Procutase versus 1% silver sulphadiazine in the treatment of minor burns

Wound infection among children with moderate burns - An explorative review of the association between reported frequency and diagnosis

INTRODUCTION

The Linkoping burn centre in Sweden has, even though being a high income country, reported high burn wound infections (BWI) frequencies in scalded children compared to similar populations in other parts of the world.

AIM

The aim was to investigate possible explanations for differences in frequency of BWI among children with partial thickness burns treated at the Linköping burn centre in Sweden, and that reported in other studies.

METHOD

In order to investigate what BWI criteria that were used in similar studies a literature search on PubMed Central was done along with a retrospective analysis of children previously diagnosed as infected to confirm or reject the high infection frequency reported earlier.

RESULT

Of the 34 selected publications reporting on BWI frequency 16 (47%) did not define a criteria for the BWI diagnosis and almost a third did not report on wound culturing. Of those who did report the use a third do not mention any bacterial growth found is these cultures. The retrospective analysis on children at the centre did not show any decrease in infection frequency even with some disagreement on onset for the BWI.

CONCLUSION

The reporting of criteria and diagnosis of burn wound infection is highly variable making it difficult to interpret results and come to conclusions. The high frequency of BWI at the centre might be a result of close monitoring due to study participation, use of clean instead of sterile routine at dressing changes or low thresholds for the diagnosis in respect to changes in infection markers.

Recent advances in nanotherapeutics for the treatment of burn wounds

Moderate or severe burns are potentially devastating injuries that can even cause death, and many of them occur every year. Infection prevention, anti-inflammation, pain management and administration of growth factors play key roles in the treatment of burn wounds. Novel therapeutic strategies under development, such as nanotherapeutics, are promising prospects for burn wound treatment. Nanotherapeutics, including metallic and polymeric nanoformulations, have been extensively developed to manage various types of burns. Both human and animal studies have demonstrated that nanotherapeutics are biocompatible and effective in this application. Herein, we provide comprehensive knowledge of and an update on the progress of various nanoformulations for the treatment of burn wounds.

Current status and future outlook of nano-based systems for burn wound management

Wound healing process is a natural and intricate response of the body to its injuries and includes a well-orchestrated sequence of biochemical and cellular phenomena to restore the integrity of skin and injured tissues. Complex nature and associated complications of burn wounds lead to an incomplete and prolonged recovery of these types of wounds. Among different materials and systems which have been used in treating the wounds, nanotechnology driven therapeutic systems showed a great opportunity to improvement and enhancement of the healing process of different type of wounds. The aim of this study is to provide an overview of the recent studies about the various nanotechnology-based management of burn wounds and the future outlook of these systems in this area. Laboratory and animal models for assessing the efficacy of these systems in burn wound management also discussed.

Icariin-Loaded Polyvinyl Alcohol/Agar Hydrogel: Development, Characterization, and In Vivo Evaluation in a Full-Thickness Burn Model

Tissue regeneration has become a promising strategy for repairing damaged skin tissues. Among the hydrogels for tissue regeneration applications, topical hydrogels have demonstrated great potential for use as 3D-scaffolds in the burn wound healing process. Currently, no report has been published specifically on icariin-loaded polyvinyl alcohol (PVA)/agar hydrogel on full-thickness burn wounds. In the present study, burn tissue regeneration based on biomimetic hydrogel scaffolds was used for repairing damaged extracellular matrix. Furthermore, a skin burn model was developed in rats, and the icariin-loaded PVA/agar hydrogels were implanted into the damaged portions. The regeneration of the damaged tissues with the help of the icariin-loaded hydrogel group exhibited new translucent skin tissues and repaired extracellular matrix, indicating that the hydrogel can enhance the wound healing process. Moreover, characterization studies such as X-ray diffraction, Fourier-transformed infrared spectroscopy, and differential scanning calorimetry reported the extent of compatibility between icariin and its polymers. Results of the field emission scanning electron microscopy images revealed the extent of the spread of icariin within the polymer-based hydrogel. Furthermore, the wound healing potential, confirmed by histopathological and histochemical findings at the end of 21 days, revealed the visual evidence for the biomimetic property of icariin-loaded PVA/agar hydrogel scaffolds with the extracellular matrix for tissue regeneration.

