1/19 The Role of Topical Silver Preparations in Wound Healing Nancy Tomaselli Wound, Ostomy and Continence Nurses Society July/August 2006

2/19  This article reviews the effects of silver on wound bioburden and its role in the management of complex wounds.  Many wounds healing by secondary intention become indolent, resulting in pain and suffering to the patient and increased healthcare costs.

3/19  Wound bioburden impedes healing and compromises the effectiveness of advanced wound care therapies.  Identifying bioburden as the cause of indolent wound healing is difficult because many affected wounds do not exhibit classic signs of infection and, therefore, go untreated

4/19 History  1900s: colloidal silver was used to treat indolent wounds  1920s: the US Food and Drug Administration accepted colloidal silver as a wound treatment.  1940s: research on medical applications of silver declined.  1968: 35 years later, is still the leading topical agent for the treatment of burns

5/19 Wound Bed Preparation  Silver preparations may not be effective if the steps to optimize the wound bed are not addressed before initiating therapy.  optimize the wound bed to ensure unimpeded tissue repair and regeneration.

6/19  Specificinterventions required to achieve this goal include debridement,elimination of bacterial burden, establishing a moisture balance, eliminating edema, correcting causativefactors, and addressing local and systemic factors.  Silver agents contribute to wound bed prepara- tion by controlling the bacterial bioburden  silver preparationsshould be used as a compo- nent of a total wound bed preparationplan if they are to be effective Wound Bed Preparation

7/19 Levels of Bacterial Contamination  The first level of bacterial involvement is contamination  The second level of bacterial involvement is colonization  The third level of bacterial involvement is critical colonization  The fourth level of bacterial involvement is infection

8/19 Levels of Bacterial Contamination  Contamination All chronic wounds are contaminated,but this level of bacterial presence does not interfere with tissue repair and is therefore considered normal  colonization organisms attach to the wound bed and begin to multiply, but no accompanying host response and no interferencewith wound healing

9/19 Levels of Bacterial Contamination  critical colonization 1.Bacteria that generate more potent toxins are more virulent and are associated with greater tissue damage. 2.its presence does not typically produce the redness,heat, swelling, and pain that are traditionally  infection Concentrations of 10 5 of bacteria per gram of tissue indicate a clinical infection.

10/19 Antimicrobial Benefits of Topical Silver Preparations  One of the reasons for the renewed interest in the use of silver preparations is the increasing incidence of bacterial resistance and the recognition that antibiotics should be reserved for invasive infections.  Low levels of silver can prevent replication and cause the death of microorganisms  Silver resulting in antimicrobial activity against a broad range of aerobic, anaerobic, Gram- negative, and Gram-positive bacteria, yeast, filamentous fungi, and viruses

11/19 Antimicrobial Performance of Silver Dressings  Silver is effective against superficial pathogens, but it may not inhibit bacteria that have penetrated a signifi-cant distance into the wound bed  silver is indicated for mild wound infections, but not cellulitis. Antimicrobial silver preparations can be used to help decrease the bacterial count when colonization or critical colonization is suspected.

12/19 Differences in Various Types of Silver Preparations  All silver-based dressings contain the same active ingredient, the silver cation, but use different methods for creating and incorporating a reservoir for the release of the silver cation.  There are differences in the composition of the dressings that affect their performance in terms of maintaining moisture or managing exudate.

13/19  The use of saline should be avoided because it will reduce the release of ionic silver. Papain-urea debriding ointment is inactivated by silver salts and should not be used in combination with antimicrobial silver dressings  Maintenance debridement is needed to remove both bacterial debris and exudate. Differences in Various Types of Silver Preparations

14/19  More silver is not necessarily better because excessive concentrations may delay healing if the silver attacks host cells Differences in Various Types of Silver Preparations

15/19  Providing the patient, family, and care providers with a greater understanding of the treatment plan will encourage their participation in wound management and ensure appropriate application of silver products.  Education includes appropriate wound care techniques, signs and symptoms of infection, and when to contact a healthcare professional. Differences in Various Types of Silver Preparations

16/19 Antimicrobial Silver Dressings

17/19 Antimicrobial Silver Dressings

18/19 Disadvantages of Antimicrobial Topical Silver Preparations  Although silver may reduce the amount of exotoxins being produced, it does not reverse the adverse effects of existing exotoxins.  Gram-negative bacteria are destroyed, endotoxins are released  Concern associated with the overuse of silver and the consequent emergence of bacterial resistance is being raised

19/19 Conclusion  To ensure positive results with advanced wound therapies, bioburden must be reduced.  Topical silver preparations provide excellent antimicrobial protection that reduces wound bioburden and may enhance wound closure.