was used to treat indolent wounds because it was found to

diminish rubor, suggesting a change from an inﬂamed to

noninﬂamed healing state. In the 1920s, the US Food and

■

July/August 2006 367



Nancy Tomaselli, MSN, RN, CS, CRNP, CWOCN, CLNC, President

and CEO of Premier Health Solutions, Cherry Hill, New Jersey.

Corresponding author: Nancy Tomaselli, MSN, RN, CS, CRNP,

CWOCN, CLNC, President and CEO, Premier Health Solutions,

LLC, 4 St. Martins Road, Cherry Hill, NJ 08002

(e-mail: ntomaselli@PremierHealthSolutions.com).

WOUND CARE

The Role of Topical Silver Preparations

in Wound Healing

Nancy Tomaselli

Since ancient times, it has been known that silver reduces

inﬂammation of wounds and promotes healing. Partially owing

to concerns over bacterial resistance and a growing awareness

of the deleterious effects of bacteria and their toxins on wound

healing, a wide variety of silver products are now commercially

available. 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 pa-

tient and increased healthcare costs. The resurgence of in-

terest in silver preparations is directly related to concerns

about the deleterious effects of bacteria and the toxic chem-

icals they produce, commonly referred to as wound bio-

burden, on healing. The character and severity of wound

bioburden are attributable to the quantity of colonized

microbes, the virulence and number of different species

in a particular wound, and the adverse effects of the tox-

ins they produce.1Wound bioburden impedes healing and

compromises the effectiveness of advanced wound care

therapies such as topical exogenous growth factors and

bioengineered tissues. Identifying bioburden as the cause

of indolent wound healing is difﬁcult because many af-

fected wounds do not exhibit classic signs of infection and,

therefore, go untreated. As a result, many clinicians have

overlooked the signiﬁcance of bioburden at the subinfec-

tious level.2

■History

Silver has been used as a healing agent since the time of

the ancient Romans.3In the early 1900s, colloidal silver

Drug Administration accepted colloidal silver as a wound

treatment. With the introduction of antibiotics in the

1940s, research on medical applications of silver declined.

Nevertheless, Fox introduced 1% silver sulfadiazine cream

in 1968, which, 35 years later, is still the leading topical

agent for the treatment of burns.3

■Wound Bed Preparation

Silver preparations may not be effective if the steps to opti-

mize the wound bed are not addressed before initiating

therapy. According to Falanga4and Sibbald and associates,5

the goal of preparation is to optimize the wound bed to en-

sure unimpeded tissue repair and regeneration. Specific

interventions required to achieve this goal include de-

bridement, elimination of bacterial burden, establishing a

moisture balance, eliminating edema, correcting causative

factors, and addressing local and systemic factors. Silver

agents contribute to wound bed preparation by controlling

the bacterial bioburden. However, silver preparations

should be used as a component of a total wound bed prepa-

ration plan if they are to be effective.

Some wounds exhibit severely impaired healing or do

not heal despite comprehensive wound bed preparation.4,5

In these cases, cellular and biochemical abnormalities have

been identiﬁed that are hypothesized to impair wound

healing, but their precise role in wound bed preparation is

not yet understood.

■Levels of Bacterial Contamination

The potential for a wound to become infected is determined

by the microbial load, the type of microorganism, and the

J Wound Ostomy Continence Nurs. 2006;33(4):367-380.

Published by Lippincott Williams & Wilkins

ilver has been used as a healing agent since

the time of the ancient Romans.

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July/August 2006

ability of the host to resist infection, as represented by the

following conceptual formula5:

The signiﬁcance of bacterial loads and wound infec-

tions is reﬂected in the following observations: (1) bio-

burden is present in more than 90% of all wounds, (2) more

than half of chronic wounds progress from contamination

to infection, and (3) surgical site infections are the third

most frequently reported nosocomial infection.6,7

The ﬁrst level of bacterial involvement is contamination.

Contamination exists when bacteria are present within the

wound bed but are not proliferating. All chronic wounds are

contaminated, but this level of bacterial presence does

not interfere with tissue repair and is therefore considered

normal.

The second level of bacterial involvement is coloniza-

tion. Wounds are said to be colonized when organisms at-

tach to the wound bed and begin to multiply. Simple

colonization indicates proliferation of bacteria within a

wound but no accompanying host response and no inter-

ference with wound healing. However, colonization may

be associated with the formation of a bioﬁlm, which cre-

ates a physical barrier around the bacterial cell mem-

brane. Bioﬁlm formation interferes with treatment when

simple colonization progresses to critical colonization or

infection.