Comparative study of Silver Sulfadiazine with other materials for healing and infection prevention in burns: A systematic review and meta-analysis

The aim of this systematic review with meta-analysis was to compare the effect of Silver Sulfadiazine (SSD) with other new dressings, with or without silver, on healing and infection prevention in burns. The electronic search was carried out in the electronic databases of Pubmed, ScienceDirect, Lilacs and BVS. The articles included were randomized clinical trials about burn treatment with SSD, which evaluated the healing and infection of burn wounds in humans. The exclusion criteria included articles, editorials and letters published in the form of abstracts, unpublished reports and case series, cross-sectional, observational experimental studies, and the use of sulfadiazine for other types of wounds. The search identified 873 references, and 24 studies were included in accordance with the eligibility criteria. The results showed a statistically favorable difference related to the time of healing for silver dressings (p<0.0001; MD 3.83; 95% CI 2.03-5.62) and dressings without silver (p<0.007; MD 2.9; 95% CI 0.81-5.00) in comparison with SSD. The rate of infection showed no difference in the group treated with SSD compared with the group treated with dressings containing silver (p>0.05). The rate of infection was significantly higher in the SSD group compared with the group treated with dressings without silver (p<0.005; MD 25.29% and MD 12.97%). Considering the clinical trials conducted up to the present time, the authors concluded that new dressings with and without silver show better results than SSD for wound healing, and burns treated with dressings without silver are less likely to become infected than burns with SSD. No differences between SSD and new silver materials were observed in relation to infection prevention.

Nursing preference of topical silver sulfadiazine versus collagenase ointment for treatment of partial thickness burns in children: survey follow-up of a prospective randomized trial

We performed a nursing survey to inquire about nursing preferences toward the use of silver sulfadiazine (SSD) and collagenase (CO). We performed a survey between September 2012 and December 2012 asking nurses to rate the application/removal of both products and provide a description of their preferences. Ten study nurses (83%) preferred CO over SSD (P < .001). Two nurses (17%) had no preference. Negative comments on SSD were pseudoeschar (50%), difficult application burns (25%), messiness (67%), and increased number of dressing changes (25%). Negative comments on CO were the need for an additional antimicrobial agent (58%), although 1 nurse noted the higher expense with CO. Nurses preferred CO because of cleanliness of dressing (17%), lack of pseudoeschar (25%), and less pain with dressing changes (8%). Despite no difference in outcomes between SSD and CO, experienced burn nurses prefer CO because of perceptions of decreased trauma and frequency of dressing changes.

The efficacy of hydrogel dressings as a first aid measure for burn wound management in the pre-hospital setting: a systematic review of the literature

The aim of this systematic review was to determine the supporting evidence for the clinical use of hydrogel dressings as a first aid measure for burn wound management in the pre-hospital setting. Two authors searched three databases (Ovid Medline, Ovid Embase and The Cochrane Library) for relevant English language articles published through September 2014. Reference lists, conference proceedings and non-indexed academic journals were manually searched. A separate search was conducted using the Internet search engine Google to source additional studies from burns advisory agencies, first aid bodies, military institutions, manufacturer and paramedic websites. Two authors independently assessed study eligibility and relevance of non-traditional data forms for inclusion. Studies were independently assessed and included if Hydrogel-based burn dressings (HBD) were examined in first aid practices in the pre-hospital setting. A total of 129 studies were considered for inclusion, of which no pre-hospital studies were identified. The review highlights that current use of HBD in the pre-hospital setting appears to be driven by sources of information that do not reflect the paramedic environment. We recommend researchers in the pre-hospital settings undertake clinical trials in this field. More so, the review supports the need for expert consensus to identify key demographic, clinical and injury outcomes for clinicians and researchers undertaking further research into the use of dressings as a first aid measure.

Do silver-based wound dressings reduce pain? A prospective study and review of the literature

Silver-containing dressings are a mainstay in the management of burn injury and acute and chronic wounds. In addition to antimicrobial activity, there is anecdotal evidence that silver dressings may modulate or reduce wound pain. Pain is subjective and difficult to quantify, and most studies of silver-containing dressings evaluate pain as a secondary rather than a primary outcome. Nevertheless, a dressing with a proven ability to reduce pain independent of systemic analgesics would have great utility. In this study, we compared patient-reported pain levels in patients previously randomized to receiving silver-nylon dressings vs. conventional gauze dressings in a study of surgical site infection. Compared to gauze dressings, patients in the silver dressing group reported less pain between postoperative days 0 and 9 (p<0.02). Post hoc analysis of analgesic use did not reach statistical significance between the groups. The study was completed with a literature review of the effect of silver on pain. Silver-based dressings may reduce wound pain by providing an occlusive barrier or by other as-yet undefined mechanisms. The role of silver in pain relief, however, cannot be definitively stated until well-designed prospective randomized studies evaluating pain as a primary endpoint are carried out.

