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11.p188,190-1 stang.aq (PS/CL) 12/17/04 3:10 PM Page 1

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The use of Aquacel Ag in the management of ulcers

Duncan Stang

ARTICLE POINTS Introduction The over-prescription of has led a worrying increase in the number Over-prescription of 1antibiotics has led to of caused by resistant organisms such as methicillin-resistant a worrying increase in aureus (MRSA) and vancomycin-resistant Enterococci (VRE) the number of inections (Van der Mee-Marquet, 2004). As a result, the potential for unconventional caused by resistant antimicrobial therapy use in the treatment of and soft tissue has organisms such as increased. This article will explore the possible use of an antimicrobial MRSA and VRE. as a way of reducing the amount of antibiotics prescribed for people with diabetic foot ulcers. The specific effects of silver ions (Ag+) 2 he antimicrobicidal properties of uncommon’ (Jude, 2004). on mean that silver were apparently known to the This practice allows therapy to be dressings containing Ag+ may provide an ideal T Ancient Egyptians, who placed silver directed at those with the greatest likelihood alternative to antibiotic coins in clay pots of drinking water to prevent of benefit, and minimises the risk of treatment in suitable water-borne infections (Lansdown, 2004). promoting bacterial resistance in those with a . When silver is used in antimicrobial dressings low bacterial load, which could be managed in care, the generation of silver ions by alternative means. Dressings containing (Ag+) leads to direct binding of Ag+ ions to Our reasons for not prescribing 3Ag+ ions are being proteins within the of the prophylactic antibiotics are based on the used increasingly, bacteria, resulting in selective cell wall following notions: particularly as they damage. In addition, Ag+ ions block cellular Over-prescription of antibiotics has led to possess many of the respiration pathways within the bacteria bacterial resistance (Van der Mee-Marquet, characteristics sought in enhancing their microbicidal effects (Diprov 2004). an ideal topical dressing. et al, 2002). There is often an ischaemic element + The author uses the In contrast, in tissue cells Ag ions induce resulting in impaired microcirculation 4Aquacel Ag dressing the expression of two proteins, MT-1 and MT- (Edmonds et al, 2004; Krentz et al, 2001). as a principal therapy for 2, which are beneficial in This may result in an impaired delivery of healing foot ulcers in (Demling and DiSanti, 2001). Thus, dressings white blood cells to the site of infection in patients meeting containing Ag+ ions may provide an ideal addition to lowered tissue levels of criteria. alternative to antibiotic treatment in suitable antibiotics. wounds, and ultimately reduce the potential Some patients report side-effects during a KEY WORDS for increasing antibiotic resistance amongst course of antibiotics (Dancer, 2004). This Wound care the common pathogens causing foot can interrupt their eating habits and Silver infections in patients with diabetes. destabilise their diabetes control. MRSA / VRE Modern wound care has advanced with the Dressings Current practice recent development of dressings Wound healing In the diabetic foot clinic of Hairmyres incorporating potent antimicrobial agents. Hospital, the current policy is to limit the Dressings containing Ag+ ions are being used prescription of antibiotic therapy to those increasingly, particularly as they possess many patients who present with clinical signs of of the characteristics we seek in an ideal infection. However, we do have a low topical dressing. threshold for prescription, in keeping with In particular, when assessing the properties current expert guidance: ‘Clinical diagnosis of of a topical antimicrobial dressing, the infection is based on the presence of following were felt to be particularly Duncan Stang is Chief Podiatrist at the Department of Diabetes, discharge from the , cellulitis, warmth important by our multidisciplinary team: Hairmyres Hospital, East Kilbride and signs of toxicity, though the latter is Providing a broad spectrum of sustained