The third level of bacterial involvement is critical colo-

nization. Although enjoying increasing acceptance among

clinicians and researchers, speciﬁc criteria deﬁning the pres-

ence of critical colonization have not yet been validated.8-11

Nevertheless, critical colonization remains an important

clinical concept.12 Critical colonization refers to levels of

bacteria on the surface of the wound that, in combination

with secreted toxins, cytokines, and proteases, are sufﬁcient

to interfere with wound healing. Toxins are chemicals that

cause an adverse host response and vary in terms of po-

tency. Bacterial species capable of generating more potent

toxins are more virulent and are associated with a greater

risk of critical colonization and subsequent tissue damage.

Risk of wound infection Bacterial dose viru

=×llence

Host resistance

less potent but contribute to the formation of bioﬁlms and

the production of matrix metalloproteases. In addition, en-

dotoxins adversely effect collagen deposition and cross-

linking, reducing wound tensile strength and increasing the

risk of wound dehiscence. Thus, both endotoxins and exo-

toxins can signiﬁcantly compromise the tissue repair.

Although it is clear that critical colonization requires

treatment, its presence does not typically produce the red-

ness, heat, swelling, and pain that are traditionally consid-

ered the “hallmarks of infection.” Nevertheless, clinical

indicators of critical colonization are gradually being de-

ﬁned. They include (1) a sudden reduction in the quantity

or quality of granulation tissue (a pale edematous wound

bed that is nongranular in appearance, granulation tissue

that is a dull dark red, or granulation tissue that is bright

red, foamy, and bleeds easily), (2) new areas of unex-

plained breakdown in the wound bed, (3) epithelial bridg-

ing, (4) an increase in the volume of exudate or change in

color of exudate (eg, green-blue staining), and (5) an in-

crease in pain or change in character of wound pain.13 A

sudden plateau in healing may also be an indicator of crit-

ical colonization.14

The fourth level of bacterial involvement is infection.

Infection occurs when bacteria proliferate and invade

healthy tissues, overwhelming the local host immune re-

sponse. Concentrations of 105of bacteria per gram of tissue

indicate a clinical infection.

■Antimicrobial Beneﬁts of Topical

Silver Preparations

One of the reasons for the renewed interest in the use of sil-

ver preparations is the increasing incidence of bacterial re-

sistance and the recognition that antibiotics should be

reserved for invasive infections.1Research has demon-

strated that a positive ionic energy is released from col-

loidal silver when it is combined with a neutral liquid.6

This ionic charge enables the silver cation to bind to and

damage bacterial cells at multiple sites. Low levels of silver

can prevent replication and cause the death of micro-

organisms. Silver is nonselective, resulting in antimicro-

bial activity against a broad range of aerobic, anaerobic,

Gram-negative, and Gram-positive bacteria, yeast, ﬁlamen-

tous fungi, and viruses.6,12,3 Ovington12 reports that anti-

microbial dressings, such as silver, play a role in reducing

bacterial numbers and exotoxin release. Silver also has

other prohealing or anti-inﬂammatory properties, as sug-

gested by the loss of rubor in chronic wounds treated with

silver.15 Because of the biological compatibility of colloidal

silver, it can be used in many topical forms, such as creams,

gels, and wound dressings.

■Antimicrobial Performance

of Silver Dressings

The concentration of silver needed to exert a bacteriostatic

or bacteriocidal effect depends on the local wound environ-

acteria that generate more potent toxins

are more virulent and are associated with

greater tissue damage.

Bacteria generate 2 major types of toxins: exotoxins and en-

dotoxins. Exotoxins are produced by both Gram-positive

bacterial species, such as Staphylococci and Streptococci, and

by Gram-negative species, such as Pseudomonas. They attack

many types of cells and can cause generalized tissue necro-

sis at the wound surface. In contrast, endotoxins are pro-

duced only by Gram-negative bacteria. They are generally

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Volume 33/Number 4 Tomaselli 369

ment.3Silver is effective against superﬁcial pathogens, but

it may not inhibit bacteria that have penetrated a signiﬁ-

cant distance into the wound bed (deep infection). Sibbald

and associates16 suggest this may not be an issue for contam-

inated or critically colonized wounds where the organ-

isms have not penetrated the wound bed. Consequently,

silver is indicated for mild wound infections, but not celluli-

tis. Antimicrobial silver preparations can be used to help de-

crease the bacterial count when colonization or critical

colonization is suspected.

