[The use of a topical antibacterial agent (silver sulfadiazine) on soft-tissue wounds]

Reducing the quantitative level of bacterial contamination in an open, acute or chronic, soft tissue wound below the critical level of 10(5) bacteria per gram of viable tissue is essential to delayed primary closure. First step in the management of the contaminated or infected wound is accurate local debridement, preferably with pulsating jet irrigation. Topical antibacterial agents, specifically silver sulfadiazine cream, are then usefully employed to reduce the bacterial count. Contrary to systemic antibiotics, these agents penetrate adequately into the open, granulating wound with a direct bacteriostatic or bactericidal action on a wide spectrum of gram positive and negative organisms, without the effect of local tissue injury typical of topical antiseptics. The use of topical antibacterials, traditionally confined to the treatment of the burn wound, the open "difficult" wound for excellence where control of local infection is first priority, provides a rapid local reduction of the bacterial level and paves the way to the final goal of primary delayed closure of the wound, either direct or with the use of grafts or local, distant, or free flaps.

Comparative evaluation of zinc sulfadiazine and silver sulfadiazine in burn wound infection

One percent silver sulfadiazine has been commonly used as a topical antimicrobial agent after a burn injury. Incidence of burn wound colonization by Staphylococcus aureus in patients treated with silver sulfadiazine has spurred research for other agents. A topical preparation that contains zinc and sulfadiazine (Zad-G) was evaluated for in vitro antibacterial spectrum and in vivo efficacy. Muscle biopsy specimens of rats treated with Zad-G appear to have fewer colonies of S. aureus than groups treated with silver sulfadiazine. Topical therapy with Zad-G for patients with burns was comfortable, reduced wound infection, and was comparable to therapy with silver sulfadiazine. A topical Zad-G preparation that contains zinc sulfadiazine appears to be an effective alternative to silver sulfadiazine in the treatment of burn wounds.

Sildimac: a new delivery system for silver sulfadiazine in the treatment of full-thickness burn injuries

Wound care is painful for the patient with a burn injury and tedious for the burn unit staff but necessary to remove exudates and debris and to limit infections. In an effort to circumvent daily dressing changes while ensuring optimal wound protection, Sildimac (Marion Laboratories, Kansas City, Mo.), a new drug delivery system for silver sulfadiazine, was developed. When silver sulfadiazine, a topical antimicrobial commonly used for the treatment of burns, is incorporated into the delivery system, the drug is released in a sustained fashion. We report here the results of a multicenter evaluation of the safety and efficiency of Sildimac for treatment of full-thickness burn wounds. Sildimac, when left in place for up to 4 days, appears to be as effective as twice-daily wound cleansing and application of Silvadene cream 1% (Marion Laboratories, Kansas City, Mo.) for the treatment of full-thickness burns.

[Serum and tissue silver levels after burns treated with silver compounds]

This study was performed in order to investigate serum and tissue silver levels in burns which were used 10 percent silver nitrate as a topical agent. We formed four groups of animals and pulverized 10 percent silver nitrate solution to the first group (GI) that included ten rabbits of which backs were burned by boiling water and silver sulphadiazine cream to second group (GII) with nine rabbits. We carried out 10 percent silver nitrate solution to the first control group (GIII) and silver sulphadiazine cream to the second control group (GIV) each of which had seven animals with unburned skin. We obtained blood samples from every animal before and after application of topical agent on the 1st, 3rd, 7th, 15th, 21st and 28th. We determined serum and tissue silver levels by atomic absorption spectrophotometer in kidney and liver of the animals which were sacrificed on the 28th day. In first and second groups we found that serum silver values reached on 3rd day to the maximum level and then the values decreased gradually. We also determined that diminution of the serum silver levels were prominent following on 15th day. It was shown that there was no silver in the serum on 28th day except four animals. The silver deposition in the liver was much more than in the kidney. Between these two groups there was significant difference neither in the serum on the same days nor the tissue silver levels. According to these data it was concluded that serum and tissue silver levels with 10 percent silver nitrate used in burns produced no difference from that of 1 percent silver sulphadiazine cream.

