An in vitro study of the anti-microbial efficacy of a 1% silver sulphadiazine and 0.2% chlorhexidine digluconate cream, 1% silver sulphadiazine cream and a silver coated dressing

Fabrication of gelatin-based antibacterial bilayer wound dressing using direct writing and electrospinning methods

Fabricating a fibrous well-ordered wound dressing for accelerating full-thickness wounds is a desirable treatment vector. Here, through modifications in the material extrusion device and adding a pneumatic-based injection, a material extrusion method for gelatin was introduced with the ability to fabricate 3D structure with repeat layers to support cell activity for the under layer. Furthermore, in the upper layer, the co-electrospinning of PU with gelatin was designed to simultaneously exploit the oxygen permeability and mechanical stability of PU with regenerative properties and collagen-like structure of gelatin. Moreover, zinc oxide nanoparticles (ZnO) was added into the 3D-printed under layer to synergistically benefit from the antibacterial properties of ZnO and the excellent biocompatibility of gelatin. The controllable porosity of the under layer, enabled through the additive manufacturing method, was adjusted to mimic the extracellular matrix of natural tissue with around (127.28 ± 20.70) μm pore size after swelling with smooth fibers. S. aureus, E. coli, Bacillus subtilis, and Pseudomonas with inhibition zone diameters at ∼ 2.14 cm and ∼ 1.96 cm, ∼ 4.01 cm, and ∼ 2.24 cm, respectively. Moreover, the scaffold showed great biocompatibility toward fibroblast cells after 7 days of cell culture with ∼ 89 % cell viability.

The effect of topical magnesium on healing of pre-clinical burn wounds

BACKGROUND

Magnesium (Mg) is an essential factor in the healing process. This study aimed to evaluate the effect of Mg creams on healing burn wounds in the rat model.

METHODS

To induce burns under general anaesthesia, a 2 × 2 cm2, 100 °C plate was placed for 12 s between the scapulas in 100 male adult Sprague Dawley rats. Animals were divided into five groups (n = 20); positive control (induced burn without treatment); vehicle control (received daily Eucerin cream base topically); comparative control (induced burn and treated daily with Alpha burn cream topically); Treatment 1 and 2 (received daily Mg cream 2% and 4% topically, respectively). All animals were bled for hematological assessment of malondialdehyde (MDA) and TNF-α and sacrificed on days 0, 1, 7, 14, and 21 after interventions for biomechanical, histological, and stereological studies.

RESULTS

Stereologically speaking, in treatment groups an increase in dermal collagen volume and fibroblasts was noticed. In treatment groups, the length of vessels, angiogenesis, and skin stretch increased, but the wound area, MDA, and TNF-α level decreased.

CONCLUSION

Mg cream was effective in healing burns.

Application of bacterial nanocellulose-based wound dressings in the management of thermal injuries: Experience in 92 children

BACKGROUND

Management of pediatric thermal injuries involves a high standard of care in a multidisciplinary setting. To avoid physical and psychological sequelae, wound dressings should minimize hospitalization time and anesthesia while maximizing patient comfort.

PATIENTS AND METHODS

190 children with thermal injuries of the torso, arms and legs were treated with polyurethane foam dressings or bacterial nanocellulose sheets. Data were analyzed retrospectively regarding hospitalization, procedures with general anesthesia, scar formation, rate of infection and need for skin grafting.

RESULTS

The groups did not differ significantly concerning age, gender distribution or percentage of injured total body surface area. Statistical analysis showed that length of hospitalized care and procedures undergoing anesthesia were significantly reduced in the nanocellulose group (each p < 0.0001). There was no significant difference in rate of complications, wound healing and rate of skin grafting between the two subgroups.

DISCUSSION

Acting as a temporary epidermal substitute, bacterial nanocellulose enables undisturbed reepithelialization without further wound dressing changes. In children, no additional topical antimicrobial agents are indicated for unimpaired wound healing.

CONCLUSIONS

Bacterial nanocellulose is superior to polyurethane foam regarding length of hospitalization and number of interventions under anesthesia. It offers a safe, cost-effective treatment option and provides excellent comfort in pediatric patients.

Advances in Nanotechnology towards Development of Silver Nanoparticle-Based Wound-Healing Agents

Since antiquity, silver-based therapies have been used in wound healing, wound care and management of infections to provide adequate healing. These therapies are associated with certain limitations, such as toxicity, skin discolouration and bacterial resistance, which have limited their use. As a result, new and innovative wound therapies, or strategies to improve the existing therapies, are sought after. Silver nanoparticles (AgNPs) have shown the potential to circumvent the limitations associated with conventional silver-based therapies as described above. AgNPs are effective against a broad spectrum of microorganisms and are less toxic, effective at lower concentrations and produce no skin discolouration. Furthermore, AgNPs can be decorated or coupled with other healing-promoting materials to provide optimum healing. This review details the history and impact of silver-based therapies leading up to AgNPs and AgNP-based nanoformulations in wound healing. It also highlights the properties of AgNPs that aid in wound healing and that make them superior to conventional silver-based wound treatment therapies.