proteins, and bioﬁlm bacteria are surrounded by a nonpro-

tein material that may protect the bacteria against the anti-

microbial. Because of complex factors such as the presence

of a bioﬁlm, mixture of multiple bacterial species, tissue pro-

teins, and anions, silver dressings may never achieve the kill

rates in vivo that are seen in vitro. Without the availability

of in vivo studies, clinicians must make assumptions about

the superiority of one dressing over another on the basis of

in vitro data.17

■Differences in Various Types

of Silver Preparations

Silver with a positive charge is known as ionic silver or the

silver cation and is abbreviated as Ag+. All silver-based

dressings contain the same active ingredient, the silver

cation, but use different methods for creating and incor-

porating 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. Antimicrobial silver dress-

ings also differ in the amount of silver they contain and

the rate at which silver is released. Ovington17 reports that

although in vitro studies show varied performance among

dressings with higher amounts or faster release rates of sil-

ver, no in vivo data exist to support this assumption. There

are a variety of delivery vehicles for delivering silver cations

(Ag+), including creams, cloths, hydrofibers, alginates,

foams, pad and island dressings, hydrocolloids, barrier

dressings, cavity strands, perforated sheets, gels, adhesive

strips, elastic wraps, tubular stretch nets, and gloves. Table 1

categorizes antimicrobial silver dressings according to form,

description, function, antimicrobial sensitivity, and indi-

cation. These preparations are designed to treat speciﬁc in-

fections as indicated by the manufacturers. They do not

cure infection but can inhibit the progression of bacterial

penetration. The use of saline should be avoided because

it will reduce the release of ionic silver. Papain-urea debrid-

ing ointment is inactivated by silver salts and should not

be used in combination with antimicrobial silver dress-

ings.18

Selection of the most appropriate silver dressings must

be individualized.19-21 Maintenance debridement is needed

to remove both bacterial debris and exudate, which pro-

duce senescent cells. More silver is not necessarily better be-

cause excessive concentrations may delay healing if the

silver attacks host cells.22 In addition, wide variability exists

in the amount of clinical evidence supporting the use of in-

dividual products.23

Providing the patient, family, and care providers with

a greater understanding of the treatment plan will encour-

age their participation in wound management and ensure

appropriate application of silver products. Education in-

cludes appropriate wound care techniques, signs and symp-

toms of infection, and when to contact a healthcare

professional.24

ntimicrobial silver preparations can be

used to help decrease the bacterial count

when colonization or critical colonization is

suspected.

The antimicrobial performance of silver dressings may

be evaluated by a variety of in vitro methods. The ﬁrst is a

zone of inhibition study. An agar plate is inoculated with

bacteria and a silver dressing is placed on the plate. During

incubation, bacteria grow and the silver dressing releases

cations. If the cations kill the bacterial cells, no growth or a

clear area around the dressing will be visible, called the zone

of inhibition.17 The second in vitro method is a log reduc-

tion study, which measures the decline in colony forming

units (CFU). An antimicrobial silver dressing is added to a

test tube containing a solution with bacteria. Measurement

requires removal of a portion of the solution from the test

tube at different time points to determine whether bacte-

rial counts are decreasing. The efﬁcacy of silver against a

speciﬁc strain of bacteria is measured as a logarithmic re-

duction in CFU over time.17 Silver preparations are consid-

ered bactericidal if they induce a 3 or greater log reduction

in a 30-minute assay. Alternatively, percentages may be

used to measure reduction in CFUs. The clinician should

note that the reduction in logs is much less when calculated

as a percentage.

Speciﬁc terms are used to analyze the effective concen-

tration of silver. Minimum inhibitory concentration refers

to the minimum concentration of silver that an agent must

have to be bacteriostatic. A minimum of 0.08 parts per mil-

lion of silver is required to control the growth of bacteria.

Minimum bactericidal concentration refers to the mini-

mum concentration of silver that an agent must have to be

bactericidal. A minimum of 0.4 parts per million of silver is

required to kill bacteria.

In vitro studies using the testing methods described in

the preceding sections have been performed on simulated

wound ﬂuid in the laboratory.17 These data are not from real

life situations, and clinical studies on human wound ﬂuid

are necessary for comparative data. In vivo studies need to

be conducted to determine if bacteria in bioﬁlm are less sus-

ceptible to antimicrobial silver dressings. Silver binds to

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TABLE 1.

Antimicrobial Silver Dressings

Antimicrobial Product;

Form Description Function Sensitivity Indications Manufacturer

Silver sulfadiazine cream

(apply twice daily)

Cloth (7 days)

Alginate (>3 days)

Collagen (daily or as per

physician’s

recommendation;

frequency depends of

level of exudate)

Silver +sulfonamide

antibiotic in an aqueous

cream vehicle

Activated charcoal cloth

impregnated with

0.15% metallic silver;

antimicrobial binding

dressing; kills organisms

that are adsorbed

(bound) onto the charcoal

Calcium alginate,

carboxymethylcellulose,

guluronic acid, silver

coated nylon ﬁbers

Matrix composed of 55%

Type I bovine collagen

(derived from cow hide).