Long-term experience with 1 per cent topical silver sulphadiazine cream in the management of burn wounds

Three hundred and forty-two patients with 10-50 per cent body surface area burns were studied prospectively over the 5-year period from 1982 to 1986 for the effectiveness of topical 1 per cent silver sulphadiazine. Various parameters were studied including: (i) healing time of deep partial skin thickness burns, (ii) eschar separation time, (iii) conversion rate of deep dermal burns to full skin thickness burns, (iv) burn wound surface bacterial flora and their changing pattern over the years, (v) incidence of invasive sepsis and (vi) overall mortality. There was a remarkable decrease in the time taken for the healing of deep dermal burns, and the conversion rate of deep dermal burns to full skin thickness was significantly reduced. Eschar separation was delayed considerably. There was a total change in the predominent surface micro-organisms from Staph. aureus, which was predominant in 1982, to pseudomonas species and klebsiella in 1986. Moreover, there was the emergence of a new variety of micro-organism within the last 2 years. The incidence of invasive infection and overall mortality was significantly reduced.

[A trial of silver sulfadiazine in the local treatment of venous ulcer]

Silver sulfadiazine, in cream form, has been mostly used in the treatment of burns. Its trial in the treatment of leg ulcers has been satisfactory. This preparation is well tolerated, and effective on wound cleansing and granulation tissue formation. It is particularly indicated in cases of superinfected ulcers, effective on most Gram + and Gram - bacteria.

Minor burns: treatment using a new drug delivery system with silver sulfadiazine

We investigated a new product for treatment of burn wounds in outpatients. The product is a drug delivery system composed of polyethylene glycol 400, poly-2-hydroxyethyl methacrylate, and dimethyl sulfoxide into which silver sulfadiazine is incorporated for sustained release. It is applied to the wound and changed every four to five days until the wound has epithelialized. Of the 20 patients we treated by this method, none had wound infections. Most patients had partial-thickness injuries that epithelialized without difficulty. One patient with full-thickness injuries required subsequent excision and grafting. Application of the product over joint surfaces facilitated range of motion. The product was easy to apply, it diminished pain, and it produced no abnormal effects except for an occasional bad odor.

Use of topically applied silver sulphadiazine plus cerium nitrate in major burns

All patients hospitalized between May 1987 and June 1988 suffering from burns covering over 50 per cent of the body surface area were treated by topical application of a cream containing cerium nitrate (0.05 M) and silver sulphadiazine (0.03 M) (CN + SSD). Eleven patients were included in this series, with a mean age of 35 years (range 22-65), a mean total burn size of 78 per cent (range 50-96 per cent) and full skin thickness covering a mean of 48 per cent (range 10-91 per cent). Eight patients survived (73 per cent) (mean age 36 years; mean total burn surface 73 per cent; mean full skin thickness burn surface, 38 per cent). These results are far better than those obtained in our Unit where a survival rate of 34 per cent was obtained in a comparable series of patients treated before 1987. Sixty positive blood cultures were obtained, which included a large variety of organisms with a slight predominance of Staph. aureus, Candida albicans and Ps. aeruginosa. Wound cultures were positive in 72 per cent of swabs and showed a predominance of Ps. aeruginosa (59 per cent of all the strains isolated). Even if CN + SSD appears in this series not to be very efficient in preventing wound colonization and septic complications, it permitted a very high survival rate in the treated patients, taking into account the extreme severity of the injuries. This beneficial effect is probably the consequence of the protective action of the yellow-green eschar formed by CN + SSD.(ABSTRACT TRUNCATED AT 250 WORDS)