Current and Emerging Therapies to Combat Cystic Fibrosis Lung Infections

The ultimate aim of any antimicrobial treatment is a better infection outcome for the patient. Here, we review the current state of treatment for bacterial infections in cystic fibrosis (CF) lung while also investigating potential new treatments being developed to see how they may change the dynamics of antimicrobial therapy. Treatment with antibiotics coupled with regular physical therapy has been shown to reduce exacerbations and may eradicate some strains. Therapies such as hypertonic saline and inhaled PulmozymeTM (DNase-I) improve mucus clearance, while modifier drugs, singly and more successfully in combination, re-open certain mutant forms of the cystic fibrosis transmembrane conductance regulator (CFTR) to enable ion passage. No current method, however, completely eradicates infection, mainly due to bacterial survival within biofilm aggregates. Lung transplants increase lifespan, but reinfection is a continuing problem. CFTR modifiers normalise ion transport for the affected mutations, but there is conflicting evidence on bacterial clearance. Emerging treatments combine antibiotics with novel compounds including quorum-sensing inhibitors, antioxidants, and enzymes, or with bacteriophages, aiming to disrupt the biofilm matrix and improve antibiotic access. Other treatments involve bacteriophages that target, infect and kill bacteria. These novel therapeutic approaches are showing good promise in vitro, and a few have made the leap to in vivo testing.

Histopathological Changes of Organs (Lungs, Liver, Kidney, and Brain) After Using Two Types of AgiCoat and Acticoat Nanosilver Dressings on Deep Second-Degree Burn in Rat

Prevention of infections is a very important issue in treating the burn wounds. The nanosilver dressings have many promising advantages, but absorption of silver ions and its adverse effects to the body were always a question. The aim of this study was to compare Silver serum levels and acute toxic effects of nanosilver on histopathology of organs (lungs, liver, kidney, spleen, and brain) in two types of AgiCoat and Acticoat (nanosilver) dressings on second-degree deep burn in rat. This is an experimental study conducted in our animal laboratory. We divided 24 Sprague-Dawley male rats weighing 300 to 350 randomly into two groups. After anesthesia, a second deep-degree burn was made over dorsal skins of rats by standard method. For group A, Agicoat and, for group B, Acticoat dressings were used. The dressings were changed every 3 days with AgiCoat and Acticoat, respectively. After 14 days, we got blood samples and tissue samples taken from heart, liver, kidneys, spleen, lungs, and brain and a sample from dorsal skin of the rat for histopathological examinations. The results showed that the levels of serum silver in both groups were significantly higher than the standard level (1.22 part per million (PM); AgiCoat, P = .017; Acticoat, P = .000), but there was no significant difference between the groups (P = .551). Examination of the relationship between the level of serum silver and histopathological changes in liver showed that hepatotoxicity of AgiCoat was higher compared with Acticoat and the difference was significant (P = .002). There were no pathological changes in brain, kidneys, spleen, heart, and lungs. Wound healing was faster in Acticoat group. The nanosilver dressings can cause toxicity in liver but not in kidney, brain, spleen, heart, and lungs. Liver pathology and hepatotoxicity were more prominent in AgiCoat group. Wound healing was faster in Acticoat group.

Silver nanoparticle based multifunctional approach for combating COVID-19

COVID-19 is a highly contagious and widespread disease that has strained the global healthcare system to the hilt. Silver nanoparticles (AgNPs) are well known for their potent antimicrobial, antiviral, immunomodulatory and biosensing properties. AgNPs have been found to be potential antiviral agent that act against many deadly viruses and is presumed to be effective against COVID-19. AgNPs can generate free radicals and reactive oxygen species (ROS) leading to apoptosis mediated cell death thereby inhibiting viral infection. The shape and size of AgNPs play an important role in its biomedical applications as alterations may result in variable biological interaction and activity. Herein, we propose that AgNPs can be utilized for effective management of the ongoing COVID-19 pandemic by highlighting the current status of AgNPs in the fight against COVID-19.

bFGF and collagen matrix hydrogel attenuates burn wound inflammation through activation of ERK and TRK pathway

Burn injuries are most challenging to manage since it causes loss of the integrity of large portions of the skin leading to major disability or even death. Over the years, hydrogels are considered as a significant delivery system for wound treatment because of several advantages over other conventional formulations. We hypothesized that the bFGF-collagen-AgSD incorporated hydrogel formulation can accelerate the rate of burn healing in animal model and would promote fibroblast cell proliferation. Neovascularization and re-epithelialization is a hall mark of burn wound healing. In the present study, histopathological investigation and scanning electron microscopy of skin tissue of Wistar rats showed almost complete epithelialisation after 16 days in the treatment group. The developed hydrogel showed significantly accelerated wound closure compared with a standard and control group. The faster wound closure resulted from increased re-epithelialization and granulation tissue formation because of the presence of collagen and growth factor. Expressions of proteins such as TrkA, p- TrkA, ERK1/2, p-ERK1/2, NF-kβ, and p-NF-kβ involved in nerve growth factor (NGF) signalling pathway were analysed by western blot. All the findings obtained from this study indicated that the hydrogel can be considered as a promising delivery system against second degree burn by faster healing.

