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We tested this hypothesis in a population of 117 older individuals with venous leg ulcers who were receiving standardised therapy, including frequent debridement. Debridement specimens were analysed for the amount of bacterial biomass by two independent methods: a microscopic approach that scored the relative size and number of bacterial aggregates, interpreted as a biofilm metric, and conventional enumeration by agar plating for viable bacteria. The plating protocol yielded three distinct values: the total viable bacterial count, bleach\u2010tolerant bacteria, and the log reduction in viable bacteria upon bleach treatment. Wound healing rates over an 8\u2010week observation period were calculated as the rate of decrease of the equivalent diameter of the wound. There was no statistically significant association between wound healing and the biofilm metric in any of the three analyses performed (<jats:italic>p<\/jats:italic>\u2009\u22650.15). In all three statistical tests, wound healing was associated with the log reduction caused by bleach treatment (<jats:italic>p<\/jats:italic>\u2009\u22640.004); wounds that harboured bacteria that were more bleach\u2010susceptible healed more slowly. A refinement of the model of chronic wound infection pathogenesis is proposed in which dormant bacteria constitute a persistent nidus and outgrowth of metabolically active cells impairs healing. This model constitutes a new hypothesis as metabolic activity was not directly measured in this investigation.<\/jats:p>","DOI":"10.1111\/wrr.13230","type":"journal-article","created":{"date-parts":[[2024,10,19]],"date-time":"2024-10-19T07:54:55Z","timestamp":1729324495000},"page":"858-871","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Association of biofilm and microbial metrics with healing rate in older adults with chronic venous leg ulcers"],"prefix":"10.1111","volume":"32","author":[{"given":"Philip S.","family":"Stewart","sequence":"first","affiliation":[{"name":"Center for Biofilm Engineering Montana State University  Bozeman Montana USA"},{"name":"Department of Chemical and Biological Engineering Montana State University  Bozeman Montana USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Junglyun","family":"Kim","sequence":"additional","affiliation":[{"name":"Chungnam National University 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