|Year : 2017 | Volume
| Issue : 1 | Page : 38-43
Silver sulfadiazine versus sustained-release silver dressings in the treatment of burns: A surprising result
Shobhit Gupta, Naveen Kumar, Vinay K Tiwari
PGIMER & Dr. R.M.L. Hospital, New Delhi, India
|Date of Web Publication||13-Dec-2017|
Dr Naveen Kumar
D-107, Prateek Laurel, Sec-120, Noida, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: In recent times, there has been an increased use of dressings containing silver. Although there are many studies showing the impact of sustained-release silver foam dressings on microbial assay, there is a scarcity of studies on clinical and economical parameters. This study highlights the comparison between sustained-release silver dressings and 1% silver sulfadiazine (SSD) with respect to patient comfort, its impact on wound healing, and cost estimation in patients with burns.
Materials and Methods: This prospective observational study was conducted from 1st August 2015 to 31st December 2015. Patients with second-degree burns (scald and flame burns) covering 20–60% of the total body surface area and belonging to the age group from 18 to 60 years were selected. The patients were divided into the following groups on alternate basis: Group 1–dressing with 1% SSD; Group 2–dressing with sustained-release silver dressings. The following variables were used: pain during change of dressing using visual analogue scale (VAS) score, the percentage of wound healing on the 5th, 10th, 15th, and 20th days on the anterior and posterior trunk using graphs, duration of hospital stay, cost calculation accounting for dressings and hospital expenses.
Results: Statistical analysis showed an advantage of sustained-release silver foam dressing over SSD with respect to reduced pain on the basis of VAS score on the 5th, 10th, 15th, and 20th days (7.47, 6.27, 3.8, and 3.87 in Group 1 vs. 4.4, 3.13, 2.53, and 1.93 in Group 2) with P < 0.005. In addition, statistically, wound healing was faster among the patients in Group 2 than those in Group 1 on the 10th, 15th, and 20th days (25.67, 39.27, and 64.53% vs. 22.07, 54.6, and 84.53% in Group 2) with P < 0.005. The patients belonging to Group 2 were discharged earlier (14.6 vs. 22.47 days) with P < 0.005. Surprisingly, accounting both hospital expenses and dressing cost, the patients belonging to Group 2 had lesser expense than those in Group 1.
Conclusion: Comparative study shows that sustained-release silver foam dressing has faster wound healing, lesser pain with earlier hospital discharge than SSD, and lesser expenses when total hospital burden was accounted.
Keywords: Burns, costs, dressings, pain, silver, silver sulfadiazine, wound healing
|How to cite this article:|
Gupta S, Kumar N, Tiwari VK. Silver sulfadiazine versus sustained-release silver dressings in the treatment of burns: A surprising result. Indian J Burns 2017;25:38-43
|How to cite this URL:|
Gupta S, Kumar N, Tiwari VK. Silver sulfadiazine versus sustained-release silver dressings in the treatment of burns: A surprising result. Indian J Burns [serial online] 2017 [cited 2018 Aug 17];25:38-43. Available from: http://www.ijburns.com/text.asp?2017/25/1/38/220653
| Introduction|| |
Silver has been used as an antimicrobial since the 1800s. Silver has antiseptic, antimicrobial, and anti-inflammatory properties and is a broad-spectrum antibiotic., In the late 1960s, Fox introduced silver sulfadiazine (SSD) cream for the management of burn wound. SSD cream has a relatively short action, its penetration of the burn eschar is poor, and it forms a pseudo-eschar. Both silver nitrate dressings and SSD cream require a high frequency of dressing changes.
In recent times, there has been an increased use of dressings containing silver. Although there are many studies showing the impact of sustained-release silver foam dressings on microbial assay, there is a scarcity of studies on clinical and economical parameters.