44% ORC, and 1% silver-

ORC salt. The silver-ORC

salt releases 0.25% ionic

silver

Delivers low levels of silver

without injury to host

cells

Delivers collagen to provide

a structural support for

cellular and capillary

ingrowth

Combines antimicrobial

action of silver ions with

the antibiotic action of

sulfonamide anions

Barrier to bacterial

penetration; traps bacteria

and odor; charcoal binds

and reduces endotoxin

levels

Manages wound exudate,

intact removal from

wound bed; sustained-

release of silver ions at the

wound surface

Comes in contact with the

wound surface after

hydration from wound

ﬂuid or with saline solution

Biodegradable gel is

naturally absorbed into

the body over time

Gel absorbs destructive

components such as

bacteria and proteases

into the dressing

Bacteria absorbed into the

dressing are killed by ionic

silver

Broad-spectrum

antimicrobial activity

Bactericidal for many Gram-

negative and positive

bacteria and yeast

No studies for MRSA and

VRE

Broad-spectrum

antimicrobial; effective vs

>150 wound pathogens,

Staph aureus,

VRE,

MRSA,

P. aeruginosa

S. pyogenes, E. coli, C.

perfringens, Candida

sp.

Bactericidal activity vs >150

strains of clinically

relevant bacteria

Second and third degree

burns (note: not for those

with sensitivity to silver or

sulfa); skin discoloration

may occur; may leave

pseudo-eschar

Partial and full-thickness

wounds; can be used

under compression

bandages

Partial and full-thickness

wounds with moderate-

to-high volume exudate

(note: do not use on

third-degree burns or on

patients with known

sensitivity to silver)

Diabetic foot ulcers, venous

ulcers, pressure ulcers,

ulcers due to mixed

vascular etiologies, full-

thickness and partial-

thickness wounds, donor

sites and other bleeding

surface wounds,

abrasions, traumatic

wounds healing by

secondary intention,

dehisced surgical wounds

for wounds with low

exudate moisten with

saline solution

May be used under

compression therapy with

professional healthcare

supervision or infection

when proper medical

Silvadene,

Monarch

Pharmaceuticals

Thermazene,

Kendal

Flamazine*,

Smith

Nephew

Actisorb* Silver 220,

Johnson & Johnson

Silver

cel* Johnson &

Johnson

Promogran Prisma*Matrix,

Johnson & Johnson

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Volume 33/Number 4 Tomaselli 371

Sodium

carboxymethylcellulose,

1.2% silver

Hydroﬁber: sodium in

wound exudate binds to

the dressing, causing

release of silver from the

dressing ﬁbers

Controlled release of

nanocrystalline silver;

small particle size allows

for greatly increased

surface area of silver in

contact with the wound

surface

Acticoat*7: Two rayon/

polyester nonwoven inner

cores laminated between

three layers of silver-

coated, high-density

polyethylene mesh

Antimicrobial

Absorbs ﬂuid, forming a

cohesive gel

Silver kills microorganisms

that become locked in the

dressing

Bacteria killed at wound-

dressing interface (reduces

wound bioburden)

Antimicrobial barrier with

controlled release of ionic

silver

Modulates MMPs

MRSA, VRE, resistant strains

Pseudomonas

aeruginosa,

Anaerobic

wound pathogens

Bactericidal to a wide range

of bacteria (inhibits >

150 organisms), antibiotic

resistant bacteria and

fungi

treatment addresses the

underlying cause (note:

do not use with third-

degree burns, or in

patients with known

sensitivity to silver, ORC,

or collagen)

Acute and chronic wounds

with moderate to heavy

exudate

Diabetic foot ulcers, partial-

thickness burns (second

degree burns) on children

and adults, skin graft and

donor sites, surgical

wounds, leg ulcers,

pressure ulcers

Can be moistened with

water or saline for use in

dry wounds

Can be used with

compression or pressure-

relieving devices (note:

do not use on patients

with known sensitivity to

this dressing or any of its

components)

Acticoat*7 (note: must

moisten with sterile

water)

Absorbent dressing:

moderate to heavy

exudate

Aquacel Ag Hydroﬁber

Wound Dressing,

ConvaTec

Acticoat*7,

Smith &

Nephew

Hydroﬁber pad or ribbon

(7 days)

Burns (14 days)

Cover with secondary

dressing (can be

changed more

frequently than 7 days)

Barrier dressing (7 days)

(Continues)

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July/August 2006

Alginate dressing and rope

(3 days)

Barrier dressing (3 days)

Moisture control dressing

(7 days)

Dressings: contact, pad,

island adhesive strip,

elastic wrap, tubular

stretch net, gloves

TABLE 1.