Crafting Polymeric and Peptidic Hydrogels for Improved Wound Healing

Wound healing is a multifaceted biological process involving the replacement of damaged tissues and cellular structures, restoring the skin barrier's function, and maintaining internal homeostasis. Over the past two decades, numerous approaches are undertaken to improve the quality and healing rate of complex acute and chronic wounds, including synthetic and natural polymeric scaffolds, skin grafts, and supramolecular hydrogels. In this context, this review assesses the advantages and drawbacks of various types of supramolecular hydrogels including both polymeric and peptide-based hydrogels for wound healing applications. The molecular design features of natural and synthetic polymers are examined, as well as therapeutic-based and drug-free peptide hydrogels, and the strategies for each system are analyzed to integrate key elements such as biocompatibility, bioactivity, stimuli-responsiveness, site specificity, biodegradability, and clearance.

A study of long-term stability and antimicrobial activity of chlorhexidine, polyhexamethylene biguanide, and silver nanoparticle incorporated in sericin-based wound dressing

In this study, three kinds of antiseptics which were 0.05% chlorhexidine, 0.2% polyhexamethylene biguanide (PHMB), or 200 ppm silver nanoparticle was introduced to incorporate in the sericin-based scaffold to produce the antimicrobial dressing for the treatment of infected chronic wound. The effects of antiseptic incorporation on the stability, release of sericin, and short-term and long-term (6 months) antimicrobial activity of the sericin dressing against gram-negative and gram-positive bacteria were investigated. We showed that the incorporation of each antiseptic did not have significant effect on the internal morphology (pore size ~ 73-105 μm), elasticity (Young's modulus ~ 200-500 kPa), and the sericin release behavior of the sericin-based dressing. The release of sericin from the dressing was prolonged over 120 h and thereafter. Comparing among three antiseptics, 0.05% chlorhexidine incorporated in the sericin dressing showed the highest immediate and long-term (6 months) antimicrobial effect (largest inhibition zone) against most bacteria either gram-positive or gram-negative bacteria. The in vivo safety test following ISO10993 standard (Biological evaluation of medical devices - Part 6: Tests for local effects after implantation) confirmed that the sericin dressing incorporating 0.05% chlorhexidine did not irritate to tissue, comparing with the commercial material used generally in clinic (Allevyn®, Smith & Nephew). We suggested the sericin dressing incorporating 0.05% chlorhexidine for the treatment of infected chronic wound. Chlorhexidine would reduce the risk of infection while the sericin may promote wound healing.

A new, bioactive, antibacterial-eluting, composite graft for infection-free wound healing

The current work focuses on the in vivo performance of a newly developed injectable composite graft in infected full-thickness wounds. The composite graft was composed of bioactive porous Poly dl-lactide-co-glycolide scaffolds, antibiotic gentamicin, and crosslinked gelatin as carrier gel. Treated infected wounds exhibited a faster wound closure, rapid weight gain, lower neutrophil count, higher breaking strength, and 100 times lesser microbial count (10(2) colony forming units/g in infected treated vs. 10(4)  colony forming units/g in infected control group) in comparison with infected control group 28 days post treatment. During healing, collagen production was more in the treated groups at day 7 than controls and thereafter gradually reduced to normal levels. Histology revealed a mature scar tissue formation, fibroblast proliferation, epidermal resurfacing, and collagen deposition in reticular alignment similar to normal healthy skin in treated wounds. Further, the plasma concentration of gentamicin was 35-45 μg/mL during the initial 12 hours and reduced to 1 μg/mL in 24 hours, which indicated safe levels of the antibiotic drug during healing. These results clearly indicate a faster, infection-free, and safe after treatment with the developed graft.

Assessment of the effectiveness of silver-coated dressing, chlorhexidine acetate (0.5%), citric acid (3%), and silver sulfadiazine (1%) for topical antibacterial effects against the multi-drug resistant Pseudomonas aeruginosa infecting full-skin thickness burn wounds on rats

The aim of this study was to compare the effects of four different topical antimicrobial dressings on a multi-drug resistant Pseudomonas aeruginosa contaminated full-thickness burn wound rat model. A total of 40 adult male Wistar albino rats were used. The control group (group 1), silver sulfadiazine (1%) group 2, chlorhexidine acetate (0.5%) group 3, citric acid (3%) group 4, and silver-coated dressing group 5 were compared to assess the antibacterial effects of a daily application to a 30% full-skin thickness burn wound seeded 10 minutes earlier with 10(8) CFU (colony forming unit)/0.5 mL of a multi-drug resistant Pseudomonas aeruginosa strain. Five groups (1 control group and 4 treatment groups) were compared. The administration of third-degree burns to all rats was confirmed based on histopathologic data. The tissue cultures from groups 2 and 5 exhibited significant differences compared to those of the other 3 groups, whereas no significant differences were observed between groups 1, 3, and 4. The effectiveness of the treatments was as follows: 1% silver sulfadiazine > silver-coated dressing > 3% citric acid > 0.5% chlorhexidine acetate > control group. Our results supported the efficacy of topical therapy by silver sulfadiazine and silver-coated dressing on infections caused by multi-drug resistant Pseudomonas spp.

The use of polymeric microcarriers loaded with anti-inflammatory substances in the therapy of experimental skin wounds

We studied the effects of anti-inflammatory substances incorporated in polymeric microparticles made of degradable natural polyhydroxyalkanoate polyesters on experimental skin wounds caused by chemical burns in laboratory animals. Treatment with encapsulated forms of anti-inflammatory substances (applied in gel) accelerated wound healing in comparison with routine therapy (estimated by area of burn wound, wound healing activity, number of acanthotic cells, and number of hair and sebaceous follicles). The results showed the perspectives of usage of developed form of substances (degradable polymeric microparticles) for treatment of skin defects.

