IntroductionStatement of Issue

The use of silver containing wound dressings and topical agents are common in the treatment of partial thickness burns.

This product’s efficacy needs to be established if silver is going to continue to be used as a standard protocol of burn wound dressings (Storm-Versloot, Vos, Ubbink & Vermeulen, 2010).

Clinical Relevance Burn wound infections lead to slower wound healing, increased scarring,

longer hospitalizations, increased costs and the risk for sepsis (Muangman, Pundee, Opasanon& Muangman, 2010).

Faced with many different types of wound dressing options, it is crucial that nurses apply the principles of evidenced based practice to determine which methods are most effective.

The tendency to utilize dressing practices that one is familiar with and comfortable using, must be backed by established clinical outcomes.

Need For Evidenced Based Reviews There is a need for evidenced based review because these products

may be able to decrease the rate of infections in burn wound healing better than non-silver methods.

These products have not been established as an effective alternative to non-silver wound dressings (Hermans, 2006).

However, if proven effective, it could greatly decrease infection rates leading to better patient outcomes.

MethodsTypes of Studies Included

We considered all types of systematic reviews, randomized control trials published in English, prospective randomized control single center studies, randomized comparative cohort clinical trials, quasi experimental trials, open prospective single center parallel group comparative evaluations, descriptive, retrospective descriptive correlational studies and literature review of randomized prospective studies that compared the use of silver containing products versus non silver containing products in burn wound infection rate and healing time.

Types of Interventions We looked at topical silver-containing agents compared with topical

agents without silver, dressings containing silver compared with any dressings without silver, comparisons between alternative topical preparations of silver and comparisons between alternative silver containing dressings.

Databases Searched We searched Ovid MEDLINE, CINAHL and PubMed. With the OvidMEDLINE search, we came up with 92 results and then

narrowed it down to seven with our inclusions and exclusion criteria. Using CINAHL, we came up with 87 results and narrowed them down to

5. Our PubMed search resulted in 139, to which we narrowed them down to

four articles Relevant articles totaled at 16.

We reviewed the abstracts of the search results and selected relevant articles to include in our Evidenced Based Systematic Review. We selected articles based on the following inclusion and exclusion criteria.Inclusion Criteria

All silver containing products

Burn wounds only All classifications of

burns All types of non surgical

burn treatments Humans All Ages All Races

Exclusion Criteria Animals Surgical burn treatments Non burn-related

integumentary wounds Inhalation injuries

Primary Outcomes Wound infection rate Wound Healing/Proportion of

burns healed at a specified timeSecondary Outcomes

Number of dressing changes Cost of dressing changes Level of pain associated with

dressing changes Quality of life Length of hospital stay Antibiotic use Inflammation Use of oral & IV analgesics Surgical intervention

Silver and Burns: A Healing Combination

For adults with partial thickness burns, does the use of silver containing wound dressings, reduce the risk of wound infection within the first 28 days following

burn injury compared to the use of non silver containing wound dressings?

Kate Goss, Kevin Knicely, Ryan Thompson, Alyssa Wolf, Haden Hopkins

Summary of Data

Burns in a 45 year-old woman after 16 days of treatment with silver sulfadiazine (left) and aloe (right) creams.

Burns in a 30 year-old woman with silver sulphadiazine (right) and honey (left).

Eleven days post-injury: silver sulfadiazine-treated side (left) still not completely closed; propolis skin cream-treated

wound (right) is completely re- reepithelialized.

Discussion The efficacy of silver with regards to wound healing time and infection rate

proved to be paradoxical to its intended effect. There was evidence that silver containing products may delay wound

healing and be more painful when applied to burns. Silver containing products may have serious cytotoxic activity on various

host cells (Storm-Versloot, Ubbink & Vermeulen, 2010). Various reports suggest that silver containing products delay wound healing

enhancing the proinflammatory cytokines and its use may lead to abnormal scarring (Piatkowski, 2011).

More studies with a low risk of bias are needed to confirm the effect of silver

containing dressings in burn wounds. Due to the wide variety of silver containing dressings and the lack of well-

controlled experimental studies examining silver containing burn treatments, the research examining this topic needs to be re-evaluated.

Understanding the characteristic of these effects will help use the different types of silver more appropriately.

Recommendations It is recommended that silver products not be used to treat partial thickness

burns until there is better research on these products. Grade B for Infection rates Grade B+ for Healing times

References Caruso, D. M., Foster, K. N., Hermans, M.H., & Rick, C. (2004). Aquacel

Ag in the management of partial-thickness burns: Results of a clinical trial. Journal of Burn Care & Rehabilitation, 25, 89-97. doi: 10.1079/01 .bcr.0000107202.85453.63

Hermans, M. H. (2006). Silver-containing dressings and the need for evidence. American Journal of Nursing, 106, 60-68.

Khorasani, G., Hosseinimehr, S. J., Azadbakht, M., Zamani, A., & Mahdavi, M. R. (2009). Aloe versus silver sulfadiazine creams for second-degree burns: a randomized controlled study. Surg Today. 2009;39(7):587-91. doi: 10.1007/s00595-008-3944-y

Malik, K. I., Malik, MA, & Aslam, A. (2010). Honey compared with silver sulphadiazine in the treatment of superficial partial-thickness burns. International Wound Journal, 7, 413-417.

Muangman, P.; Pundee, C.; Opasanon, S.; Muangman, S. (2010) A prospective, randomized trial of silver containing hydrofiber dressing versus 1% silver sulfadiazine for the treatment of partial thickness burns. International Wound Journal, 7 (4) 271-276

Piatkowski A, Drummer N, Andriessen A, Ulrich D, Pallua N. (2011) Randomized controlled single center study comparing a polyhexanide containing bio-cellulose dressing with silver sulfadiazine cream in partial-thickness dermal burns. Burns. doi:10.1016/j.burns.2011.01.027

Storm-Versloot, M., Vos, C., Ubbink, D., & Vermeulen, H. (2010). Topical silver for preventing wound infection. Cochrane Database of Systematic Reviews, (3), Retrieved from EBSCOhost.

Wasiak J, Cleland H, Campbell F. 2008 Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev. 8;(4):CD002106.

We all contributed equally to this project. We each reviewed databases, relevant articles, and created the poster together.

Systematic Reviews Silver impregnated dressings are likely to reduce

healing rates compared to biosynthetic dressings, hydrogels, silicon coated dressings and antimicrobial dressings (Wasiak, Cleland & Campbell, 2008).

The evidence is inconclusive regarding the effectiveness of silver containing dressings in reducing wound infection rates.

The use of silver impregnated dressings on burn wounds needs to be reconsidered.

Randomized Control Trials Four studies showed faster healing time of the non

silver containing product. Two studies showed equal healing times with both

silver and non silver products. In three studies, infection rates were decreased with

non silver products Four articles showed the exact same infection rate

with silver and on silver products. Only honey, xenoderm and Acticoat another silver

containing dressing, showed decreased infection rates when compared to silver. The other four non silver containing items all had the same infection rate as silver.

Descriptive Overall healing times before and after the

introduction of silver based dressings showed no significant differences. However, pain levels were decreased with the use of silver containing products (Hermans, 2006).

Literature Review The effects of the various silver products on wound

healing are variable. Understanding the characteristics of these effects will help use the different types of silver more appropriately (Bishara, Costagliola, Shady & Saad, 2006).