188 The Diabetic Foot Vol 7 No 4 2004 11.p188,190-1 stang.aq (PS/CL) 12/17/04 3:10 PM Page 2

THE USE OF AQUACEL AG IN THE MANAGEMENT OF DIABETIC FOOT ULCERS

antimicrobial activity course of antibiotic therapy. PAGE POINTS Efficacy against methicillin-resistant These criteria are used to select patients for Studies have shown Staphylococcus aureus (MRSA) and dressing use, and are illustrated below in a 1the Aquacel Ag vancomycin-resistant Enerococci (VRE) case study from our unit. dressing to provide broad Establishing a host-manageable bio-burden spectrum sustained Containing bacteria within the wound Case study antimicrobial activity in dressing Mr AJ is a 77-year-old male with type 2 vitro. Providing a moist wound environment diabetes who presented to our clinic with Managing wound to prevent neuro-ischaemic ulceration of the right first The author’s use of maceration of surrounding skin toe. He has profound sensory neuropathy 2the dressing as a Ease of application and removal due to diabetes and memory impairment due principal therapy for the Cost-effectiveness when compared with to Alzheimer’s disease, and relies on carers to treatment of diabetic foot antibiotic therapy. detect foot problems. ulcers is based on patients meeting certain As a result of these demands, our team Angiography of his lower limbs showed criteria (e.g. ulcers often choose the Aquacel Ag dressing critical narrowing of the distal external iliac showing no signs of (Convatec) as we feel it meets most of the artery and a percutaneous angioplasty was clnical infection). criteria. Studies have shown the dressing to performed which improved the perfusion to provide broad-spectrum sustained anti- the foot. Although the circulation was The use of the microbial activity in vitro (Bowler et al, 2003). improved, it was too late to salvage the toe. 3dressing is illustrated Additionally, Caruso and colleagues (2004) It was decided to allow auto- to in a case study of a man carried out a phase II non-comparative trial in take place and the patient could be managed with who superficial, mid-dermal and mixed partial- as an outpatient with regular visits to the presented to the clinic thickness burns and found that the dressing clinic with support by district nurse services with neuro-ischaemic rated positively in conformability and ease of and his son. ulceration of the right use, with the speed of re-epithelialisation The line of demarcation at the first toe. being satisfactory, and appeared similar at interphalangeal joint had a degree of slough least to results achieved with silver present but there was very little sulphadiazine (Caruso et al, 2004). surrounding erythema and no cellulitis was Of more interest to our practice was a present (Figure 1). Due to the favourable study on 134 non-ischaemic diabetic foot appearance, it was decided not to prescribe ulcer patients comparing Aquacel Ag to a antibiotic therapy but to apply Aquacel Ag calcium alginate (Jude, 2004). Preliminary and foam dressings to manage the bacterial Figure 1 (top). Due to the results suggest that the dressing provides favourable appearance of the improvement in healing time, enhanced toe, it was decided not to reduction in ulcer area and depth, total prescribe antibiotic therapy, healing at eight weeks, as well as synergistic but instead to use an effects in patients treated with antibiotics antimicrobial and foam (Jude, 2004). dressings. When do we use it? Our choice of Aquacel Ag as a principal therapy for healing foot ulcers in patients with diabetes is based on patients meeting one or Figure 2 (bottom). The toe more of the following criteria: auto-amputated after six Ulcers showing no signs of clinical infection weeks, leaving the bone of Chronic or slow to heal ulcers where the interphalangeal joint critical colonisation is thought to be the exposed. cause of delayed healing Ulcers where there is a localised non- spreading mild erythema In conjunction with antibiotic therapy where clinical infection has been diagnosed but where local control of infection is thought likely to be adequate after a limited