Silver can be in different forms in different dressings. Some silver dressings release silver in a sustained manner, which improves the condition of wound by continuously acting as an effective cover over microorganisms. Silver is biologically active when it is in a soluble form, that is, as Ag+ or Ag0 clusters. Ag+ is the ionic form present in silver nitrate, SSD, or other ionic silver compounds. Ag0 is the uncharged form of metallic silver present in nanocrystalline silver.
Free silver cations have a potent antimicrobial effect. Silver cations also bind and denature the bacterial Deoxynucleic acid (DNA) and Ribonucleic acid (RNA), thus inhibiting cell replication. Nanocrystalline silver utilizes nanotechnology to release the clusters of extremely small and highly reactive silver particles. The smaller the particles of silver, the greater the wound surface area that will be in contact with silver, thus increasing bioactivity and silver solubility.
Research has demonstrated that sustained-release silver products have a bactericidal action providing an effective management of odor and exudate, thus reducing the risk for colonization and preventing infection.
The high levels of bacteria, multiresistant organisms, and bacterial biofilms can impact the healing process especially in chronic wounds. Local wound infection causes tissue death, increase in wound size, wound hypoxia, and occlusion of vessels, which all further delay the wound healing process. A wound bioburden is when bacterial cells produce and secrete a variety of enzymes and toxins onto the wound.
There are many studies comparing the different silver dressings available by studying their antimicrobial spectrum; however, there is a scarcity of studies assessing clinical impact including wound healing, hospital stay, and patient comfort. Moreover, this study also compares cost burden on a tertiary care center, which is a very important factor in countries such as India, thereby making the research very important.
| Materials and methods|| |
Study duration was from 1st August 2015 to 31st December 2015. The study was designed as a prospective observational study. Inclusion criteria incorporated patients suffering from thermal burn injury between 20% total burn surface area (TBSA) and 60% TBSA and involving either the anterior or posterior parts of the trunk, belonging to the age group 18–60 years, and admitted within 48 h of burn injury. The patients with burns caused by electrical or chemical injuries and the patients with burns with any comorbidity or other associated injury were excluded from the study.
After taking proper consent and explaining the procedure of the study, all patients were treated according to the same basic unit treatment protocol. The patients who were in the study were selected on alternate basis for both the types of dressings. Thereafter, they were divided into the following two groups:
- Group 1–patients who had dressing with 1% SSD.
- Group 2–patients who had dressing with sustained-release silver dressing.
The patients belonging to Group 1 were dressed on alternate days and the patients belonging to Group 2 were dressed on every 5th day or earlier if soakage or purulent discharge or odor occurred. Analgesics were administered only before a change in the dressing according to the treatment protocol. Wound assessment was performed only on the anterior and posterior parts of the trunk using graphs. The percentage of epithelialized wound was calculated and compared with both the groups. A regular assessment of the wound and the patient was performed using clinical parameters and photographs. The study was approved by the institutional ethic committee board with Ref. No. IEC/7145/15 and is in accordance with the Helsinki Declaration of 1975, as revised in 2000.
Variables used to compare the dressings were the following:
- Pain during dressing change using visual analog score (VAS) at 5th, 10th, 15th, and 20th days.
- The percentage of wound healing at 5th, 10th, 15th, and 20th days on the anterior and posterior trunk using graphs.
- Hospital stay duration.
- Cost analysis.
Descriptive statistical analysis is summarized by medians ± standard deviation (SD). Significance was defined as P < 0.05. Data were analyzed using the Statistical Package for the Social Sciences software (SPSS Inc., Chicago, IL, United States).
| Results|| |
There were 30 patients (15 patients in each group) with an average age of 35.4 years for Group 1 and 37.8 years for Group 2 [Figure 1]. Group 1 consisted of seven males and eight females, and Group 2 consisted of six males and nine females [Figure 2].