Enhancement of wound healing by topical treatment with epidermal growth factor

Experimental studies in animals have demonstrated that the topical application of epidermal growth factor accelerates the rate of epidermal regeneration of partial-thickness wounds and second-degree burns. We conducted a prospective, randomized, double-blind clinical trial using skin-graft-donor sites to determine whether epidermal growth factor would accelerate the rate of epidermal regeneration in humans. Paired donor sites were created in 12 patients who required skin grafting for either burns or reconstructive surgery. One donor site from each patient was treated topically with silver sulfadiazine cream, and one was treated with silver sulfadiazine cream containing epidermal growth factor (10 micrograms per milliliter). The donor sites were photographed daily, and healing was measured with the use of planimetric analysis. The donor sites treated with silver sulfadiazine containing epidermal growth factor had an accelerated rate of epidermal regeneration in all 12 patients as compared with that in the paired donor sites treated with silver sulfadiazine alone. Treatment with epidermal growth factor significantly decreased the average length of time to 25 percent and 50 percent healing by approximately one day and that to 75 percent and 100 percent healing by approximately 1.5 days (P less than 0.02). Histologic evaluation of punch-biopsy specimens taken from the centers of donor sites three days after the onset of healing supported these results. We conclude that epidermal growth factor accelerates the rate of healing of partial-thickness skin wounds. Further studies are required to determine the clinical importance of this finding.

Assessment of topical therapy of the burn wound with silver sulphadiazine after its use for 15 years in a burn unit

A comparative study of patients receiving or not receiving topical applications of 1 per cent silver sulphadiazine cream as treatment for burn wounds has shown that the drug is still effective in significantly reducing the amount of bacterial contamination of burn wounds, even after 15 years of use in our Burn Unit. Consequently the overall mortality due to burn wound sepsis has been decreased in this Burn Unit.

Results of a multicenter outpatient burn study on the safety and efficacy of Dimac-SSD, a new delivery system for silver sulfadiazine

Dimac with silver sulfadiazine (Dimac-SSD), a new silver sulfadiazine delivery system, was evaluated prospectively in a multicenter study for the treatment of outpatient burn injuries. The goal of this study was to evaluate the effect of Dimac-SSD on the microbiology of the burn wounds and to quantitate its clinical safety and efficacy. A total of 197 patients were evaluated. Eight (4%) of these patients did not complete the study. Six patients withdrew because of local discomfort caused by the Dimac-SSD and two patients were terminated because of technical problems. The mean +/- SD duration of treatment with Dimac-SSD was 12 +/- 8.5 days, during which time the mean number of dressing changes was 2.9 per patient. During treatment with Dimac-SSD, the burn wound bacterial flora remained stable and overgrowth with Pseudomonas species or Gram-negative bacilli did not occur. Only four (2%) patients developed clinical infections; thus the Dimac-SSD appeared to have good antimicrobial effectiveness. This dressing was not associated with any organ system or metabolic side-effects and patient discomfort during application and removal was minimal. Thus this new delivery system for silver sulfadiazine was associated with excellent wound healing, a low incidence of wound infections, reduced frequency for dressing changes, and excellent patient compliance.

Leukopenia in non-septic burn patients receiving topical 1% silver sulfadiazine cream therapy: a survey

The cause of early postburn leukopenia (EPBL) is unknown. The evidence suggests that treating burn wounds with 1% silver sulfadiazine cream (SSD) is contributory, but that other factors exist, possibly including burn stress. Differences of opinion exist as to whether SSD applications to the wounds of non-septic burn patients should be discontinued if EPBL develops. A survey of opinion in 101 North American burn treatment facilities and a review of the literature show a strengthening of the perception that EPBL, whether caused by SSD or not, holds little risk for the burn patient. The majority of burn patients are now being assigned to treatment strategies in which the onset of EPBL requires discontinuance of SSD only at WBC counts lower than 2,000/cu mm or not at all. This is significantly lower (p less than .02) than the mean of the values recorded in the literature. There is now substantial experience with continuing the SSD therapy in this setting regardless of the WBC count. No complications are reported therefrom.

