is key to wound healing. Other age-related skin conditions, such as reduced water and altered lipid content, and lower production of sebum and natural moisturizing factors of the stratum corneum (SC) may also cause dry skin and itching. These conditions together with reduced immune responses, cause aging skin to be more susceptible to infections4. In light of these facts, there is paucity in studies that investigate the mechanism of how compromised skin barrier function plays a role in wound healing outcomes among Alzheimer's Disease and Related Dementias (AD/ADRD) patients.

The primary parent study will address molecular mechanisms implicated in biofilm-induced loss of skin epithelial barrier integrity in DFU patients. Within the parent study, an additional cohort of patients with a chronic wound that are diagnosed with Alzheimer's Disease and Related Dementias (AD/ADRD) will be studied to better understand the similarities and differences in molecular mechanisms and wound healing trajectory between this group and the parent cohort.

Condition Wound Infection, Wound Heal, Foot Ulcer, Ulcer Foot, Diabetic Foot, Diabetic Foot Infection
Treatment Observation of wound infection and time to wound closure, Pericam PSI-NR Laser Speckle imaging
Clinical Study IdentifierNCT05172089
SponsorIndiana University
Last Modified on11 April 2023


Yes No Not Sure

Inclusion Criteria

Male or Female, Age ≥ 18 with a clinical diagnosis of Alzheimer's Disease or Related Dementias (AD/ADRD), or any similar cognitive impairment
An available Legally Authorized Representative (LAR), as needed, to provide consent
Willing to comply with protocol instructions, including all study visits and study activities
Clinically diagnosed with diabetes as defined by the American Diabetes Association
Chronic would defined as any ulcer that has been open for ≥ 30 days
Adequate arterial blood flow as evidenced by at least one of the following (for wounds below the knee)
TcOM >30 mmHg
Ankle-brachial index ≥0.7-1.20
Toe pressure > 30 mmHg
TBI > 0.6 mmHg
AIM 4 Exclusion

Exclusion Criteria

Wounds closed or to be surgically closed by flap or graft coverage
Subjects with marked immunodeficiency (HIV/AIDS, or on immunosuppressive medications
Diabetics with a hemoglobin A1c > 12 within 3 months prior to enrollment
TcOM < 30mmHg
Subject with autoimmune connective tissue disease
Ulcer size and location that does not allow the TEWL measurement per SOP
Pregnant women
Unable to comply with study procedures and/or complete study visits
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