Visual analogue scale score
There was a clear advantage of sustained-release silver foam dressing over 1% SSD with less pain according to VAS score on the 5th, 10th, 15th, and 20th days (7.47, 6.27, 3.8, and 3.87 in Group 1 vs. 4.4, 3.13, 2.53, and 1.93 in Group 2) with P < 0.005 [Table 1], [Figure 3].
Percentage of wound healing
Statistically, wound healing was faster among patients belonging to Group 2 than those in Group 1 on the 10th, 15th, and 20th days (25.67, 39.27, and 64.53% vs. 22.07, 54.6, and 84.53% in Group 2) with P < 0.005 [Table 2], [Figure 4].
The patients belonging to Group 2 were discharged earlier (14.6 vs. 22.47 days) with P < 0.005 [Figure 5].
Surprisingly, accounting both hospital expenses and dressing cost, patients belonging to Group 2 had lesser expense than those in Group 1 (1.35 lac/patient vs. 1.05 lac/patient for 40% burn) due to long admission duration [Figure 6].
Cost analysis explained
Taking the subsidized government supply rates for dressings and hospital expenses for salaries and other costs, a comparison of cost burden was performed for both the groups.
- Group 1: Dressing was done on alternate days; therefore, for 23 days on an average 14 dressings were needed. For each dressing, around 1000 rupees is required; therefore, for 14 dressings, the cost was estimated as (14 × 1000) 14,000 rupees. The average cost for each bed was around 5500 rupees. Therefore, for 22 days (22 × 5500), 1, 21, 000 rupees is required. In conclusion, 1,35,000 rupees was the cost burden for one patient belonging to Group 1.
- Group 2: Dressing was done every 5th day; therefore, for 15 days, four dressings were needed. For one dressing, the costs was around 7500 rupees; therefore, 30,000 rupees (7500 × 4) was the total dressing cost. Hospital stay costed around 77,000 rupees (5500 × 14) for 14 days; therefore, total cost burden on the hospital was around 1,07,000 rupees for one patient belonging to Group 2.
There was statistically significant difference between the cost burdens for both the groups, with Group 2 being cheaper than Group 1 with P < 0.05 [Table 3].
| Discussion|| |
Burn wounds are generally treated by changing dressing or surgery. Despite satisfactory wound healing outcomes, surgery is not suitable for all patients because of high cost. Change of dressing, on the other hand, is cheaper and mainly used nowadays in clinical practice; however, the wounds heal slowly. Accordingly, it is of great significance to select proper dressings to control local infections and to promote healing. Ideal dressings should be easily applicable, well-penetrating, and broad-spectrum, without drug resistance, local stimulation, or systemic adverse reactions.,,,
SSD cream has been used as wound dressing for over three decades.,
Recently, silver dressings have been used instead to resist pain and to accelerate wound healing following the mechanisms below.,,
The principal aim of wound management in burn care, in particular, is to prevent nosocomial bacterial wound infection. Additionally, the wound healing should be promoted, and the pain should be minimized during the change of dressing, taking the cost burden under control. There are many studies introducing new types of silver dressings.,, In our study, we compared sustained-release silver dressings with SSD dressings.
To reduce the confounding factors, both the groups consisted of a similar type of patients in term of percentage of burn area, age group, and sex ratio. The mode of injury in both the group of patients was flame burns. Interval between the admission and burn injury was also constant in both the groups. The parameters of comparison such as patient comfort, hospital stay, wound healing percentage, and cost hold value were, thus, compared and statistically analyzed.
Statistically, we noted that VAS score was less in the patients treated with sustained-release silver dressings than in those treated with SSD. Similar results were by Caruso et al. in 2006 who evaluated pain using the John Hopkins VAS for those aged 4 years and older. Hydrogel fiber dressing reduced pain during dressing change as compared to SSD. As sustained-release silver dressings are available in pad or sheet forms, it is easier to apply and remove; thus, these dressings cause less pain during dressing change.
