In response:

We appreciate the reviewer’s attention to our article and for acknowledging the validity of one of the key takeaways, misidentification of infection-related erythema on heavily pigmented skin. It is important to clarify that fluorescence imaging is intended to supplement rather than replace current standard of care (SoC).1 This assistive approach to chronic wound management has increased 12-week diabetic foot ulcer healing rates by two-fold in a randomized controlled trial.2 The greatest healing improvements were observed when fluorescence imaging (MolecuLight, Moleculight Inc) guided clinical decision making through targeted interventions, primarily expanding the scope of debridement to tissues that would not have otherwise been debrided based on SoC assessment.1 This positive impact is echoed in real-world studies.1–5 Kelso et al3 observed that pressure injuries assessed and treated using fluorescence imaging in long-term care/skilled nursing facilities healed 4.8 weeks (27%) faster, on average, and significantly more wounds (+71%) healed by 12 weeks in the fluorescence imaging cohort (38.5%) compared with SoC (22.5%). Price et al4 reported a 23% increase in 12-week foot ulcer healing rates (48% vs 39%) when fluorescence imaging was included in wound management versus SoC alone. Similarly, fluorescence imaging provides objective, supplementary data to support the appropriate and rational use of antibiotics when holistically indicated. We are not suggesting that antimicrobials be prescribed solely based on fluorescence imaging findings; as is the case with debridement, holistic clinical context is paramount. Several studies demonstrate the positive impacts of fluorescence imaging on antimicrobial stewardship when used in conjunction with SoC. Trafelet et al5 observed that wound care centers routinely using fluorescence imaging prescribed 44% fewer antibiotics. This, in parallel with a marked shift toward targeted and topical preparations, is in line with the tenants of antimicrobial stewardship. Similarly, Price et al4 reported a 49% decrease in antimicrobial dressing use and a 33% reduction in antibiotic prescriptions when fluorescence imaging was used to supplement diabetic ulcer management. Kelso et al3 observed superior healing outcomes despite using 49% less systemic antibiotic in the fluorescence imaging cohort compared with the SoC cohort for pressure injury management, again with an evident shift toward topical preparations. It is important to note that the reviewer’s comment on systemic antibiotics being inappropriate for treating biofilm-related colonization is subjective, and directly opposes published guidelines on biofilm-based wound care. Debridement provides a window of opportunity in which the biofilm defenses are temporarily interrupted, allowing for increased efficacy of topical and systemic management strategies, including antibiotics.6 The reviewer’s concerns about indiscriminate killing of all wound bacteria were also surprising, given the extensive published research demonstrating the healing benefits of serial wound debridements,7 historically performed in a manner that could not distinguish between commensal, pathogenic, planktonic bacteria, or biofilm. Charles A. Andersen, MD, MAPWCAMadigan Army Medical Center Joint Base Lewis-McChord, Tacoma, WashingtonGabriel Ayoola, PhDUniversity of Michigan, Ann Arbor, MichiganAlton R. Johnson, Jr, DPM, CWSPUniversity of Michigan Medical School, Ann Arbor, MichiganJonathan Johnson, MD, MBAComprehensive Wound Care Services and Capital Aesthetic & Laser Center, Washington, District of ColumbiaMartha R. Kelso, RN, HBOTWound Care Plus LLC, Blue Springs, MissouriThomas E. Serena, MD, MAPWCASerenaGroup Inc, Cambridge, MassachusettsAlisha Oropallo, MDHofstra University/Northwell Health, Hempstead, New York, and Comprehensive Wound Healing Center and Hyperbarics, Northwell Health, Lake Success, New York