Antimicrobial Silver Dressings (Continued )

Antimicrobial Product;

Form Description Function Sensitivity Indications Manufacturer

Acticoat* absorbent: silver-

coated calcium alginate

fabric

Upon contact with moisture,

silver ions are released

Acticoat*3: rayon/polyester

nonwoven inner cores

laminated between an

upper and lower layer of

silver high-density

polyethylene mesh

Acticoat* Moisture Control:

nonadhesive wound

contact layer, highly

absorbent hydrocellular

technology, water ﬁlm,

visible strikethrough

indicates when dressing

change is required

Island dressing: multiple

layers incorporate a silver

wound contact layer,

absorbent rayon pad

covered with a ﬁlm,

transparent (urethane)

layer, and an adhesive

border of nonwoven

fabric tape

Pad dressing: semi-adherent

silver wound contact

layer with absorbent

rayon pad covered with

transparent ﬁlm

Forms a gel that maintains

moist wound healing

Maintains a moist wound

environment, wicks away

excess exudate

Antimicrobial

Permits oxygen and ﬂuids to

pass to and from the

wound surface

Reduces swelling,

inﬂammation, and pain

Pad: provides moisture

control (not absorbency)

Broad spectrum of bacteria,

MRSA, VRE

All dressings: partial and

full-thickness wounds:

pressure, venous and

diabetic ulcers, ﬁrst and

second degree burns,

donor sites, recipient

graft sites

Dressings can be used under

compression dressings

and before and after

application of Dermagraft

(note: do not use on

those with known

sensitivity to silver or

during MRI examinations)

Wide variety of acute and

chronic wounds: burns,

incisions, skin grafts,

lacerations, abrasions,

dermal ulcers, rashes,

animal bites, insect bites;

diabetic and pediatric

care

May require moistening

Acticoat*Absorbent,

Smith

& Nephew

Acticoat*3,

Smith &

Nephew

Acticoat* Moisture Control,

Smith & Nephew

Silverlon Wound & Burn

Contact Dressing,

Argentum Medical, LLC

Silverlon Wound Pad

Dressing,

Argentum

Medical, LLC

Silverlon Island Wound and

Surgical Dressing,

Argentum Medical, LLC

Silverlon Wound Packing

Strip,

Argentum Medical,

LLC

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Volume 33/Number 4 Tomaselli 373

Negative pressure dressing:

silver plated nylon mesh

with ﬂowports that allow

passage of ﬂuid

Combines ionic silver with

slow-released polymers

Silver is delivered

continuously at a

constant rate

Powder contains alginate

and must be activated by

moisture-forms gel

Film with alginate pad

Alginate with controlled

release, noncytotoxic

ionic silver

Combination of nonwoven

alginate and CMC ﬁber

Antibacterial, antifungal,

alginate provides

absorption

Releases silver ions in a

controlled manner for up

to 4 days

Wound exudate mixes with

alginate to form a gel

Broad spectrum of bacteria

and fungi

Staph aureus, P.

Aeruginosa, E. coli, C.

albicans, A. niger.

MRSA, VRE

Broad spectrum of bacteria

and fungi, including

MRSA and VRE

Negative pressure dressing:

use with negative

pressure therapy

Surgical and chronic wounds

Film: use with line sites,

postoperative incisions

and donor sites

Powder can be used with

the VAC (change every

Monday and Thursday)

Deep, tunneling, wounds

with High volume

exudates (note: do not

use on dry wounds, black

necrotic tissue, third

degree burns, or those

with known sensitivity to

silver)

Partial and full-thickness

wounds with moderate-to-

high volume exudate,

postoperative wounds,

traumatic wounds, leg

ulcers, pressure ulcers,

diabetic ulcers, graft and

donor sites (note: do not

use for third-degree burns,

dry wounds with light

volume exudate, those

with known sensitivity to

alginates or silver, surgical

implantation, or to control

heavy bleeding)

Silverlon Adhesive Strip,

Argentum Medical, LLC

Silverlon Elastic Wraps,

Argentum Medical, LLC

Silverlon Tubular Stretch Net,

Argentum Medical, LLC

Silverlon Gloves

Antimicrobial,

Argentum

Medical, LLC

Silverlon Negative Pressure

Dressing,

Argentum

Medical, LLC

Arglaes Film,

Medline

Industries, Inc

Arglaes Alginate Powder,

Medline Industries, Inc

Arglaes Island,

Medline

Industries, Inc.

Maxorb Extra Ag+,

Medline

Industries, Inc.

Negative pressure dressing

(7 days)

Transparent ﬁlm dressing

(7 days)

Alginate powder (5 days)

Island dressing (5 days)

Alginate (4 days)

(Continues)

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July/August 2006

Seeded with ionic silver

compound called silver

sodium hydrogen

zirconium phosphate,

which is activated by

exposure to sodium in

wound exudate

Biocompatible, nonirritating,

nonsensitizing (will not

harm granulation tissue)

Polyacrylate sheet

Constant sustained-release

of ionic silver when in

contact with moisture

Advanced ﬂuid management

Amorphous gel with

controlled-release of

silver

Ionic silver, alginate,

maltodextrin

Immediate and sustained

antimicrobial activity

Foam backing

Exudate activates a

sustained release of silver

ions; silver is released

according to the amount

of exudate and bacteria

present

CMC ﬁber improves vertical

wicking and ﬂuid handling

Reduces odor

Antimicrobial

MicroLattice synthetic matrix

donates or absorbs

moisture

Antimicrobial

Alginate provides absorption

Antimicrobial

Gram-positive and Gram-

negative bacteria

Strains of yeast and fungi,

MRSA, VRE,

E. coli, S.

aureus, P. aeruginosa, C.

