ReviewComparative study of Silver Sulfadiazine with other materials for healing and infection prevention in burns: A systematic review and meta-analysis
Introduction
Burns are defined as organic tissue lesions resulting from some trauma of thermal, electrical, radioactive or chemical origin, promoting tissue destruction by protein denaturation and/or ionization of cell content [1].
Definition of the best treatment is based on the evaluation of multiple variables, such as depth, extension, localization of the burn, age of the patient, presence or absence of inhalation injury, electrical burn, associated trauma, and pre-existing diseases [2]. In clinical treatment topical agents have been used, the majority of these being antimicrobial agents [3]. Among them, Silver Sulfadiazine (SSD) is frequently used because it is easy to apply, low cost, and painless. It is widely used for treating second- and third-degree burns [4].
In 2010, the Cochrane Wounds Group published a systematic review emphasizing the lack of evidence for the effects of dressings with silver on the prevention of infection and healing of wounds in general, including burns [5]. With regard to burns, no beneficial effect of SSD was shown for the prevention of infection of wounds in patients with partial thickness burns. Hussain and Ferguson pointed out that although there was evidence of the antimicrobial effect, there was no direct evidence of prevention of infection and reported the occurrence of delay in the healing process [6].
These silver agents, which are toxic to bacterial cells, may also affect the cells of the skin itself and delay healing, and SSD is known to be capable of retarding the growth of keratinocytes and fibroblasts [7]. Recent discoveries have indicated that compounds containing silver delay the wound-healing process, and that silver may have severe cytotoxic activity in various host cells [8]. As a metal, silver is relatively inert, but once it is ionized by fluids, it becomes highly reactive, and binds to the proteins of cell membranes, leading to cellular denaturation and mitochondrial dysfunction in a large number of the cells, similar to events that occur in the cells of invading microorganisms [7]. Irrespective of the vehicle for the release of silver (solutions, creams, ointments, or in nanocrystalline form), it is highly toxic both to keratinocytes and fibroblasts [7]. Therefore, in spite of SSD being used on a large scale by the majority of burn treatment centers, we still have no definite answer about its effect on the prevention of infections and the promotion of the healing process, in comparison with other dressings containing silver or not.
In view of the aforementioned information, the aim of the present study was to conduct a systematic review with meta-analysis, to compare the effect of SSD with other materials, with or without silver, for the topical treatment of second- and third-degree burns in relation to wound healing and infection prevention.
Section snippets
Method
This was a systematic review with meta-analysis, using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist for control [9].
Characterization of studies included
Initially 873 articles were found, and after reading the title and abstract, only 53 studies remained. After evaluating the texts in full, the sample consisted of 24 randomized clinical trials (Chart 1).
Characterization of studies included
A high proportion of the studies selected used SSD as a control group for evaluating some other type of dressing, so that in total, 20 different types of dressings were used. In all the studies, the majority of the sample was composed of patients with superficial or deep second-degree burns.
Outcome: healing
To perform the meta-analysis, all the articles that did not present the mean and standard deviation of the wound-healing time were excluded. Thus, of the 22 initial articles that evaluated the outcome of healing, only 9 could be used in the meta-analysis, 5 in the dressings without silver group (E2, E3, E8, E9 and E14) and 4 in the dressings with silver group (E10, E13, E16 and E19).
The random effects analysis showed a favorable statistical difference for number of days of healing for the
Discussion
The large number of therapeutic options for the topical treatment of burns, makes it difficult for healthcare professionals to make decisions regarding the best procedures to be adopted. In both second- and third-degree lesions, SSD continues to be the drug most frequently used by reason of its low cost and high level of availability. However, in spite of its consolidated use, we lack evidence for the efficacy of SSD compared with other new materials in preventing infection and helping the
Conclusion
The authors concluded that there were new dressings (with or without silver) which show better results than SSD on the outcome of wound healing, reducing the time necessary to restore burn lesions. There is immediate need for conducting RCTs with adequate methodological quality and high statistical power to investigate the effectiveness of SSD and silver dressings for preventing infection in patients with burns.
Conflict of interest
None of the authors has to disclose any conflict of interest.
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2022, InjuryCitation Excerpt :Conservative treatments can be used effectively in superficial partial-thickness burns, as they involve the covering of the affected areas in order to maintain a moist environment, as well as, the delivery of antimicrobial compounds, which prevent the infection and progression (i.e., deeper penetration) of the burn wounds. Several conservative treatment methods can be used [11,12], but direct, parallel comparisons of the treatments under standardized conditions are scarce, hence the results of different trials can be compared indirectly by meta-analyses, which are, however, hindered by the methodological quality and heterogeneity of the analyzed studies [34,35]. In the present study we selected four treatment options (see below) and compared their effects on different parameters of wound healing in our newly developed rat model of superficial partial-thickness burns.
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2022, Journal of Herbal MedicineCitation Excerpt :Although no serious side effects were observed among our patients in SSD-treated group, previous studies have highlighted several limitations related to its application, such as the development of antibacterial resistance, delayed wound healing, renal toxicity and leucopenia (Klasen, 2000). Therefore, it is recommended that prolonged topical application of SSD to extensive wounds should be avoided (Nímia et al., 2019). In terms of patients’ satisfaction, more patients expressed satisfaction with GT cream.