Antibacterial properties of metal and metalloid ions in chronic periodontitis and peri-implantitis therapy

Periodontal diseases like periodontitis and peri-implantitis have been linked with Gram-negative anaerobes. The incorporation of various chemotherapeutic agents, including metal ions, into several materials and devices has been extensively studied against periodontal bacteria, and materials doped with metal ions have been proposed for the treatment of periodontal and peri-implant diseases. The aim of this review is to discuss the effectiveness of materials doped with metal and metalloid ions already used in the treatment of periodontal diseases, as well as the potential use of alternative materials that are currently available for other applications but have been proved to be cytotoxic to the specific periodontal pathogens. The sources of this review included English articles using Google Scholar™, ScienceDirect, Scopus and PubMed. Search terms included the combinations of the descriptors "disease", "ionic species" and "bacterium". Articles that discuss the biocidal properties of materials doped with metal and metalloid ions against the specific periodontal bacteria were included. The articles were independently extracted by two authors using predefined data fields. The evaluation of resources was based on the quality of the content and the relevance to the topic, which was evaluated by the ionic species and the bacteria used in the study, while the final application was not considered as relevant. The present review summarizes the extensive previous and current research efforts concerning the use of metal ions in periodontal diseases therapy, while it points out the challenges and opportunities lying ahead.

Use of silver in the prevention and treatment of infections: silver review

BACKGROUND

The use of silver for the treatment of various maladies or to prevent the transmission of infection dates back to at least 4000 b.c.e. Medical applications are documented in the literature throughout the 17th and 18th centuries. The bactericidal activity of silver is well established. Silver nitrate was used topically throughout the 1800 s for the treatment of burns, ulcerations, and infected wounds, and although its use declined after World War II and the advent of antibiotics, Fox revitalized its use in the form of silver sulfadiazine in 1968.

METHOD

Review of the pertinent English-language literature.

RESULTS

Since Fox's work, the use of topical silver to reduce bacterial burden and promote healing has been investigated in the setting of chronic wounds and ulcers, post-operative incision dressings, blood and urinary catheter designs, endotracheal tubes, orthopedic devices, vascular prostheses, and the sewing ring of prosthetic heart valves. The beneficial effects of silver in reducing or preventing infection have been seen in the topical treatment of burns and chronic wounds and in its use as a coating for many medical devices. However, silver has been unsuccessful in certain applications, such as the Silzone heart valve. In other settings, such as orthopedic hardware coatings, its benefit remains unproved.

CONCLUSION

Silver remains a reasonable addition to the armamentarium against infection and has relatively few side effects. However, one should weigh the benefits of silver-containing products against the known side effects and the other options available for the intended purpose when selecting the most appropriate therapy.

Extremity Trauma, Dressings, and Wound Infection

The manner in which high-energy transfer limb injuries are dressed can alter the wound environment through manipulation of the bacterial burden, thus minimizing tissue degradation and influencing healing potential. Infection is the principal complication of such wounds, and antiseptic soaked gauze is accepted in early coverage of extremity wounds despite a lack of evidence to support this practice. There has been resurgence in the use of silver in acute wounds, through dressings manipulated to deliver sustained elemental silver to the wound interface. In vitro and in vivo experimentation of silver dressings are characterized however by methodological compromise, primarily through lack of similarity of models to the physiology of the healing wound. Results from in vitro studies caution against the use of silver because of evidence of cytotoxicity, but this is not reproduced in in vivo or clinical experimentation, leading to ambiguity. Review of silver dressing application in burns and chronic wound studies fails to support its use over other dressing systems. Similarly, evidence for the use of silver in acute limb wounds is lacking. This article provides a comprehensive overview of the use of silver dressings in acute wound care and highlights in particular the paucity of evidence regarding its routine use in extremity injury.

Therapeutic efficacy of an antibiotic-loaded nanosheet in a murine burn-wound infection model

Polymeric ultra-thin films (nanosheets) possess unique properties that make them suitable materials for various biomedical applications. In our previous study, we assessed the use of an antibiotic (tetracycline, TC)-loaded nanosheet (or "TC-nanosheet") for the treatment of gastrointestinal tissue defects. The nanosheet consisted of three functional layers: layer-by-layer nanosheet as a stable platform, TC as an antimicrobial agent with autofluorescence for tracing, and a poly(vinyl acetate) nanosheet to act as a protecting layer. The TC-nanosheet has high flexibility, adhesive strength and transparency. Here, we evaluated the effectiveness of the TC-nanosheet in preventing full thickness burn-wound infections. In an in vivo study, murine dorsal skin was injured by full-thickness burns and then infected with Pseudomonas aeruginosa (P. aeruginosa), a common bacterium causing burn-associated infections. The wound site was treated either with a TC-nanosheet, TC-unloaded nanosheet or left untreated. Wound management was facilitated by the high transparency of the TC-nanosheet. The TC-nanosheet significantly improved burn-wound infection by P. aeruginosa in mice. Indeed, all mice treated with the TC-nanosheet survived, whereas the other treatment groups displayed increased rates of mortality due to bacterial infection. According to histological analyses and viable bacterial counting in the liver (bacterial translocation), the TC-nanosheets were able to prevent not only the local inflammation but also systemic inflammation. We conclude that the TC-nanosheet can act as an effective treatment for full-thickness burn-wound infection. Hence, the TC-nanosheet is a promising therapeutic tool for burn-wound management in severely burn-injured patients.