albicans

Broad spectrum of wound

pathogens

MRSA,

S. aureus, P.

aeruginosa, E. coli

Broad spectrum of surface

and tissue bacteria,

MRSA, VRE, yeast

Partial and full-thickness

wounds with light to

moderate exudate

Pressure ulcers, diabetic foot

ulcers, leg ulcers, skin

tears, ﬁrst and second

degree burns, grafted

wounds and donor sites,

surgical wounds,

lacerations and abrasions

Venous ulcers, pressure

ulcers, dermal lesions,

second degree burns,

donor sites

(note: do not use for third-

degree burns, ulcers

resulting from infections,

lesions associated with

active vasculitis, or in

those with known

sensitivity to silver)

Hydrocolloid: low to

moderate exudating

wounds

SilvaSorb Antimicrobial

Silver Dressing,

Medline

Industries, Inc

SilvaSorb Gel,

Medline

Industries, Inc.

Algidex Ag,

DeRoyal

Contreet hydrocolloid,

Coloplast

Cavity strands sheets

Perforated sheets (7 days)

Gel (3 days)

Alginate with foam

backing (7 days)

Hydrocolloid (7 days)

TABLE 1.

Antimicrobial Silver Dressings (Continued )

Antimicrobial Product;

Form Description Function Sensitivity Indications Manufacturer

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Volume 33/Number 4 Tomaselli 375

Local treatment is found to

be more effective than

systemic when local

wound perfusion is

impaired

Hydrophilic polyurethane

membrane matrix

Same as PolyMem with

addition of silver

Nanometer silver particles

for maximum surface area

Surface is 99.9% pure

metallic silver,

autocatalytic plated to

pure nylon

Delivers silver ions passively

in the presence of

moisture

Will not stain or tattoo the

skin

Ionic silver compound is

distributed within the

dressing

Exudate management

Autolytic debridement

Effective against odor

causing bacteria

Wound exudate is absorbed

into the dressing and

liberates silver ions from

the matrix

Broad spectrum of bacteria,

fungi, yeast, including

MRSA and VRE

Silver ions are released

within 30 minutes

Conductivity reduces pain

and inﬂammation

Assists with autolysis of

necrotic wounds

Hypoallergenic

Provides a combination of

sustained antibacterial

activity, exudate manage-

ment, and moisture

control; reduces odor

Broad spectrum of bacteria:

fungi, yeast, MRSA, VRE

Local broad-spectrum

antimicrobial activity for

bacteria and fungi,

including MRSA, VRE,

aeruginosa, E. faecalis

In vitro antibacterial activity

for certain strains known

to be detrimental to

wound healing;

bactericidal for wide

range of surface bacteria,

Can be used under

compression bandaging

Foams: wounds with

moderate-to-high volume

exudate (note: foams may

cause transient discolor-

ation; not for those with

known sensitivity to

silver; do not use with

hypochlorite solutions or

hydrogen peroxide)

Pressure and leg ulcers and

dermatologic disorders

Acute wounds and skin tears

Donor and graft sites and ﬁrst

and second degree burns

Chronic wounds, burns,

traumatic wounds,

surgical wounds, leg

ulcers, diabetic foot

ulcers, pressure ulcers,

pyoderma gangrenosa,

incisions, lacerations,

animal bites, abrasions

Can be used with the VAC

and Apligraf (note: do not

use with plain

radiographic and CT

images or MRI)

Requires moistening with

sterile water initially and

q12-24 hours if dressing

becomes dry

Do not use with those who

are sensitive to silver or

nylon

Wounds with moderate to

high exudate

Contreet adhesive foam,

Coloplast

Contreet nonadhesive foam,

Coloplast

Contreet Foam cavity,

Coloplast

PolyMem Silver Island

Dressing,

Ferris Mfg.

Corp

PolyMem Silver

Nonadhesive dressing,

Ferris Mfg. Corp

PolyWic Silver Cavity Wound

Filler,

Ferris Mfg. Corp.

SilverDerm 7,

DermaRite

Industries, LLC

AgIE-GRX,

Geritrex Corp.

Adhesive foam (7 days)

Nonadhesive foam (7 days)

Contreet foam cavity

(7 days)

Island dressing (7 days)

Nonadhesive dressing

(7 days)

Cavity wound ﬁller (7 days)

Nylon cloth (7 days)

Nonadhesive foam sponge

dressing (7 days)

(Continues)

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376 Tomaselli J WOCN

■

July/August 2006

Hydrocolloid island

dressing (3 days)

Hydrogel (7 days)

Wound contact dressing

(7 days)

MRSA, methicillin-resistant

Staphylococcus aureus

; VRE, vancomycin-resistant

Enterococci

; ORC, oxidized regenerated cellulose; MRI, magnetic resonance imaging; CMC, carboxymethylcellulose; CT, computed to-

mography; MMP, matrix metalloproteinases. Reprinted by permission of Premier Health Solutions, LLC.