Polymeric hydrogels for burn wound care: Advanced skin wound dressings and regenerative templates

Wound closure represents a primary goal in the treatment of very deep and/or large wounds, for which the mortality rate is particularly high. However, the spontaneous healing of adult skin eventually results in the formation of epithelialized scar and scar contracture (repair), which might distort the tissues and cause lifelong deformities and disabilities. This clinical evidence suggests that wound closure attained by means of skin regeneration, instead of repair, should be the true goal of burn wound management. The traditional concept of temporary wound dressings, able to stimulate skin healing by repair, is thus being increasingly replaced by the idea of temporary scaffolds, or regenerative templates, able to promote healing by regeneration. As wound dressings, polymeric hydrogels provide an ideal moisture environment for healing while protecting the wound, with the additional advantage of being comfortable to the patient, due to their cooling effect and non-adhesiveness to the wound tissue. More importantly, recent advances in regenerative medicine demonstrate that bioactive hydrogels can be properly designed to induce at least partial skin regeneration in vivo. The aim of this review is to provide a concise insight on the key properties of hydrogels for skin healing and regeneration, particularly highlighting the emerging role of hydrogels as next generation skin substitutes for the treatment of full-thickness burns.

Antibiotic prophylaxis for preventing burn wound infection

BACKGROUND

Infection of burn wounds is a serious problem because it can delay healing, increase scarring and invasive infection may result in the death of the patient. Antibiotic prophylaxis is one of several interventions that may prevent burn wound infection and protect the burned patient from invasive infections.

OBJECTIVES

To assess the effects of antibiotic prophylaxis on rates of burn wound infection.

SEARCH METHODS

In January 2013 we searched the Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE - In-Process & Other Non-Indexed Citations (2013); Ovid EMBASE; EBSCO CINAHL and reference lists of relevant articles. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that evaluated the efficacy and safety of antibiotic prophylaxis for the prevention of BWI. Quasi-randomised studies were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias, and extracted relevant data. Risk ratio (RR) and mean difference (MD) were estimated for dichotomous data and continuous data, respectively. When sufficient numbers of comparable RCTs were available, trials were pooled in a meta-analysis to estimate the combined effect.

MAIN RESULTS

This review includes 36 RCTs (2117 participants); twenty six (72%) evaluated topical antibiotics, seven evaluated systemic antibiotics (four of these administered the antibiotic perioperatively and three administered upon hospital admission or during routine treatment), two evaluated prophylaxis with non absorbable antibiotics, and one evaluated local antibiotics administered via the airway.The 11 trials (645 participants) that evaluated topical prophylaxis with silver sulfadiazine were pooled in a meta analysis. There was a statistically significant increase in burn wound infection associated with silver sulfadiazine compared with dressings/skin substitute (OR = 1.87; 95% CI: 1.09 to 3.19, I(2) = 0%). These trials were at high, or unclear, risk of bias. Silver sulfadiazine was also associated with significantly longer length of hospital stay compared with dressings/skin substitute (MD = 2.11 days; 95% CI: 1.93 to 2.28).Systemic antibiotic prophylaxis in non-surgical patients was evaluated in three trials (119 participants) and there was no evidence of an effect on rates of burn wound infection. Systemic antibiotics (trimethoprim-sulfamethoxazole) were associated with a significant reduction in pneumonia (only one trial, 40 participants) (RR = 0.18; 95% CI: 0.05 to 0.72) but not sepsis (two trials 59 participants) (RR = 0.43; 95% CI: 0.12 to 1.61).Perioperative systemic antibiotic prophylaxis had no effect on any of the outcomes of this review.Selective decontamination of the digestive tract with non-absorbable antibiotics had no significant effect on rates of all types of infection (2 trials, 140 participants). Moreover, there was a statistically significant increase in rates of MRSA associated with use of non-absorbable antibiotics plus cefotaxime compared with placebo (RR = 2.22; 95% CI: 1.21 to 4.07).There was no evidence of a difference in mortality or rates of sepsis with local airway antibiotic prophylaxis compared with placebo (only one trial, 30 participants).

AUTHORS' CONCLUSIONS

The conclusions we are able to draw regarding the effects of prophylactic antibiotics in people with burns are limited by the volume and quality of the existing research (largely small numbers of small studies at unclear or high risk of bias for each comparison). The largest volume of evidence suggests that topical silver sulfadiazine is associated with a significant increase in rates of burn wound infection and increased length of hospital stay compared with dressings or skin substitutes; this evidence is at unclear or high risk of bias. Currently the effects of other forms of antibiotic prophylaxis on burn wound infection are unclear. One small study reported a reduction in incidence of pneumonia associated with a specific systematic antibiotic regimen.

Dressings for superficial and partial thickness burns

BACKGROUND

An acute burn wound is a complex and evolving injury. Extensive burns produce systemic consequences, in addition to local tissue damage. Treatment of partial thickness burn wounds is directed towards promoting healing and a wide variety of dressings are currently available. Improvements in technology and advances in understanding of wound healing have driven the development of new dressings. Dressing selection should be based on their effects on healing, but ease of application and removal, dressing change requirements, cost and patient comfort should also be considered.