Biosynthetic skin substitute vs. 1% silver sulfadiazine for treatment of inpatient partial-thickness thermal burns

When used appropriately on superficial or moderate-depth partial-thickness burns, Biobrane significantly decreased total healing time to complete reepithelialization, reduced pain, and was associated with decreased nursing time and costs when compared to 1% silver sulfadiazine cream. Care must be used in selecting wounds for Biobrane therapy. They must be fresh, noninfected, and free of eschar and debris with a moist, sensate surface that demonstrates capillary blanching and refill. Wounds must be inspected regularly for nonadherence and signs of infection. Early fluid accumulation requires prompt aspiration. Biobrane should be removed if fluid reaccumulates or the Biobrane becomes nonadherent at any time after 48 hours. When used appropriately, Biobrane offers significant advantages over conventional therapy of acute partial-thickness burns.

Combined topical use of silver sulfadiazine and antibiotics as a possible solution to bacterial resistance in burn wounds

The superior efficacy of quinolones (norfloxacin, pefloxacin, and enoxacin) in controlling burn wound infections signals the discovery of new topical agents. However, there are a few reports on the emergence of resistant mutants to quinolones. Since attempts to develop AgSD resistant strains in vitro were unsuccessful and the emergence of AgSD resistance in vivo is a rare occurrence, we decided to investigate if the combined use of AgSD with other effective antibiotics, especially quinolones, would minimize the development of resistant bacteria. Our in vitro results indicate that when Ps. aeruginosa cultures were serially transferred 10 times through subinhibitory concentrations of norfloxacin, pefloxacin, etc., the MIC increased 40 times while when the cultures were passed through a combination of AgSD and these quinolones, the MIC of quinolones increased only tenfold. In vivo, when burned mice infected with either AgSD sensitive or resistant Ps. aeruginosa strains were treated with a topical cream containing 10mM silver sulfadiazine and 5mM norfloxacin or 5mM pefloxacin, the mortality was much lower than that of 10mM silver sulfadiazine alone or 5mM quinolones alone. Thus, combined use of silver sulfadiazine and quinolones appears to diminish the ability of Ps. aeruginosa strains to form resistant mutants. Furthermore, when the combination is used as a topical agent in burn wounds, lesser amounts of the individual drug are needed to control infection thereby reducing the toxic effects, if any, associated with these drugs. This combination does not in any way interfere with the antifungal or antibacterial properties of these individual drugs.

The role of topical treatment as a determinant of infection in outpatient burns

Up to 95% of all burned patients are treated as outpatients. While uniform guidelines exist to evaluate the severity of an outpatient's burn, treatment forms vary greatly. Furthermore, the relative merits of one treatment modality over another have not been demonstrated. This study reviews 262 patients with uncomplicated, thermal partial-thickness burns. All of these patients were treated with either a petrolatum fine-mesh gauze (FMG = 102), a topical penetrating antibacterial agent (TPA = 58), or a topical nonpenetrating antibacterial agent (TNA = 102). The size of the injury along with its location and etiology, the age of the patient, the time from injury to treatment, and comorbid factors were comparable among the major treatment groups. On follow-up, a wound was classified as infected if it exhibited erythema, tenderness, increased warmth, and edema (cellulitis). Infection rates were 2.0% (2/102) in the FMG group, 5.2% (3/58) in the TPA group, and 2.0% (2/102) in the TNA group. The differences among the rates did not reach statistical significance (P = 0.41). Given the cost of treatment, frequency of dressing changes and overall patient comfort, we advocate FMG as the optimal method for the care of uncomplicated partial-thickness outpatient burns.