We also saw an improved percentage of wound healing in the group with sustained-release silver dressings as compared to SSD. Aziz et al. said that silver-containing dressings and topical silver were either no better or worse than control dressings in preventing wound infection and promoting the healing of burn wounds. Silverstein et al. compared silver-containing silicon dressings and SSD and said that silver-containing soft silicone foam dressing was as effective in the treatment of patients with SSD when their wound healing was compared; however, the patients treated with the soft silicone foam dressing demonstrated decreased pain and lower costs associated with treatment. Caruso et al. in 2006 compared a hydrogel fiber dressing with SSD. No significant difference was found between the hydrogel dressing and SSD with regard to time for wound healing. As already stated, wound healing depends upon wound infection and wound bioburden; thus, when less wound infection is there, there is a greater chance for faster and better wound healing, which also results in less hospital stay as shown in our study.
When we compared total cost burden accounting primary dressing material, secondary dressing material, and hospital cost, we saw that the patients who were dressed with sustained-release silver dressings had less treatment costs when compared to the other group. The reason behind this was longer hospital stay and more secondary dressing material needed. This result is in contrast to the generally prevalent idea regarding the cost burden of both types of silver dressings. Similar to our research, Wasiak et al. on retrospectively assessing many studies saw that the mean total cost of primary dressings during the study was significantly greater for the hydrogel fiber dressing than for SSD. As expected, the mean cost for the secondary dressing (i.e., gauze dressing application over primary dressing) was lower for the hydrogel fiber group than the SSD. When total treatment costs were compared, costs were comparable between the two groups.
Therefore, as a consensus of this research, it can be said that modern dressings such as sustained-release silver dressings can be used for burn wound and other chronic wounds, and they are better in respect to patient comfort, wound healing, and cost burden to the hospital. However, further studies with more number of patients in different centers are needed to issue a generalized statement.
| Conclusion|| |
Comparative study shows that sustained-release silver dressing has faster wound healing, lesser pain with earlier hospital discharge than SSD, and lesser expenses when total hospital burden was accounted. However, there are various limitations of this study such as small sample size, single institution study, and limited follow-up. Modern silver dressings are very important in the coming years for burn treatment; thus, its clinical efficacy with the cost effectiveness is a very important subject in burn management.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fong J. The use of silver products in the management of burn wounds: Change in practice for the burn unit at Royal Perth Hospital. Prim Intent 2005;13:S16-22.
Demling R, DeSanti L. The role of silver technology in wound healing: Part 1: Effects of silver on wound management. Wounds 2001;13(Suppl A):4-15.
Hoffman S. Silver sulfadiazine: An antibacterial agent for topical use in burns. Scand J Plast Reconstr Surg 1984;18:119-26.
Dunn K, Edwards-Jones V. The role of Acticoat™ with nanocrystalline silver in the management of burns. Burns 2004;30(Supp 1):S1-9.
Tredget E, Shankovsky R, Groenveld A, Burrell R. A matched-pair, randomised study evaluating the efficacy and safety of Acticoat silver-coated dressing for the treatment of burn wounds. J Burn Care Rehabil 1998;19:531-7.
Smith, Nephew. Dynamic Silver Release Rapid Destruction, Sustained Protection, Acticoat With Silvercryst. Smith and Nephew Pty. Ltd.; 2003. [Product information].
Deitch E, Marin A, Malakanov V, Albright JA. Silver nylon cloth: In vivo
and in vitro
evaluation of antimicrobial activity. J Trauma 1987;27:301-4.
Templeton S. Management of chronic wounds: The role of silver containing dressings. Prim Intent 2005;13:170-9.
Woodward M. Silver dressings in wound healing: What is the evidence? Prim Intent 2005;13:153-60.
White R, Cooper R, Kingsley A. A topical issue: The use of antibacterials in wound pathogen control. In: White R, editor. Trends in Wound Care. UK: Bath Press; 2002. p. 16-7.