190 The Diabetic Foot Vol 7 No 4 2004 11.p188,190-1 stang.aq (PS/CL) 12/17/04 3:10 PM Page 3

THE USE OF AQUACEL AG IN THE MANAGEMENT OF DIABETIC FOOT ULCERS

– i.e. swelling, spreading erythema, rise in blood sugars and feeling generally unwell – as well as having a clear plan of action if these factors occur. Large randomised control trials are required to investigate the use of the prophylactic prescription of antibiotics verses Figure 3. The toe auto-amputated after six weeks the use of antimicrobial dressing in the of treatment with silver and foam dressings management of non-clinically infected diabetic foot ulcers. Only by assessing these dressings burden and wound exudate. in this way can we be confident that we can At each visit to the clinic the slough around move away from prophylactic antibiotics. the line of demarcation was removed using In our recent experience, the use of sharp and the silver and foam Aquacel Ag as a topical antimicrobial therapy dressings were reapplied. The foot has proved very successful and raises the temperature was monitored at each visit and possibility that not all patients with diabetic the surrounding skin checked for any signs of foot ulcers require antibiotic therapy, clinical infection. especially if there are no clinical signs of The toe auto-amputated (with help from a infection. However, this mode of treatment number 15 scalpel blade) after six weeks, can only be carried out with very close leaving the bone of the interphalangeal joint monitoring and education of everyone exposed (Figures 2 and 3). involved in the delivery of care. At this stage there was very little slough present and very little erythema in the ACKNOWLEDGEMENT: I thank Dr Andrew Jamieson surrounding tissues. The final barrier to for help with this manuscript. wound healing and closure was the exposed Bowler P, Schank J, Bates-Jensen B (2003) Infection control bone, so this was removed at the next visit practices relating to chronic wounds. Poster presentation, (Figure 4). 8th National Conference NPUAP (National Pressure At subsequent visits, Aquacel Ag and foam Ulcer Advisory Panel), New Orleans Caruso DM, Foster KN, Hermans MHE, Rick C (2004) dressings were applied after debridement and Aquacel Ag in the mamagement of partial thickness the ulcer progressed to complete healing in burns: Results of a clinical trial. Journal of Burn Care Rehabilitation 25: 89–97 Figure 4 (above). The another six weeks (Figures 5 and 6). The Dancer SJ (2004) How antibiotics can make us sick: the exposed bone was removed at patient was then referred to the orthotist for less obvious adverse effects of antimicrobial the subsequent visit. prescription footwear and total contact casts chemotherapy. Lancet Infectious Diseases 4(10): 611–19 Demling RH, DiSanti L (2001) Effects of silver on wound Figures 5 and 6 (below). The to redistribute the pressure evenly to aid management. Wounds 13(suppl A): 5–15 antimicrobial and foam walking and prevent further breakdown. To Dibrov P, Dzioba J, Gosink KK, Hase CC (2002) Chemiosmotic mechanism of antimicrobial activity of dressings were applied after date the foot remains intact. Ag(+) in Vibrio cholerae. Antimicrobial Agents and debridement on subsequent Chemotherapy 46(8): 2668–70 vists to complete healing. Edmonds ME, Foster AVM, Sanders S (2004) A Practical Conclusion Manual of Diabetic Foot Care. Blackwell Publishing, Central to the management of healing in a London patient with a is the need Foster A, Edmonds M (2001) An overview of foot disease in patients with diabetes. Nursing Standard for a multidisciplinary foot team to address 16(12): 45–52; quiz 54–55 the multifactorial nature of the pathogenesis Jude E (2004) Non-ischemic diabetic foot ulcer: effects of Aquacel Ag with hydrofibre versus . Oral of the ulcer (Foster and Edmonds, 2001). In presentation, 2nd World Union of Wound Healing addition, it is essential to remember that if Societies’ Meeting, Paris infection does occur in a diabetic foot ulcer, it Krentz AJ, Mani R, Shearman CP (2001) Peripheral arterial disease in diabetes: time for a co-ordinated can spread very rapidly. Therefore, when any approach to management. British Journal of Diabetes and patient is being managed without prophylactic Vascular Disease 3: 92–96 Lansdown AB (2004) A review of the use of silver in antibiotic therapy, they must be monitored wound care: facts and fallacies. British Journal of Nursing very closely. Good lines of communication 13(6 Suppl): S6–19 Van der Mee-Marquet N, Blanchard M, Domelier AS, between all healthcare professionals who may Quentin R; the Infection Survey study group of the be sharing the patient’s care must be in place. Relais d'Hygiene du Centre (2004) Virulence and Similarly, patients and their carers must be antibiotic susceptibility of Staphylococcus aureus strains isolated from various origins. Pathol Biol (Paris) 52(10): educated in recognising the signs of infection 579–83

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