Comparison of standard and chlorhexidine-derivative topical antibacterial agents on the infected burned rat wound

The effect of daily treatment with three current topical antibacterial agents and four experimental formulations of chlorhexidine was evaluated after 1 week in rats with full thickness burns. The burn was seeded with 1 x 10(8) colony forming units (CFU) of a strain of P. aeruginosa isolated from the infected wound of a burn patient. Mafenide acetate resulted in the lowest incidence of muscle invasion and yielded the lowest mean eschar and muscle concentrations. Mafenide acetate, gentamicin, and chlorhexidine diphosphanilate (0.5 per cent) had lower mean eschar and muscle concentrations than silver sulphadiazine 1 per cent alone. Addition of chlorhexidine digluconate (0.5 per cent or 1.0 per cent) to silver sulphadiazine reduced mean eschar concentrations but not muscle concentrations compared to silver sulphadiazine alone. All treatments effectively suppressed systemic invasion of lung and blood and prevented death compared with controls. Mafenide acetate, gentamicin sulphate and chlorhexidine disphosphanilate 0.5 per cent were most effective against this patient strain of P. aeruginosa.

Topical silver sulphadiazine--a new drug for ocular keratomycosis

The efficacy of silver sulphadiazine in human keratomycosis has not been evaluated so far. Encouraged by the success of an earlier experimental trial, a prospective, controlled, randomised double masked clinical study was designed to evaluate the efficacy of 1% silver sulphadiazine ophthalmic ointment in 20 eyes of mycotic keratitis. Miconazole 1% was used for comparative evaluation in another 20 eyes. Silver sulphadiazine had a higher success rate (80% vs 55%) than miconazole. It had broad antifungal activity and was found to be effective in fusarium keratitis. Absence of side effects, economy, and its efficacy in deeper and extensive lesions were additional advantages. It is concluded from this study that silver sulphadiazine is a safe and effective broad spectrum antifungal agent which can be used for the treatment of human keratomycosis.

Comparative evaluation of aloe vera in the management of burn wounds in guinea pigs

An experimental study was designed using Hartley guinea pigs, who received full-thickness burns covering 3 percent of their body surface area by direct contact with a hot plate. A total of 40 animals were equally divided among four modalities of closed burn wound management as follows: group I: silver sulfadiazine (Silvadine); group II: aloe vera gel extract (Carrington Dermal Wound Gel); group III: salicylic acid cream (aspirin); and group IV: plain gauze occlusive dressing only. The dressings were changed daily, and the size and appearance of each burn wound were recorded until complete healing. On the sixth postburn day, quantitative burn wound cultures were made. The average time to complete healing in the control group was 50 days, and the only significant difference was found in the aloe vera-treated animals, which healed on an average of 30 days (p less than 0.02). Wound bacterial counts were effectively decreased by silver sulfadiazine (p = 0.015) and by aloe vera extract (p = 0.015). From our data it appears that aloe gel extracts permit a faster healing of burn wounds.

Randomized study of six umbilical cord care regimens. Comparing length of attachment, microbial control, and satisfaction

Two hundred and seventy one infants were enrolled in a study to compare six different methods of treating the umbilical cord. Antimicrobial control was equal for all methods. Repeated triple dye application was considered least acceptable by staff and parents and had the longest attachment time. Povidone-iodine was associated with the shortest attachment time and was most liked. If there is no special need to treat a specific nosocomial outbreak, duration of cord attachment and satisfaction of staff and parents can help clinicians decide on a cord care regimen.

Pyoderma gangrenosum in an elderly woman. Course marked by extensive morbidity

A case of extensive medical and functional morbidity in an elderly patient during treatment of pyoderma gangrenosum is described. Pyoderma gangrenosum is an uncommon cause of ulcerative skin lesions often involving areas of skin trauma about the lower extremity. Because of the possibility of underlying disease and the special treatment requirements, the condition must be differentiated from other, more common causes of skin ulceration. Treatment includes local care, systemic corticosteroid therapy, and control of any underlying disease. Pyoderma gangrenosum serves as a model for the interactions of various types of morbidity in the healthcare of the elderly.

