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    Clinical relevance of silver in wound care

    Silver has been used as a topical antimicrobial agent for hundreds of years in wound care 6 and there is consensus that topical silver treatment in combination with good wound bed preparation can help resolve wound infection 1,4,5 . Furthermore, silver dressings can be used as a barrier to microorganisms in wounds at risk of infection or re-infection, e.g. burns, surgical wounds, pressure ulcers near the anus, or wounds in patients who are immunocompromised, have poor circulation, or unstable diabetes 5.

    Appropriate use of silver

    It has been recommended to do a ‘2-week challenge’ to determine the clinical efficacy of silver dressings. Thereafter, the wound, the patient and the management approach should be reevaluated 5.If there is improvement in the wound, but continuing signs of infection, treatment with silver dressing can be continued with regular reviews. If the wound has improved and the signs and symptoms of wound infection are no longer present, the silver dressing can be discontinued. If there is no improvement after 2 weeks, the silver dressing should be discontinued and consideration given to changing to a different antimicrobial agent, using a systemic antibiotic and/or re-evaluate possible untreated comorbidities5.

    Reviews of the efficacy of silver in wound management

    Published reviews of the clinical efficacy of silver-containing topical wound treatments have yieldedheterogeneous results, which have created some confusion and debate. To understand these differences in outcomes, a scoping literature review was performed by Rodriguez-Arguello et al.(2018)7. It included recent research (until 2016) and closely examined the study details. Although there was some inconsistency, in the majority of controlled clinical studies, silver-containing dressings were indeed effective. Another recent literature review of clinical evidence for silver in wound care similarly found that silver-containing dressings are effective and can improve wound healing, as well as quality of life and cost-effectiveness of treatment8. It was concluded that the evidence base for silver in wound management is significantly better than perceived in the current scientific debate. Difficulties in interpreting and comparing studies arise mainly from some studies including a small number of patients and the use of a wide range of different inclusion criteria, study protocols and end points5 . Differences in products, interventions, study designs, and protocol shamper the ability to draw firm conclusions about the effectiveness across all silver-containing treatments7. A Cochrane review published in 2018 looks at dressings and topical agents for treating venous leg ulcers and concludes that silver dressings may increase the probability of venous legulcer healing compared with non adherent dressings9.

    Not all silver dressings are the same

    Clinical studies on Biatain® Silicone Ag and Biatain Ag have consistently shown positive clinical results in non-healing wounds with signs of infection10-14. In the Cochrane review, a subgroup analysis of silver dressings vs. foam comparators shows statistically significant benefit for silver dressings9. All studies included in this subgroup analysis are studies on Biatain Ag. The efficacy for Biatain Ag in the treatment of non-healing, venous leg ulcers was previously presented in a meta analysis and the health economic perspectives were subsequently analysed and published 16. These data will be presented in detail in a later chapter along with a new study on Biatain Silicone Ag for infected diabetic foot ulcers looking at both microbiological and clinical measures14 .

    Reference list

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    1. International Wound Infection Institute (IWII). Wound infection in clinical practice. Wounds International. 2016.

    2. Coloplast A/S, ReD associates. Data on file. 2014.

    3. Schultz G, Bjarnsholt T, James GA, Leaper DJ, McBain AJ, Malone M, et al. Consensus guidelines for the identification and treatment ofbiofilms in chronic nonhealing wounds. Wound Repair and Regeneration. 2017;25(5):744-57.

    4. World Union of Wound Healing Societies (WUWHS). Florence Congress, Position Document. Management of biofilm. 2016.

    5. Appropriate use of silver dressings in wounds. An expert working group consensus. International consensus. London; 2012.

    6. Lansdown AB. A review of the use of silver in wound care: facts and fallacies. British Journal of Nursing. 2004;13(6):s6-19.

    7. Rodriguez-Arguello J, Lienhard K, Patel P, Geransar R, Somayaji R, Parsons L, et al. A Scoping Review of the Use of Silver-impregnatedDressings for the Treatment of Chronic Wounds. Ostomy Wound Management. 2018;64(3):14-31.

    8. Dissemond J, Bottrich JG, Braunwarth H, Hilt J, Wilken P, Munter KC. Evidence for silver in wound care - meta-analysis of clinical studiesfrom 2000-2015. Journal of the German Society of Dermatology. 2017;15(5):524-35.

    9. Norman G, Westby MJ, Rithalia AD, Stubbs N, Soares MO, Dumville JC. Dressings and topical agents for treating venous leg ulcers.Cochrane Database of Systematic Reviews. 2018(6):1-289.

    10. Münter KC, Beele H, Russell L, Crespi A, Grochenig E, Basse P, et al. Effect of a sustained silver-releasing dressing on ulcers with delayedhealing: the CONTOP study. Journal of wound care. 2006;15(5):199-206.

    11. Jørgensen B, Price P, Andersen KE, Gottrup F, Bech-Thomsen N, Scanlon E, et al. The silver-releasing foam dressing, Contreet Foam,promotes faster healing of critically colonised venous leg ulcers: a randomised, controlled trial. International wound journal. 2005;2(1):64-73.

    12. Rayman G, Rayman A, Baker NR, Jurgeviciene N, Dargis V, Sulcaite R, et al. Sustained silver-releasing dressing in the treatment of diabeticfoot ulcers British Journal of Nursing. 2004;14(2);109-14.

    13. Humbert P, Zuccarelli F, Debure C, Vendeaud Busquet F, Bressieux J-M, Bedane C, et al. Leg Ulcers Presenting Local Signs of Infection:Interest of Biatain Argent Wound Dressing. Journal des Plaies et Cicatrisations. 2006;52(9):41-7.