TABLE 1.

Antimicrobial Silver Dressings (Continued )

Antimicrobial Product;

Form Description Function Sensitivity Indications Manufacturer

Foam structure ensures high

retention and slough

handling capacity,

perforated for ﬂexible

positioning

Uses X-STATIC silver

technology for

continuous, sustained

release of silver cations

Fabric substrate with a

metallic silver surface

containing approximately

1.5% silver oxide

Consists of 1.5% of ﬁber

substrates with a metallic

silver surface containing

99.9% pure elemental

silver, 92.7% Mohm

Water, 5.5% polyethylene

oxide, 0.18%

methylparaben, and

0.05% propylparaben

Consists of 1.5% silver oxide

Hydrocolloid island dressing

and Hydrogel: permit

passage of wound ﬂuid

through the product to be

absorbed by an overlay

absorbent material

tissue bacteria, resistant

bacteria and yeast

Bactericidal activity against

a broad range of

pathogens

Chronic wounds (leg ulcers

and all stages of pressure

ulcers), partial-thickness

wounds, postoperative

wounds, skin abrasions,

donor sites, diabetic foot

ulcers

Hydrocolloid: partial and full-

thickness dermal ulcers,

leg ulcers (vascular,

venous, pressure,

diabetic), superﬁcial

wounds, abrasions, ﬁrst

and second degree burns,

donor sites

Hydrogel: Same as

hydrocolloid +débrided

and grafted partial-

thickness wounds

Contact: same as

hydrocolloid +incisions,

granulating areas, skin

grafts, graft ﬁxation,

lacerations, dermatologic

lesions, excisions, delayed

closure wounds

Should be moistened with

sterile water

Silver seal Hydrocolloid

Island Dressing,

Noble

Biomaterials

Silver Seal Hydrogel

Dressing,

Noble

Biomaterials

Silver Seal Wound contact

dressing,

Noble

Biomaterials

3727-WJ330404-Tomaselli.qxd 7/3/06 4:05 PM Page 376

■Disadvantages of Antimicrobial

Topical Silver Preparations

Like all wound care strategies, silver products are associated

with certain limitations. For example, the active form of

silver is rapidly inactivated in the wound bed, requiring re-

peated applications to be effective. Silver can also stain tis-

sues and equipment, particularly when it is applied in the

presence of moisture. Argyria, a bluish hue to the skin as a

result of the deposition of silver in the dermis, also may

occur.6Although silver may reduce the amount of exotox-

ins being produced, it does not reverse the adverse effects of

existing exotoxins. In addition, as Gram-negative bacteria

are destroyed, endotoxins are released that could poten-

tially exert a negative effect on wound healing.12 The use

of silver is rapidly increasing in the ﬁeld of wound care,

and a wide variety of silver-containing dressings are now

available. Concern associated with the overuse of silver and

the consequent emergence of bacterial resistance is being

raised.25,26 Finally, a small number of cases of silver toxicity

have been reported, although no cases of hypersensitivity

or allergic responses have occurred.3,8,27-30

✔Ionic silver has broad-spectrum antimicrobial effects and can

play an important role in the management of wound bioburden.

✔Silver preparations reduce bacterial counts on the wound

surface but are ineffective against invasive infection (cellulitis).

✔Silver products should be used as a component of a compre-

hensive wound management program and should be selected on

the basis of wound characteristics and properties of the speciﬁc

dressing.

✔Overuse of silver should be avoided.

✔There are many unanswered questions regarding the optimal

use of silver preparations, which can only be resolved with addi-

tional in vivo and clinical studies.

■References

1. Kingsley A. The wound infection continuum and its applica-

tion to clinical practice. Ostomy Wound Manage. 2003;49(7A

suppl):1-7.

2. Cutting KF, White R. Criteria for identifying wound infection-

revisited. Ostomy Wound Manage. 2005;51(1):28-34.

3. Burrell BE. A scientiﬁc perspective on the use of topical silver

preparations. Ostomy Wound Manage. 2003;49(5A suppl):19-24.

4. Falanga V. Wound bed preparation: future approaches. Ostomy

Wound Manage. 2003;49(5A suppl):30-33.

5. Sibbald RG, Orsted H, Schultz GS, et al. Preparing the wound

bed 2003: focus on infection and inﬂammation. Ostomy

Wound Manage. 2003;49(11):24-51.

6. Gibbons B. The antimicrobial beneﬁts of silver and the rele-

vance of microlattice technology. Ostomy Wound Manage.