Subtractive hybridization yields a silver resistance determinant unique to nosocomial pathogens in the Enterobacter cloacae complex

The heterogeneity and the increasing clinical importance of the Enterobacter cloacae complex have often been discussed. However, little is known about molecular factors causing pathogenicity within this nomenspecies. Here, we analyzed the genetic differences between an avirulent plant isolate and a pathogenic strain causing an outbreak with septicemia in three patients. We identified an IncHI-2 plasmid as a major difference between these two strains. Besides resistance to several antibiotics, this plasmid encoded a silver resistance determinant. We further showed that this sil determinant was present not only in the analyzed outbreak strain but also in the vast majority of clinical isolates of the E. cloacae complex, predominantly in (sub)species that frequently cause nosocomial infections. The identified sil determinant was highly conserved within the E. cloacae complex and mediated resistance to up to 600 μM silver nitrate. As silver is often used as a disinfectant and treatment for burn wounds, we present here an important fitness factor within the clinically most prevalent subspecies of the E. cloacae complex. This provides a possible explanation for their unequal involvement in nosocomial and especially burn wound infections.

Polymeric multilayers that localize the release of chlorhexidine from biologic wound dressings

Biologic wound dressings contain animal-derived components and are susceptible to high infection rates. To address this issue, we report an approach that permits incorporation of non-toxic levels of the small molecule antiseptic 'chlorhexidine' into biologic dressings. The approach relies on the fabrication of polyelectrolyte multilayer (PEMs) films containing poly(allylaminehydrochloride) (PAH), poly(acrylicacid) (PAA), and chlorhexidine acetate (CX) on elastomeric poly(dimethylsiloxane) (PDMS) sheets. The PEMs (20-100 nm thick) are subsequently stamped onto the wound-contact surface of a synthetic biologic dressing, Biobrane, which contains collagen peptides. Chlorhexidine loading in the PEMs was tailored by tuning the number of (CX/PAA) bilayers deposited, providing burst release of up to 0.98 ± 0.06 μg/cm(2) of CX over 24 h, followed by zero-order release of 0.35 ± 0.04 μg/cm(2)/day for another week. Although the CX concentrations released were below the reported in vitro cytotoxicity limit (5 μg/mL over 24 h) for human dermal fibroblasts, they killed 4 log(10) counts of pathogenic bacteria Staphylococcus aureus in solution. The CX/PEMs could be stamped onto Biobrane with high efficiency to provide CX release kinetics and in vitro antibacterial activity similar to that on PDMS stamps. In a full-thickness 'splinted' dermal wound-model in normal wild-type mice, the CX-functionalized Biobrane showed no decrease in either its adherence to the wound-bed or wound closure rate over 14 days. The murine wounds topically inoculated with ∼10(5) CFU/cm(2) of S. aureus and treated with CX-functionalized Biobrane demonstrated a 3 log(10) decrease in the wound's bacterial burden within 3 days, compared to persistent bacterial colonization found in wounds treated with unmodified Biobrane (n = 10 mice, p < 0.005). Overall, this study presents a promising approach to prevent bacterial colonization in wounds under biologic dressings.

Effect of Acticoat(®) and Cutinova Hydro(®) on wound healing

In this study, the effects of the wound-covering materials, Acticoat(®) and Cutinova Hydro(®) , on wound healing have been studied in rabbit models with open and tissue-lost wounds with full-thickness flank excisions. Rabbits were used as subjects with three groups of four rabbits each, and trial periods of 7, 14 and 21{\uns}days. Four circular wounds, of 1.5 cm diameter were made two on the right (one of them control) and two on the left (one of them control) of the dorsal sides of the abdomen. Acticoat(®) and Cutinova Hydro(®) were applied on the wounds with suture for a period of 21 days and one each placed on the right and left sides as control with gauze. Biopsy specimens were taken from the animals at the end of the research period to check the length of the epithelium, epithelial thickness, size of wounds, wound granulation tissue formation and histopathological evaluation for clarity. The Acticoat(®) group showed better healing and scar formation compared to the Cutinova Hydro(®) group by macroscopic examination. Epithelial wound length and clarity in terms of statistical difference occurred on day 21 (P <0.05); while the length of the wound epithelium decreased patency, epithelial thickness on days~7, 14 and 21, showed no statistical differences (P >0.05). As a result, the Acticoat(®) wound dressing was determined as a more reliable for the early wound healing. This study has shown the short-term clinical benefits of hydroactive, polyurethane dressings in the management of acute wounds. However, longer periods of wound healing procedure should be planned for reliable and safe results of wound dressing. It has also been concluded that microbiological analyses should be included for more robust and reliable comparisons.

