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Antimicrobial and antiseptic dressings

Nikki Stubbs
RGN BSc DNCert
Tissue Viability Nurse Specialist
E:nikki.stubbs2@nhs.net

Vicky Gilchrist
RGN
Tissue Viability Nurse Specialist
Leeds North West PCT

The presence of microorganisms in wounds is not unusual, but not all wounds support the same range and number of species.(1) The appropriate and timely use of antiseptics can assist in the prevention and treatment of wound infections and may facilitate healing. Over the last few years the number of antiseptic dressings available on drug tariff has increased enormously.
The terms antiseptic and antimicrobial are often used interchangeably. This can be confusing for the practitioner when choosing one product over another. The Royal Society of Medicine defines antiseptics as "agents which destroy micro-organisms or inhibit their activity to such an extent that they are less, or no longer, harmful to health".(2) "Antimicrobial", on the other hand, is a general term used to describe the therapeutic use of agents such as antiseptics and antibiotics in preventing and treating infection.(3) It is essential that practitioners understand how and when to use antimicrobial treatments before recommending their use.

History of antiseptics
Pringle first referred to the term antiseptic in 1750; however, the use of antiseptic products, such as silver, dates back to ancient Greek and Roman civilisations.(4) Despite this long history, there is still a lack of conclusive evidence to support the use of antiseptics, and a lack of consensus exists among professionals regarding their efficacy.(5) The antiseptic debate has been ongoing since Fleming's controversial lecture to the Royal College of Surgeons in 1919, in which he reported reduced rates of gas gangrene in patients treated with 2% iodine.(6)

Antiseptic usage
Before the discovery of penicillin in 1929, the use of antiseptics, such as iodine, sodium hydrochlorite and brilliant green, was widespread. However, their use declined with the large-scale production of penicillin in the 1940s. The indiscriminate use of broad-­spectrum antibiotics has since resulted in antibiotic-resistant pathogens, such as MRSA (methicillin-resistant Staphylococcus aureus).(7) This has refocused attention on the benefits of antiseptics in the form of solutions and dressings in the management of the wound bioburden.(8)

How antiseptics work
Most antiseptics have a bactericidal effect owing to a chemical reaction with proteins. They are nonspecific and will react with all proteins in human tissue and living cells, as well as bacteria. Antibiotics, on the other hand, specifically target certain bacteria.
Antiseptics are available in a number of preparations, including soaps, solutions, ointments and dressings. They are used for a variety of purposes, including skin disinfection, wound irrigation, cleansing and wound debridement, in addition to the prevention and treatment of wound colonisation and infection.(5) Owing to the large number of products available and their myriad of uses, it is not surprising that nurses become confused about when and why to use antiseptics.

Colonisation and infection
To use antiseptics appropriately it is important to understand the difference between infection and colonisation. Kingsley described a continuum that can be used to plot the course of a wound from sterility to infection and the necessary action to be taken at each stage.(9)
Most practitioners agree that, for a wound to deteriorate from sterility to infection, certain circumstances need to prevail, particularly with regard to the risk factors that are unique to that individual patient (see Table 1). Assessment of the overall health of the individual is therefore essential.(11)

[[NIP21_table1_80]]

One of the key recommendations made by Kingsley is to consider the use of antiseptic dressings at the critical colonisation stage. A combination of Kingsley's theory and a thorough assessment in conjunction with wound management expertise should assist practitioners in deciding when to use an antiseptic dressing.

Antiseptic products

Silver-containing dressings
This is probably the most widely used antiseptic and is available in combination with a number of preparations (see Table 2). These dressings deliver a sustained release of small quantities of ionic silver over a period of time to decrease bacterial load and reduce the risk of toxicity.(12) Reported incidences of toxicity are usually associated with silver nitrate and silver sulphadiazine,(13) and not the more modern silver dressings, such as Actisorb Silver 220 (Johnson & Johnson) and Acticoat (Smith & Nephew).(12) To further underline the effectiveness of silver in wound care, Elastoplast (Beiersdorf) has brought out a new range of plasters, the SilverHealing range, that contain silver and can be used in the home.