In vivo comparison of two silver sulfadiazine antimicrobial agents on burn wound infection

A controversy exists with regard to the relative efficacy of two preparations of silver sulfadiazine (AgSD), Silvadene and Flint's Silver Sulfadiazine Cream. We compared the susceptibility of Staphylococcus aureus and clinical Gram-positive cocci, Gram-negative rods, and mixed floral isolates by the Nathan's agar well diffusion method and found no differences. However, when S aureus-infected rat burn wounds were treated with these antimicrobial creams over a period of ten days, Silvadene significantly lowered bacterial counts, whereas results after treatment with Flint's Silver Sulfadiazine Cream were no different from those of the control group, which received no treatment. These data imply that Silvadene controls S aureus-generated burn wound infections better than the Flint product.

A laboratory method to evaluate formulation effects on the in vitro antimicrobial activity of topical creams and ointments

A simple and reproducible method is described to assess the effect of formulation on the bactericidal and fungicidal activity of topical antimicrobial agents. The technique involves direct inoculation of test and control articles followed by aliquot sampling, neutralization of active antimicrobial ingredients and enumeration of viable microorganisms by standard methods. Two silver sulphadiazine cream formulations, differing in their aliphatic alcohol content, were evaluated as manufactured and in diluted forms in this manner using three bacterial and one fungal burn wound isolates. Results were analysed by a multivariate analysis of variance to test formulation effects, concentration effects and their interaction over time. The results demonstrate that the antimicrobial activity of both creams is equivalent.

Release and antimicrobial activity of silver sulphadiazine from different creams

The release and antimicrobial activity of silver sulphadiazine from five different creams were studied: unguentum emulsificans aquosum, unguentum hydrophylicum non ionogenicum, paraffin cream (15 per cent), a homemade preparation and a commercially available preparation (Flamazine). A diffusion cell was used to measure the release and the agar well diffusion technique to determine the antibacterial activity of the silver sulphadiazine released. The paraffin cream (15 per cent) preparation had the highest release rate, followed by the homemade cream and the commercially available cream. The antibacterial activity ran parallel with the release results. This study shows the silver sulphadiazine paraffin cream to be superior to the other four preparations, including the commercially available silver sulphadiazine cream, using release and antibacterial activity as criteria.

Serum and urinary silver levels in thermal injury patients

Although silver sulfadiazine has been used extensively as an effective topical antimicrobial agent in thermal injury patients, little is known about the cutaneous absorption of the silver moiety in these patients. Therefore, we longitudinally evaluated both serum silver concentration and 24-hour urinary excretion of silver in 23 patients with second- and third-degree thermal burns. Mean serum silver concentrations were modestly elevated throughout the patients' hospital course. Urinary excretion of silver was markedly elevated, especially in those patients with more severe burns. Indeed, in patients who had burns covering more than 60% of the total body surface area mean peak silver excretion was 1100 micrograms/24 hr (normal, less than 1 micrograms/24 hr). Thus, silver ion is absorbed across the burn wound in thermal injury patients treated with silver sulfadiazine. The 24-hour urinary excretion of silver appears to be a very sensitive indicator of cutaneous absorption in these patients. Possible implications of this cutaneous silver absorption warrant further evaluation.

Response of varicella zoster virus and herpes zoster to silver sulfadiazine

The addition of silver sulfadiazine to cultures of varicella zoster virus resulted in inactivation of the viral infectivity. At a concentration of 10 micrograms/ml or higher the virus was inactivated after thirty minutes exposure at 37 degrees C. Forty-two patients with herpes zoster were treated topically with 1 percent silver sulfadiazine cream applied four times a day. All patients experienced complete drying of vesicles, marked reduction erythema and edema, and striking elimination of pain and burning sensation within twenty-four to seventy-two hours. The sooner the treatment began after the onset of symptoms, the more dramatic was the response. Postherpetic neuralgia was either mild or did not occur. Signs of local, systemic, or laboratory-documented toxicity were not observed.