Negative pressure wound therapy in the management of neonates with complex gastroschisis

Negative pressure wound therapy (NPWT) is an accepted form of treatment in managing complex wounds in adults and children. It is not as widely used in the neonatal population due to limited clinical experience. We describe the application of the RENASYS™ system (Smith and Nephew, UK) in delivering NPWT to four neonates with complex gastroschisis, all of whom achieved successful outcomes.

Topical antibacterial agents

Decreased systemic toxicity, ease of application, and increased concentrations at the target site are some of the important advantages topical antibacterial agents offer. This article reviews the literature on selected indications for these agents and provides in-depth examination of specific agents for the prophylaxis and treatment of skin and wound infections.

The association between oral microorgansims and aspiration pneumonia in the institutionalized elderly: review and recommendations

Aspiration pneumonia is a leading cause of illness and death in persons who reside in long-term-care facilities and, combined with the lack of proper oral health care and services, the risk of aspiration pneumonia rises. The purpose of this article is to review recent literature on oral hygiene and oral care in long-term-care facilities and report new findings regarding associated risks for aspiration pneumonia, as well as research on oral care and health outcomes. The PubMed MeSH database was utilized to direct a specific search by entering terms "aspiration pneumonia" and "oral hygiene" from 1970 to 2009, which yielded 34 articles. The Ovid and Google Scholar databases were utilized as well and provided no additional references for the two terms. A manual search of references from other articles, including three systematic reviews published over the past decade, provided additional information regarding oral microorganisms and respiratory pathogens, as well as investigations of oral care. Finally, a brief but comprehensive introductory review was organized regarding oral microorganisms, biofilm, periodontal disease, and pneumonia to establish a framework for discussion. Overall, studies suggest (1) an association between poor oral hygiene and respiratory pathogens, (2) a decrease in the incidence of respiratory complications when patients are provided chemical or mechanical interventions for improved oral care, (3) the complex nature of periodontal disease and aspiration pneumonia make direct connections between the two challenging, and (4) additional studies are warranted to determine adequate oral hygiene protocols for nursing home patients to further reduce the incidence of aspiration pneumonia.

In vitro evaluation of the antimicrobial effectiveness and moisture binding properties of wound dressings

A variety of silver-coated dressings and some impregnated with other chemicals are now available in the market; however, there have been few studies analyzing their comparative efficacies as antimicrobial agents. Moreover, their properties for retaining an appropriate level of moisture that is critical for effective wound healing have never been reported. Five commercially available silver-containing and chlorhexidine dressings, Urgotul SSD(®), Bactigras(®), Acticoat(®), Askina Calgitrol Ag(®) and Aquacel Ag(®), were tested to determine their comparative antimicrobial effectiveness in vitro against five common wound pathogens, namely methicillin-sensitive and -resistant Staphylococcus aureus, Bacillus subtilis, Escherichia coli and Pseudomonas aeruginosa. Mepitel(®), a flexible polyamide net coated with soft silicone, was used as a control. The zones of inhibition and both the rapidity and the extent of killing of these pathogens were evaluated. All five antimicrobial dressings investigated exerted some bactericidal activity, particularly against E. coli. The spectrum and rapidity of action ranged widely for the different dressings. Acticoat(®) had a broad spectrum of action against both Gram-positive and -negative bacteria. Other dressings demonstrated a narrower range of bactericidal activities. Regarding the absorption and release of moisture, Askina Calgitrol Ag(®) absorbed and released the most moisture from the environment. Aquacel Ag(®) also exhibited good moisture absorption and moisture release, but to a lower degree. The other tested dressings absorbed or released very little moisture. Askina Calgitrol Ag(®) and Aquacel Ag(®) are good alternative dressings for treating wounds with high exudates and pus. An understanding of the characteristics of these dressings will be useful for utilizing them for specific requirements under specified conditions.

Use of Acticoat dressings in burns: what is the evidence?

The virtues of silver as an antimicrobial agent have been known for some time. Various silver containing dressings are currently used for the treatment of wounds. Introduced in the late 1990s, Acticoat is a nanocrystalline silver dressing developed to overcome some shortcomings of the older dressings by providing sustained release of silver up to 7 days. We aim to determine the level of evidence available in the literature in view of recent increased usage of Acticoat. A Medline search was conducted to identify articles evaluating the use of Acticoat in burn wounds. A level of evidence adapted from the Oxford Centre for Evidence-Based-Medicine was assigned to each of these articles. Only one study was considered to be LOE 1, which is a multicentre randomised controlled trial comparing Acticoat against Silver Sulfadiazine. One further randomised control trial was downgraded to LOE 2 due to a wide confidence interval. Twenty studies (66%) were LOE 5 of which 6 were case reports and 14 were in vitro/animal studies. The available LOE 1 study demonstrates that Acticoat has better antimicrobial activity compared to another available silver dressing. Other studies suggest Acticoat has fewer adverse effects and reduces healing times. Its ease of application and low frequency of change makes it an ideal dressing in burn wounds. More well designed and properly reported randomised controlled trials are essential for informed clinical decision-making.

Topical antibacterial agents

Decreased systemic toxicity, ease of application, and increased concentrations at the target site are some of the important advantages topical antibacterial agents offer. This article reviews the literature on selected indications for these agents and provides in-depth examination of specific agents for the prophylaxis and treatment of skin and wound infections.