[[NIP21_table2_81]]

Iodine
There are a number of different types of iodine product for use in wound care (see Table 2). Polyvinyl pyrrolidone iodine (PVP-1) comes in a number of different preparations. This is sometimes used in the treatment of burns. However, it is inactivated by wound exudate, and therefore frequent dressing changes are necessary.
The most commonly used iodine products include inadine, a rayon dressing containing 10% povidone iodine, which is effective against MRSA. It usually requires frequent dressing changes as once the dressing has turned "white" it no longer has an antimicrobial effect. However, it can be applied in layers to give a longer-acting, slow-release effect. Cadexomer iodine, marketed as Iodosorb and Iodoflex (Smith & Nephew), contains 0.9% iodine and is effective against Staph aureus, pseudomonas and beta-haemolytic streptococci. The iodine is slowly released, and the dressing absorbs up to six times its own weight in exudate and inorganic matter.(14) Like inadine, these products change from dark brown to off-white when the iodine has been released.

Honey
A recent addition to the drug tariff is a tulle dressing impregnated with honey (Activon Tulle; Advancis Medical).
Like silver, honey has been used in wound care for thousands of years and is increasingly being used as an antiseptic for use on critically colonised wounds. The high sugar content of honey inhibits the growth of both Gram-negative and Gram-positive bacteria. This, in addition to a low pH (approx 3.7), inhibits bacterial growth and renders it effective against resistant strains of bacteria, such as MRSA, as well as pseudomonas.(15)
Honey is derived from the flowers of the Manuka bush. Although allergic reactions are rare,(16) some patients report a transient stinging sensation following the application of honey. Caution should be exercised in the use of honey in patients with diabetes as some of the sugars could be absorbed systemically.

Conclusion
Antiseptics offer many benefits in wound care. The development of modern, sustained-release antiseptic dressings has eliminated some of the problems identified with more traditional products. Agents such as silver, iodine and honey offer a broad-spectrum effect against bacteria that can be responsible for delayed healing and wound infection. To avoid excessive and inappropriate use of antiseptics, practitioners must ensure that they fully understand the modes of action of antiseptics as well as their indications and contraindications.(5)
Uncomplicated wounds should be treated in an uncomplicated manner. However, where there is evidence of critical colonisation, or where risk factors for infection have been identified, topical antiseptics should be considered, with due consideration to the potential risks and benefits.
There are still a number of unanswered questions relating to antiseptics. Systematic reviews of randomised controlled trials have failed to find any robust evidence regarding the possible benefits or harm of antiseptic products in wound care. It is clear that more clinical research is needed to direct clinical practice.

References

  1. Cooper R, Lawrence JC. The role of antimicrobial agents in wound care.J Wound Care 1996;5:374-80.
  2. Royal Society of Medicine. The ­medicines guide. London:?RSM; 2002.
  3. White R, et al. Wound colonization and infection: the role of topical anti­microbials. Br J Nurs 2001;10:563-78.
  4. White R. An historical overview of the use of silver in wound management. In: White R, editor. The silver book. Salisbury: MA Healthcare; 2003. p. 59-68.
  5. Scanlon E, Stubbs N. To use or not to use? The debate on the use of ­antiseptics in wound care. In: White R, editor. Trends in wound care. Salisbury: MA Healthcare; 2003. p. 108-17.
  6. Fleming A. The action of chemical and physiological antiseptics in a septic wound. Br J Surg 1919;17(25):99-129.
  7. Leaper D. Defining infection.J Wound Care 1998;7:373.
  8. Cutting K. A dedicated follower of fashion? Topical medications and wounds. Br J Nurs 2001;10(15):9-16.
  9. Kingsley A. A proactive approach to wound infection. Nurs Standard 2001;15(30):50-8.
  10. Cruise PJE, Ford R. A five year prospective study of 23,649 surgical wounds. Arch Surg 1973;107:206-71.
  11. Bale S, Jones V. Wound care ­nursing: a patient-centred approach. London: Ballière Tindall; 2000.
  12. Cutting K. A dedicated follower of fashion? Topical medications and wounds. In White R, editor. The silver book. Salisbury: MA Healthcare; 2003. p. 19-32.
  13. Demling RH, DeSanti L. The role of silver in wound healing. Part 1: effects of silver on wound management. Wounds 2001;13 Suppl 1:A3-15.
  14. O'Brian M. Exploring methods of wound debridement. In: White R, editor. Trends in wound care. Salisbury: MA Healthcare; 2003. p. 95-107.
  15. Molan P. Honey as a topical ­antibacterial agent for treatment of infected wounds. Available from URL:http://www.worldwidewounds.com
  16. Wood B, et al. Manuka honey, a low cost leg ulcer dressing. NZ Med J 1997;110(1040):107.

Resources
Wound Care Society
PO Box 170
Hartford
Huntingdon
PE29 1PL
W:www.woundcaresociety.org
Tissue Viability Society
W:www.tvs.org.uk
T:01722 429057