Adjunctive surgical management of cutaneous Mycobacterium fortuitum infection

Atypical mycobacteria of the fortuitum-chelonei complex are being identified with increasing frequency as causes of resistant, cutaneous infection. We report a case of Mycobacterium fortuitum infection of the face, unresponsive to conventional antimicrobial therapy, which resolved following adjunctive surgical resection. We believe that prompt surgical debridement of affected tissue in such infections, combined with appropriate antimicrobial therapy, will shorten both the duration and morbidity often associated with this disease.

Drug-loaded synthetic dressings: effect on contraction, epithelialization, and collagen synthesis of deep second-degree experimental burns

The effect of drug-loaded synthetic dressings on the contraction, epithelialization, and collagen synthesis of deep second-degree burns was followed for 21 days in 44 guinea pigs. Two symmetrical burns were inflicted on the back of each animal; the animals were then divided at random into the following test groups: Group 1 (n = 10), a prefabricated, precut, pliable, and noncracking dressing designated as Dimac (DM), versus Dimac plus 2% silver sulfadiazine (DM+); Group 2 (n = 10), Hydron loaded with 2% silver sulfadiazine (HAgS) one versus fine mesh gauze and 1% silver-sulfadiazine cream (GAgS); Group 3 (n = 12), Hydron (Hyd) versus fine mesh gauze (G); Group 4 (n = 4), fine mesh gauze versus Telfa (Tel); Group 5 (n = 6), Telfa versus Telfa; Group 6 (n = 2), gauze versus gauze. Epithelialization and contraction rates were measured at dressing changes on postburn days 6, 12, 18, and 21, with a computerized sonic digitizer. Collagen biosynthesis was measured from the wound scar on PBD 21 and expressed as relative collagen biosynthesis. Contraction on PBDs 18 to 21 was significantly lower (p less than 0.05) in the DM and DM+ treated burns. Epithelialization of the DM and DM+ treated groups on PBD 21 was significantly (p less than 0.05) higher than in the Hyd, HAgS, GAgS, and Tel treated burns, and did not differ from the G treated wounds. The relative collagen biosynthesis method was inapplicable to this burn wound model.

Hyperosmolality induced by propylene glycol. A complication of silver sulfadiazine therapy

An 8-month-old male infant was treated with topical silver sulfadiazine for a burn and complicating toxic epidermal necrolysis involving 78% of his total body surface area. Transdermal absorption of propylene glycol from the silver sulfadiazine produced hyperosmolality with an increased osmolal gap. A peak propylene glycol concentration of 1,059 mg/dL was documented, and its osmotic effect was that predicted from its concentration. Our data support either zero-order elimination at a rate of 13.5 mg/dL/hr or first-order elimination with a half-life of 16.9 hours. Elevated concentrations of propylene glycol may have contributed to the patient's cardiorespiratory arrest. The osmolal gap may be used as a screen for suspected propylene glycol intoxication in selected clinical settings.

Tissue deposition of silver following topical use of silver sulphadiazine in extensive burns

Silver sulphadiazine has been applied to the burn wounds of 509 patients during the past 10 years. Eleven patients with burns covering more than 20 per cent of the body surface showed silver deposits in the mucosa of the lips, gingiva and cheeks. The colour of the burn wound was also slightly darker than in patients not treated with silver compounds. This darker colour spontaneously disappeared during the year following discharge from hospital. The pathogenesis of silver deposition has been discussed in relation to other published studies.

Synergistic action of silver sulfadiazine and sodium piperacillin on resistant Pseudomonas aeruginosa in vitro and in experimental burn wound infections