2003;Feb(suppl):4-7.

7. Tomaselli N. Prevention and treatment of surgical site infec-

tions. Infect Control Resour. 2003;2(1):1, 4-6.

8. Fumal I, Braham C, Paquet P, et al. The beneﬁcial toxicity

paradox of antimicrobials in leg ulcer healing impaired by a

polymicrobial ﬂora: a proof of concept study. Dermatology.

2002;204(suppl 1):70-74.

9. Wall IB, Davies CE, Hill KE, et al. Potential role of anaerobic

cocci in impaired human wound healing. Wound Rep Regen.

2002;10(6):346-353.

10. Stephens P, Wall IB, Wilson MJ. Cutaneous biology: anaero-

bic cocci populating the deep tissues of chronic wounds im-

pair cellular wound healing responses in vitro. Br J Dermatol.

2003;148:456-466.

11. Edwards R, Harding KG. Bacteria and wound healing. Curr

Opin Infect Dis. 2004;17(2):91-96.

12. Ovington LG. Bacterial toxins and wound healing. Ostomy

Wound Manage. 2003;49(7A suppl):8-12.

13. Kingsley A. A proactive approach to wound infection. Nurs

Standard. 2001;15(30):50-58.

14. Schultz GS, Sibbald RG, Falanga V, et al. Wound bed prepara-

tion: a systematic approach to wound management. Wound

Repair Regen. 2003;11(suppl 1):S1-S28.

15. Demling RH, DeSanti L. Effects of silver on wound manage-

ment. Wounds. 2001;13(suppl A):4.

16. Sibbald RG, Williamson D, Orsted H, et al. Preparing the

wound bed: debridement, bacterial balance and moisture bal-

ance. Ostomy Wound Manage. 2000;46(11):14.

■Conclusion

To ensure positive results with advanced wound therapies,

bioburden must be reduced. Topical silver preparations pro-

vide excellent antimicrobial protection that reduces wound

bioburden and may enhance wound closure. Although ex-

isting research has demonstrated clear beneﬁts of silver

products in the laboratory setting, in vivo studies to evalu-

ate the efﬁcacy of these products in the clinical setting and

comparing the efﬁcacy of the various topical silver prepara-

tions are needed. In addition, silver cations are known to

possess electrical conductivity, and trials are in progress to

determine whether silver also may play a role in reducing

wound pain.

✔The development of bacterial resistance has led to renewed

interest in silver products.

✔Reduction of bioburden is a critical element of wound bed

preparation and promotion of wound healing.

KEY POINTS

he use of silver is rapidly increasing in the

wound care ﬁeld, and a wide variety of silver-

containing dressings are now available.

J WOCN

■

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378 Tomaselli J WOCN

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July/August 2006

17. Ovington LG. The truth about silver. Ostomy Wound Manage.

2004;50(9A suppl):1S-10S.

18. Driver V. Silver dressing in clinical practice. Ostomy Wound

Manage. 2004;50(9A suppl):11S-15S.

19. Pah-Lavan Z. Wound care. Part 2: dressings. Nurse 2 Nurse.

2005;4(11):12-15.

20. Lansdown ABG. A guide to the properties and uses of silver

dressings in wound care. Professional Nurse. 2005;20(5):41-43.

21. Carson M, Tamulonis R, Peterson K. The use of unique deliv-

ery system of ionic silver. Acute Care Perspect. 2004;13(2):

6-9.

22. Ovington L. Overview of matrix metalloprotease modula-

tion and growth factor protection in wound healing. Part 1.

Available at: www.podiatrytoday.com/WNDS/matrix/pt1.cfm.

Accessed March 30, 2004.

23. Dowsett C. The use of silver based dressings in wound care.

Nurs Standard. 2004;19(7):56-58.

24. Tomaselli N. Teaching the patient with a chronic wound. Adv

Skin Wound Care. 2005;18(7):379-390.

25. Brett D. Silver as an antimicrobial agent. Remington Rep.

2005;(July/August suppl):4-10.

26. Brett DW. A discussion of silver as an antimicrobial agent: alle-

viating the confusion. Ostomy Wound Manage. 2006;52(1):

34-41.

27. Lansdown ABG, Williams A. How safe is silver in wound care?

J Wound Care. 2004;13(4):131-136.

28. Lansdown ABG. A review of the use of silver in wound care:

facts and fallacies. Br J Nurs. 2004:13(6)(Tissue Viability

Supplement):S6, S8, S10.

29. Drosou A, Falabella A, Kirsner RS. Antiseptics on wounds: an

area of controversy. Wounds Compend Clin Res Pract. 2003;

15(5):149-166.

30. Lansdown ABG. Silver 2: toxicity in mammals and how its

products aid wound repair. J Wound Care. 2002;11(5):173-177.

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