Effects of three different topical antibacterial dressings on Acinetobacter baumannii-contaminated full-thickness burns in rats

In this animal study, three topical antibacterial dressings, Acticoat, chlorhexidine acetate 0.5% and silver sulfadiazine 1%, were compared in the treatment of Acinetobacter baumannii contamination of burns. All treatments were effective and prevented the organism invading the muscle and causing systemic infection, so there were significant differences between the results of the treatment groups and the control group. Mean eschar concentrations did not differ significantly between the silver sulfadiazine and chlorhexidine acetate groups, but there were significant differences between these and the Acticoat group, indicating that Acticoat eliminated A. baumannii from the tissues more effectively.

Bacteriology, inflammation, and healing: a study of nanocrystalline silver dressings in chronic venous leg ulcers

BACKGROUND

Healing of venous leg ulcers (VLUs) is often stalled despite compression therapy. Increased bacterial burden and chronic inflammation are 2 factors that may prevent these chronic VLUs (CVLUs) from healing. There is evidence that nanocrystalline silver dressings may reduce bacterial levels, decrease the chronic inflammatory response, and thus promote wound healing.

OBJECTIVE

To determine the effects of a nanocrystalline silver barrier dressing on wound microflora, wound inflammation, and healing in CVLUs.

METHOD

Stalled VLUs in 15 patients were managed using nanocrystalline silver dressings under 4-layer compression bandages. Paired skin biopsies at baseline and at an average of study week 6.5 were analyzed for bacteria and inflammatory infiltrates. Serum silver levels were monitored, and wound healing was assessed using planimetry.

RESULTS

VLUs in 4 patients healed, and 8 other patients completed the 12-week study. There was a significant reduction in the log10 total bacterial count between baseline and final biopsies (P = .011). Greater numbers of lymphocytes were associated with an increased reduction of ulcer size at week 6.5 and final assessment at week 12 (P < .05). Heavy neutrophilic infiltration in skin biopsies at week 6.5 was associated with high bacterial counts and delayed healing (P = .037). The median reduction in ulcer surface area for all patients was 83.5%. Serum silver levels increased slightly, but values were within the normal range.

CONCLUSION

A nanocrystalline silver dressing combined with 4-layer bandaging was safe and successful in promoting healing in stalled CVLUs. Healing was associated with a reduction in wound bacteria and neutrophilic inflammation with an associated persistent or high lymphocyte count, as determined by wound biopsy.

A retrospective cohort study of Acticoat™ versus Silvazine™ in a paediatric population

We wished to determine whether changing our centre's practice of using Acticoat instead of Silvazine as our first-line burns dressing provided a better standard of care in terms of efficacy, cost and ease of use. A retrospective cohort study was performed examining 328 Silvazine treated patients from January 2000 to June 2001 and 241 Acticoat treated patients from July 2002 to July 2003. During those periods the respective dressings were used exclusively. There was no significant difference in age, %BSA and mechanism of burn between the groups. In the Silvazine group, 25.6% of children required grafting compared to 15.4% in the Acticoat group (p=0.001). When patients requiring grafting were excluded, the time taken for re-epithelialisation in the Acticoat group (14.9 days) was significantly less than that for the Silvazine group (18.3 days), p=0.047. There were more wounds requiring long term scar management in the Silvazine group (32.6%) compared to the Acticoat group (29.5%), however this was not significant. There was only one positive blood culture in each group, indicating that both Silvazine and Acticoat are potent antimicrobial agents. The use of Acticoat as our primary burns dressing has dramatically changed our clinical practice. Inpatients are now only 18% of the total admissions, with the vast majority of patients treated on an outpatient basis. In terms of cost, Acticoat was demonstrated to be less expensive over the treatment period than Silvazine . We have concluded that Acticoat is a safe, cost-effective, efficacious dressing that reduces the time for re-epithelialisation and the requirement for grafting and long term scar management, compared to Silvazine.

Management of local burn wounds in the ED

Each year there are over 500,000 burns that present to the emergency department (ED). Most burns are minor, and their care focuses on local wound management. The current article will present a typical case and then review the epidemiology, pathophysiology, diagnosis, and management of minor burns in the ED.

Silver dressings: their role in wound management

Dressings have a part to play in the management of wounds; whether they are sutured or open, usually chronic wounds of many aetiologies which are healing by secondary intention. They traditionally provide a moist wound environment, but this property has been extended through simple to complex, active dressings which can handle excessive exudate, aid in debridement, and promote disorganised, stalled healing. The control of infection remains a major challenge. Inappropriate antibiotic use risks allergy, toxicity and most importantly resistance, which is much reduced by the use of topical antiseptics (such as povidone iodine and chlorhexidine). The definition of what is an antimicrobial and the recognition of infection has proven difficult. Although silver has been recognised for centuries to inhibit infection its use in wound care is relatively recent. Evidence of the efficacy of the growing number of silver dressings in clinical trials, judged by the criteria of the Cochrane Collaboration, is lacking, but there are good indications for the use of silver dressings, to remove or reduce an increasing bioburden in burns and open wounds healing by secondary intention, or to act as a barrier against cross contamination of resistant organisms such as MRSA. More laboratory, and clinical data in particular, are needed to prove the value of the many silver dressings which are now available. Some confusion persists over the measurement of toxicity and antibacterial activity but all dressings provide an antibacterial action, involving several methods of delivery. Nanocrystalline technology appears to give the highest, sustained release of silver to a wound without clear risk of toxicity.