Silver sulfadiazine-resistant organisms are arising at an irregular rate and may eventually interfere with wound management. To counter this problem several new antibacterial agents were tested in combination with silver sulfadiazine. Only sodium piperacillin (Pipracil, Lederle) exhibited synergism with silver sulfadiazine both in vitro (against various species of organisms) and in burned animals. The MIC of AgSD and Pipracil was 50 nmole/ml and 250 nmole/ml, respectively, but a combination of 6 nmole/ml of AgSD and 7.5 nmole/ml of Pipracil inhibited the growth of Pseudomonas aeruginosa. In burned mice infected with either AgSD-resistant or sensitive strains, the mortality in groups receiving combinations of topical Pipracil and silver sulfadiazine was 0-10%; in contrast, treatment with Pipracil or silver sulfadiazine alone resulted in much higher mortality. Thus it would appear that a combination of silver sulfadiazine and Pipracil, each of which have long been used in patients topically and parenterally, may prove valuable in patients with burn wound infections related to or caused by organisms resistant to silver sulfadiazine.

The effect of topical hyperalimentation on wound healing rate and granulation tissue formation of experimental deep second degree burns in guinea-pigs

Revital , a product containing 19 amino acids, was applied to experimental deep second degree burns in guinea-pigs for 24 days, in order to assess the effect of this form of hyperalimentation on the healing process. Silver sulphadiazine cream served as the contralateral control standard. Epithelialization was faster in the silver sulphadiazine treated burn wounds, while contraction of both tested wounds proceeded at a similar rate. Revital significantly enhanced the formation of granulation and scar tissue in this burn wound model. These observations indicate that topical wound hyperalimentation promotes granulation tissue formation of experimental deep second degree burns in guinea-pigs.

Silver sulfadiazine: an antibacterial agent for topical use in burns. A review of the literature

Topical antibacterial treatment is of major importance in the burn patient. Silver sulfadiazine is an effective agent with low toxicity and few side effects. Deposition of silver in tissues, and absorption of sulfadiazine are both minimal. Present and future problems are represented by the emergence of resistant Gram negative bacilli, including Pseudomonas aeruginosa. The development of related metal sulfadiazines to be used against resistant bacteria is on an investigational stage, and clinical trials are few. Silver sulfadiazine may be used in a variety of other conditions than burns.

Topical therapy and the development of silver sulfadiazine

Topical therapy is a selective approach to the prevention and treatment of infection in burns and other surgical wounds. Effective compounds possess certain chemical and physical properties. Prerequisites include low solubility, slow absorption, nonreactivity with wound exudates, proteins and ions and ability to achieve prolonged antimicrobial activity in the wound. These compounds yield much higher levels in the zone of infection than can be achieved by diffusion into the wound after systemic administration. The wide spectrum of antibacterial activity, the low toxicity, minimal tissue reaction, ease of application suggest that topical silver sulfadiazine therapy can safely be extended to other wound infections, wound covers and certain transplant materials.

The role of topical dimethyl sulfoxide in burn wound infection: evaluation in the rat

The results of this study indicated that there were no statistically significant differences between the effectiveness of 1% silver sulfadiazine in DMSO and 1% silver sulfadiazine in a hydrophilic base (Silvadene), when these formulations were used as antimicrobials applied topically to thermal burn wounds. The antimicrobial efficacy of silver sulfadiazine was not destroyed by mixing this agent with DMSO, since the recovery of Pseudomonas aeruginosa was significantly lower in all animals treated with silver sulfadiazine, whatever the formulation, when compared to animals not treated with silver sulfadiazine. Further studies with higher concentrations of silver sulfadiazine in DMSO may be useful. Although the concept of DMSO as a medicinal "carrier" is not novel, with further investigation, it may prove to be germane in the treatment of eschar-covered thermal burns.

Electron-microscopic observation on silver deposition in burn wounds treated with silver sulphadiazine cream

The absorption and distribution of silver has been studied in 8 burned patients treated with silver sulphadiazine cream by electron-microscopic examination. Biopsies were taken from the burn wounds and from epithelized areas surrounding wounds. Only 1 to 2 patients treated for 12 days was observed to have silver deposits in the cytoplasm of both the epidermal cells and sweat glands. The silver deposits appeared as roughly round and oval bodies of varied size. The results indicated that very little of the silver moiety in silver sulphadiazine cream penetrated the body through the wound.