Yang B, Wang X, Li Z, Qu Q, Qiu Y. Beneficial effects of silver foam dressing on healing of wounds with ulcers and infection control of burn patients. Pak J Med Sci 2015;31:1334-9. doi: 10.12669/pjms.316.7734
Palmieri TL, Nelson-Mooney K, Kagan RJ, Stubbs TK, Meyer WJ 3rd, Herndon DN et al.
Impact of hand burns on health-related quality of life in children younger than 5 years. J Trauma Acute Care Surg 2012;73(3 Suppl 2):S197-204. doi: 10.1097/TA.0b013e318265c7ff.
Selig HF, Lumenta DB, Giretzlehner M, Jeschke MG, Upton D, Kamolz LP. The properties of an “ideal” burn wound dressing − What do we need in daily clinical practice? Results of a worldwide online survey among burn care specialists. Burns 2012;38:960-6. doi: 10.1016/j.burns.2012.04.007
Gierek M, Kawecki M, Mikuś K, Klama-Baryła A, Nowak M. Biological dressings as a substitutes of the skin in the treatment of burn wounds. Pol Przegl Chir 2013;85:354-9. doi: 10.2478/pjs-2013-0054.
Mabrouk A, Boughdadi NS, Helal HA, Zaki BM, Maher A. Moist occlusive dressing (Aquacel®
Ag) versus moist open dressing (MEBO®
) in the management of partial-thickness facial burns: A comparative study in Ain Shams University. Burns 2012;38:396-403. doi: 10.1016/j.burns.2011.09.022
Gravante G, Caruso R, Sorge R, Nicoli F, Gentile P, Cervelli V. Nanocrystalline silver: A systematic review of randomized trials conducted on burned patients and an evidence-based assessment of potential advantages over older silver formulations. Ann Plast Surg 2009;63:201-5. doi: 10.1097/SAP.0b013e3181893825
Muangman P, Pundee C, Opasanon S, Muangman S. A prospective, randomized trial of silver containing hydrofiber dressing versus 1% silver sulfadiazine for the treatment of partial thickness burns. Int Wound J 2010;7:271-6. doi: 10.1111/j.1742-481X.2010.00690.x.
Russell L. The CONTOP multinational study: Preliminary data from the UK arm. Wounds 2005;1:44-54.
Lo SF, Hayter M, Chang CJ, Hu WY, Lee LL. A systematic review of silver-releasing dressings in the management of infected chronic wounds. J Clin Nurs 2008;17:1973-85. doi: 10.1111/j.1365-2702.2007.02264.x
Lo SF, Chang CJ, Hu WY, Hayter M, Chang YT. The effectiveness of silver-releasing dressings in the management of non-healing chronic wounds: A meta-analysis. J Clin Nurs 2009;18:716-28. doi: 10.1111/j. 1365-2702.2008.02534.x
Rustogi R, Mill J, Fraser JF, Kimble RM. The use of Acticoat in neonatal burns. Burns 2005;31:878-82.
White R, Cutting K. Exploring the effects of silver in wound management − What is optimal? Wounds 2006;18:307-14.
Caruso DM, Foster KN, Blome-Eberwein SA, Twomey JA, Herndon DN, Luterman A et al.
Randomized clinical study of hydrofiber dressing with silver or silver sulfadiazine in the management of partial-thickness burns. J Burn Care Res 2006;27:298-309.
Aziz Z, Abu S, Chong N. A systematic review of silver-containing dressings and topical silver agents (used with dressings) for burn wounds. Burns 2012;38:307-18.
Silverstein P, Heimbach D, Meites H, Latenser B, Mozingo D, Mullins F et al.
An open, parallel, randomized, comparative, multicenter study to evaluate the cost-effectiveness, performance, tolerance, and safety of a silver-containing soft silicone foam dressing (intervention) vs silver sulfadiazine cream. J Burn Care Res 2011;32:617-26.
Wasiak J, Cleland H, Campbell F. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev 2008;CD002106.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]