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Silver-containing antimicrobial dressings are under close scrutiny after  recent publications have cast doubt on their clinical value (Bergin and Wraight 2006; Michaels et al 2009; Storm-Versloot et al 2010; Anon 2010)

 

It is now apparent that the availability of modern wound dressings, in particular those containing silver, are being restricted across the UK  (White 2010). This is happening ostensibly on the basis of insufficient clinical evidence as judged by systematic reviews of randomised, controlled trails (RCTs); however, this may just be serving as a smokescreen for  cost-cutting at Trust level.

The VULCAN Trial publication (Michaels et al 2009) has been cited as a part of the scientific rationale for removing silver dressings from wound formularies, based upon a demonstrated lack of healing efficacy; however, serious methodological flaws in this study have been highlighted (White et al 2009;Drake 2010 Leaper and Drake 2011).  The central flaw being the use of silver dressings for prolonged periods of time (up to twelve weeks) without clinical justification, contrary to current best practice. Unfortunately, the shortcomings were not recognised by subsequent authors who have seized upon the opportunity to extol the VULCAN trial findings, apparently without any insight into wound care practice (Anon 201009; Lo 2010). As with all antimicrobials, silver dressings must to be used, with justification, in an appropriate and structured manner for limited periods - with clear clinical objectives in mind. In this respect, the VULCAN study lacks "external > validity" (Persaud and Mamdani 2006).

To withdraw silver without adequate justification, or clinical advice on effective alternatives, will compromise care, increase morbidity and mortality. The latter has been established through audit and shows that the arbitrary withdrawal of silver has led to increased incidence of septicaemia and death (Newton 2010). Those responsible for wound formularies and purchasing should be mindful of the potential human costs associated with decisions that they take, and that in the event of a documented increase in septicaemia, should be held professionally accountable.


Responsible clinicians will continue to seek to use silver dressings in the fight against wound infection. The risks associated with arbitrary restrictions or removal of products should be borne in mind by all who have responsibility for the prevention and management of wound infection. A majority of clinicians and scientists insist that there is now good in vitro evidence and, relatively speaking, substantial clinical evidence for topical silver. Included in this group are many of the leading figures in the world of wound care.

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Have you stopped using silver dressings if so why?

Written by Professor Richard White
Saturday, 19 March 2011 0:12

Comments   

 
0 #4 Dr. Robert J. Snyder, DPM, CWS 2011-02-14 22:47
Despite the many articles, studies and anecdotal reports showing the benefits of silver in the treatment of chronic ulcers most are not based upon traditional randomized controlled trials (RCT) and thus are viewed by many in the medical profession as inadequate in proving effectiveness.
This is truly unfortunate; the evidence obtained from RCT’s represent just one factor and as such must be interpreted in light of the patients’ individual situation including the impact of comorbidities (not addressed in clinical trials), economic issues and psychosocial issues in order to come to a clinical decision. Randomized controlled trials seldom evaluate the “real world” patient. Additionally, dressings such as silver are often not meant to be used to wound closure( often the endpoint in an RCT) but rather as part of a sequential therapy model and only when necessary. Finally, wound management is unique in that decision making requires a holistic view of evidence including studies that review comparative effectiveness, case series and reports and consensus opinion as well as RCT and ultimately meta-analysis. The treating clinician must, therefore, integrate a critical evaluation of evidence with clinical expertise and patient focused care.
Snyder et al (2009) and others clearly show the cost benefits with the sequential use of silver when compared to more “traditional” standards of care. Furthermore, in a meta-analysis of 10 RCT, Margolis( 1999) clearly showed that patients with diabetes experiencing neuropathic ulcers did poorly in 12 weeks and 20 weeks( < 25% and < 31% respectively) when treated with standard care including offloading, debridement, and either saline moistened gauze or a moist healing gel).
Controlling bacterial burden in a chronic wound represents an important pathway to creating biochemical balance and in my view is essential to moving the wound towards closure; silver dressings offer coverage of more than 150 bacteria, yeasts and molds and offer an antiseptic that produces almost no bacterial resistance. Lastly, I believe that this represents the US perspective.
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0 #3 Mike Jozefiak 2011-02-14 13:50
Do hospital managers, and indeed doctors, realise the immense value of brass door handles in reducing the spread of infections? Harder to clean, and would require more staff, but just think of the benefits; no chemicals and reduced infections!

Back to the future.
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0 #2 Anita Kilroy-Findley 2011-02-13 10:38
I remember reading the VULCAN trial when it was published and being astonished that any clinician would take it seriously; maybe that's the relevant word 'clinician'. How many of the decisions to limit/remove silver from use are being made by clinicians? What I hear from other areas is that it is managers and committees taking arbitrary decisions without asking those who actually treat patients and see the impact infection has on quality of life. Rather than withdrawing silver from use we need to ensure its accurate use. Tissue Viability Nurses have a responsibility for educating staff on how and when to use silver; they also need to include when to stop using it. Too often wound care companies will tell nurses that their product can be used right through to healing; if those companies don't want to see their silver sales plummet from local 'bans' they need to wise up and provide honest time periods of up to 2 weeks. I'm lucky that this hasn't come to my area yet and I feel I can fight it if it does with case studies and figures that show wear times haven't been abused; eprescribing puts an automatic stop on all antimicrobial dressings after 14 days. The increase in septicaemia is worrying and I agree that those responsible should be professionally accountable
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0 #1 Annemarie Brown 2011-02-11 18:00
I agree with the comment that the Vulcan Trial has sometimes been used to stop the use of silver dressings despite the methodological flaws described in the above article. However, I believe that Tissue Viability Nurses can influence the use of silver dressings in the clinical area by pointing out the methodological flaws in the trial (blind them with science!!) and provide evidence of the efficacy in clinical practice. Perhaps we need to start a database of case studies where silver has been used successfully rather than relying on RCTs in wound care - since we all know that these are often flawed methodologicall y. We need to convince the "powers that be" that RCTs are no longer the "gold standard" in wound care evidence.
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