OBJECTIVES

To assess the effects of burn wound dressings on superficial and partial thickness burns.

SEARCH METHODS

For this first update we searched The Cochrane Wounds Group Specialised Register (searched 8 November 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); Ovid MEDLINE (2008 to October Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, November 07, 2012); Ovid EMBASE (2008 to 2012 Week 44); AND EBSCO CINAHL (1982 to 2 November 2012).

SELECTION CRITERIA

All randomised controlled trials (RCTs) that evaluated the effects of burn wound dressings on the healing of superficial and partial thickness burns.

DATA COLLECTION AND ANALYSIS

Two authors extracted the data independently using standardised forms. We assessed each trial for internal validity and resolved differences by discussion.

MAIN RESULTS

A total of 30 RCTs are included in this review. Overall both the quality of trial reporting and trial conduct were generally poor and meta analysis was largely precluded due to study heterogeneity or poor data reporting. In the context of this poor quality evidence, silver sulphadiazine (SSD) was consistently associated with poorer healing outcomes than biosynthetic (skin substitute) dressings, silver-containing dressings and silicon-coated dressings. Burns treated with hydrogel dressings appear to heal more quickly than those treated with usual care.

AUTHORS' CONCLUSIONS

There is a paucity of high-quality evidence regarding the effect of different dressings on the healing of superficial and partial thickness burn injuries. The studies summarised in this review evaluated a variety of interventions, comparators and clinical endpoints and all were at risk of bias. It is impossible to draw firm and confident conclusions about the effectiveness of specific dressings, however silver sulphadiazine was consistently associated with poorer healing outcomes than biosynthetic, silicon-coated and silver dressings whilst hydrogel-treated burns had better healing outcomes than those treated with usual care.

Hydrogels for biomedical applications

Hydrogels are swollen, crosslinked networks that have great potential for use in biomedicine. Their softness, biocompatibility and ability for rapid diffusion of molecules make them useful for drug delivery, cell culture, wound healing and sensing applications. The chemical functionality of the gels can be easily modified to provide signalling and growth factors for cell proliferation. To allow the ingress of large cells, either porosity of the substrate can be controlled, or the gel can be made biodegradable. One ultimate goal is the growth of entire organs in the laboratory for eventual transplantation. Gels can be used as drug-delivery vehicles, either as implantable depots, or as microgels in blood-based delivery systems. One expanding area is the use of gels as surgical aides to prevent bleeding, infection and post-operative complications.

A systematic review of silver-containing dressings and topical silver agents (used with dressings) for burn wounds

Silver preparations are commonly used for burns, but evidence of their effectiveness remains poorly defined. The aim of the study was to evaluate the effectiveness of silver-containing dressings and topical silver for preventing infection and promoting healing in burns wounds through a meta-analysis of the available evidence. The Cochrane Central Register of Controlled Trials and relevant databases were searched. Drug companies and experts in this field were also contacted. Randomised controlled trials (RCTs) of silver dressings or topical silver (used with dressings) compared with non-silver dressings were eligible for inclusion. We identified 14 RCTs involving 877 participants. One small trial of a silver-containing dressing showed significantly better healing time compared to the control [MD -3.6; 95% CI -4.94 to -2.26 for partial thickness burns and MD -3.9; 95% CI -4.54 to -3.26 for superficial burns]. Topical silver showed significantly worse healing time compared to the non-silver group [WMD 3.96; 95% CI 2.41-5.51] and showed no evidence of effectiveness in preventing wounds infection [WMD 2.48; 95% CI 0.39-15.73]. Our review suggests that silver-containing dressings and topical silver were either no better or worse than control dressings in preventing wound infection and promoting healing of burn wounds.

Optimized antimicrobial and antiproliferative activities of titanate nanofibers containing silver

Titanate nanofibers containing silver have been demonstrated through the experiments reported herein to have effective antifungal and antiproliferative activities in the presence of UV light. The titanate nanofibers containing silver can be fabricated by means of ion exchange followed by a topochemical process in an environment suitable for reductive reactions. Excellent antibacterial, antifungal, and antiproliferative activities could be demonstrated by both Ag₂Ti₅O₁₁ · xH₂O and Ag/titanate (UV light irradiation) due to their unique structures and compositions, which have photocatalytic activities to generate reactive oxygen species and capabilities to continuously release the silver ions. Therefore these materials have the potential to produce a membrane for the treatment of superficial malignant tumor, esophageal cancer, or cervical carcinoma. They may also hold utility if incorporated into a coating on stents in moderate and advanced stage esophageal carcinoma or for endoscopic retrograde biliary drainage. These approaches may significantly reduce infections, inhibit tumor growth, and importantly, improve quality of life and prolong survival time for patients with tumors.