Silver as biocides in burn and wound dressings and bacterial resistance to silver compounds

Silver products have been used for thousands of years for their beneficial effects, often for hygiene and in more recent years as antimicrobials on wounds from burns, trauma, and diabetic ulcers. Silver sulfadiazine creams (Silvazine and Flamazine) are topical ointments that are marketed globally. In recent years, a range of wound dressings with slow-release Ag compounds have been introduced, including Acticoat, Actisorb Silver, Silverlon, and others. While these are generally accepted as useful for control of bacterial infections (and also against fungi and viruses), key issues remain, including importantly the relative efficacy of different silver products for wound and burn uses and the existence of microbes that are resistant to Ag+. These are beneficial products needing further study, although each has drawbacks. The genes (and proteins) involved in bacterial resistance to Ag have been defined and studied in recent years.

Antimicrobial activities of silver dressings: an in vitro comparison

A range of silver-coated or -impregnated dressings are now commercially available for use but comparative data on their antimicrobial efficacies are limited. The antibacterial activities of five commercially available silver-coated/impregnated dressings were compared against nine common burn-wound pathogens, namely methicillin-sensitive and -resistant Staphylococcus aureus (MRSA), Enterococcus faecalis, Pseudomonas aeruginosa, Escherichia coli, Enterobacter cloacae, Proteus vulgaris, Acinetobacter baumannii and a multi-drug-efflux-positive Acinetobacter baumannii (BM4454), using a broth culture method. The rapidity and extent of killing of these pathogens under in vitro conditions were evaluated. All five silver-impregnated dressings investigated exerted bactericidal activity, particularly against Gram-negative bacteria, including Enterobacter species, Proteus species and E. coli. The spectrum and rapidity of action, however, ranged widely for different dressings. Acticoat and Contreet had a broad spectrum of bactericidal activities against both Gram-positive and -negative bacteria. Contreet was characterized by a very rapid bactericidal action and achieved a reduction of ⩾10 000 c.f.u. ml−1 in the first 30 min for Enterobacter cloacae, Proteus vulgaris, Pseudomonas aeruginosa and Acinetobacter baumanii. Other dressings demonstrated a narrower range of bactericidal activities. Understanding the characteristics of these dressings may enable them to be targeted more appropriately according to the specific requirements for use of a particular dressing, as in for prophylaxis in skin grafting or for an infected wound with MRSA.

Nanocrystalline silver dressings in wound management: a review

This paper describes the properties of nanocrystalline silver products (Acticoat) and their applications and examines available evidence supporting their use in wound management. Acticoat utilizes nanotechnology to release nanocrystalline silver crystals. Acticoat releases 30 times less silver cations than silversulfadiazine cream or 0.5% silver nitrate solution but more of the silver released (by Acticoat). Silver-impregnated slow-release dressings release minute concentrations of silver which are quickly bound up by the chloride in the wound exudate. While extrapolations from in vitro and animal studies are cautious, evidence from these studies suggests Acticoat is: effective against most common strains of wound pathogens; can be used as a protective covering over skin grafts; has a broader antibiotic spectrum activity; and is toxic to keratinocytes and fibroblasts. Animal studies suggest a role for nanocrystalline silver in altering wound inflammatory events and facilitation of the early phase of wound healing. Quality human clinical trials into nanocrystalline silver are few. However, evidence suggests using Acticoat in wound management is cost effective, reduces wound infection, decreases the frequency of dressing changes and pain levels, decreases matrix metalloproteinase activity, wound exudate and bioburden levels, and promotes wound healing in chronic wounds. Although there is no in vivo evidence to suggest nanocrystalline silver is toxic to human keratinocytes and fibroblasts, there is in vitro evidence to suggest so; thus these dressings should be used cautiously over epithelializing and proliferating wounds. Future clinical research, preferably randomized controlled trials into nanocrystalline silver technology, may provide clinicians a better understanding of its applications in wound management.

The use of Acticoat™ in neonatal burns

PURPOSE

To evaluate the safety and efficacy of Acticoat use in primary burn injuries and other skin injuries in premature neonates.

PROCEDURES

An audit of eight premature neonates who sustained burn injuries and other cutaneous injuries from various agents were treated with Acticoat. Serum silver levels were measured in three neonates. Wounds were assessed for infection and blood cultures were taken where sepsis was suspected.

FINDINGS

Neonates ranged from 23 to 28 weeks gestation (weight: 578-1078 g). Causative injury mechanisms included: alcoholic chlorhexidine, alcoholic wipes, electrode jelly, extravasated intravenous fluids, artery illuminator, temperature probe and adhesive tape removal. Total burned body surface area ranged from 1 to 30%. All neonates were treated with Acticoat dressing changed every 3-7 days. All wounds re-epithelialised by day 28 and scar management was not required. There were four mortalities secondary to problems associated with extreme prematurity. Serum silver levels ranged from 0 to 1 micromol/L. There were no wound infections or positive blood cultures during the treatment period.

CONCLUSIONS

Acticoat is a suitable dressing for premature neonates who have sustained burn injury, with the advantage of minimal handling as the dressing need only be changed every 3-7 days.