    14. Lázaro-Martínez JL, Álvaro-Afonso FJ, García-Álvarez Y, García-Morales E, Sanz-Corbalán I, Molines-Barroso RJ. Clinical and microbiologicaleffectiveness of a hydropolymer alveolar dressing with ionic silver complex and silicone adhesive. Poster, EWMA(EPP021); 2018.

    15. Leaper D, Münter C, Meaume S, Scalise A, Mompó NB, Jakobsen BP, et al. The Use of Biatain Ag in Hard-to-Heal Venous Leg Ulcers:Meta-Analysis of Randomised Controlled Trials. PLoS ONE. 2013;8(7):e67083.

    16. Jemec GB, Kerihuel JC, Ousey K, Lauemoller SL, Leaper DJ. Cost-Effective Use of Silver Dressings for the Treatment of Hard-to-HealChronic Venous Leg Ulcers. Plos One. 2014;9(6):e100582.

    17. Mouës C, Heule F, Legerstee R, Hovius S. Five Millennia of Wound Care Products - What is New? A Literature Review. Ostomy WoundManagement. 2009;55(3):16-8.

    18. Sibbald R, Williamson D, Orsted H, Campbell K, Keast D, Krasner D, et al. Preparing the Wound Bed - Debridement, Bacterial Balance, andMoisture Balance. Ostomy Wound Management. 2000;46(11):14-35.

    19. Adderley UJ. Managing wound exudate and promoting healing. British Journal of Community Nursing. 2010;15(3):15-20.

    20. Christiansen C, Huniche GB, Allesen-Holm M. In vitro evaluation of a silver foam dressing with and without silicone adhesive againstbiofilms and a broad range of microorganisms. Poster, EWMA(EPP025); 2018.

    21. Lansdown AB. Silver in health care: antimicrobial effects and safety in use. Current Problems in Dermatology. 2006;33:17-34.

    22. Percival SL, Thomas J, Linton S, Okel T, Corum L, Slone W. The antimicrobial efficacy of silver on antibiotic-resistant bacteria isolated fromburn wounds. International wound journal. 2012;9(5):488-93.

    23. Böttrich JG, Brill FHH, Dissemond J, Steinmann J, Münter KC, Schümmelfeder F, et al. A Systematic Review of the Risk of BacterialResistance to Silver. Poster, EWMA; 2018.

    24. Percival SL, Woods E, Nutekpor M, Bowler P, Radford A, Cochrane C. Prevalence of Silver Resistance in Bacteria Isolated from DiabeticFoot Ulcers and Efficacy of Silver-Containing Wound Dressings. Ostomy Wound Management. 2008;54(3):30-40.

    25. Kostenko V, Lyczak J, Turner K, Martinuzzi RJ. Impact of Silver-Containing Wound Dressings on Bacterial Biofilm Viability and Susceptibilityto Antibiotics during Prolonged Treatment. Antimicrobial Agents and Chemotherapy. 2010;54(12):5120-31.

    26. Burger C, Lemoult S, Andersen MB. Silver release profile and antibacterial effect of a new silver foam dressing with silicone adhesive.Poster, EWMA(EPP025); 2018.

    27. Malone M, Bjarnsholt T, McBain AJ, James GA, Stoodley P, Leaper D, et al. The prevalence of biofilms in chronic wounds: a systematicreview and meta-analysis of published data. Journal of wound care. 2017;26(1):20-5.

    28. Bjarnsholt T. The Role of Bacterial Biofilms in Chronic Infections. Acta pathologica, microbiologica, et immunologica Scandinavica.2013;121(s136):1-58.

    29. Costerton JW. Bacterial Biofilms: A Common Cause of Persistent Infections. Science. 1999;284(5418):1318-22.

    30. Crone S, Garde C, Bjarnsholt T, Alhede M. A novel in vitro wound biofilm model used to evaluate low-frequency ultrasonic-assisted wounddebridement. Journal of wound care. 2015;24(2):64-72.

    31. Bessa LJ, Fazii P, Di Giulio M, Cellini L. Bacterial isolates from infected wounds and their antibiotic susceptibility pattern: some remarksabout wound infection. International wound journal. 2013;12(1):47-52.

    32. Yin HQ, Langford R, Burrell RE. Comparative Evaluation of the Antimicrobial Activity of ACTICOAT Antimicrobial Barrier Dressing. Journalof Burn Care & Rehabilitation. 1999;20(3):195-200.

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    34. prEN16756 (draft). Antimicrobial wound dressings – Requirements and test methods. 2014.

    35. Howell-Jones RS, Wilson MJ, Hill KE, Howard AJ, Price PE, Thomas DW. A review of the microbiology, antibiotic usage and resistance inchronic skin wounds. Journal of Antimicrobial Chemotherapy. 2005;55(2):143-9.

    36. Bowler PG, Duerden BI, Armstrong DG. Wound Microbiology and Associated Approaches to Wound Management. Clinical MicrobiologyReviews. 2001;14(2):244-69.

    37. Daeschlein G. Antimicrobial and antiseptic strategies in wound management. International wound journal. 2013;10 Suppl 1:9-14.

    38. Thomas S. Laboratory findings on the exudate-handling capabilities of cavity foam and foam-film dressings. Journal of wound care.2010;19(5):192-9.

    39. White R, Cutting KF. Modern exudate management: a review of wound treatments. Poster, EWMA(EPP025); 2018.

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    41. Andersen MB. Comparison of 24 hours fluid handling and absorption under pressure between four wound dressings with Ag and siliconeadhesive. EWMA(EP296); 2016.

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    43. Senet P, Bause R, Jorgensen B, Fogh K. Clinical efficacy of a silver-releasing foam dressing in venous leg ulcer healing: a randomisedcontrolled trial. International wound journal. 2014;11(6):649-55.

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