Norman G, Christie J, Liu Z, Westby MJ, Jefferies JM, Hudson T, Edwards J, Mohapatra DP, Hassan IA, Dumville JC, et al.
The Cochrane database of systematic reviews. Date of publication 2017 Jul 12;volume 7():CD011821.
1. Cochrane Database Syst Rev. 2017 Jul 12;7:CD011821. doi:
10.1002/14651858.CD011821.pub2.
Antiseptics for burns.
Norman G(1), Christie J, Liu Z, Westby MJ, Jefferies JM, Hudson T, Edwards J,
Mohapatra DP, Hassan IA, Dumville JC.
Author information:
(1)Division of Nursing, Midwifery & Social Work, School of Health Sciences,
Faculty of Biology, Medicine & Health, University of Manchester, Manchester
Academic Health Science Centre, Jean McFarlane Building, Oxford Road, Manchester,
UK, M13 9PL.
BACKGROUND: Burn wounds cause high levels of morbidity and mortality worldwide.
People with burns are particularly vulnerable to infections; over 75% of all burn
deaths (after initial resuscitation) result from infection. Antiseptics are
topical agents that act to prevent growth of micro-organisms. A wide range are
used with the intention of preventing infection and promoting healing of burn
wounds.
OBJECTIVES: To assess the effects and safety of antiseptics for the treatment of
burns in any care setting.
SEARCH METHODS: In September 2016 we searched the Cochrane Wounds Specialised
Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid
MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations), Ovid Embase,
and EBSCO CINAHL. We also searched three clinical trials registries and
references of included studies and relevant systematic reviews. There were no
restrictions based on language, date of publication or study setting.
SELECTION CRITERIA: We included randomised controlled trials (RCTs) that enrolled
people with any burn wound and assessed the use of a topical treatment with
antiseptic properties.
DATA COLLECTION AND ANALYSIS: Two review authors independently performed study
selection, risk of bias assessment and data extraction.
MAIN RESULTS: We included 56 RCTs with 5807 randomised participants. Almost all
trials had poorly reported methodology, meaning that it is unclear whether they
were at high risk of bias. In many cases the primary review outcomes, wound
healing and infection, were not reported, or were reported incompletely.Most
trials enrolled people with recent burns, described as second-degree and less
than 40% of total body surface area; most participants were adults. Antiseptic
agents assessed were: silver-based, honey, Aloe Vera, iodine-based, chlorhexidine
or polyhexanide (biguanides), sodium hypochlorite, merbromin, ethacridine
lactate, cerium nitrate and Arnebia euchroma. Most studies compared antiseptic
with a topical antibiotic, primarily silver sulfadiazine (SSD); others compared
antiseptic with a non-antibacterial treatment or another antiseptic. Most
evidence was assessed as low or very low certainty, often because of imprecision
resulting from few participants, low event rates, or both, often in single
studies. Antiseptics versus topical antibioticsCompared with the topical
antibiotic, SSD, there is low certainty evidence that, on average, there is no
clear difference in the hazard of healing (chance of healing over time), between
silver-based antiseptics and SSD (HR 1.25, 95% CI 0.94 to 1.67; I2 = 0%; 3
studies; 259 participants); silver-based antiseptics may, on average, increase
the number of healing events over 21 or 28 days' follow-up (RR 1.17 95% CI 1.00
to 1.37; I2 = 45%; 5 studies; 408 participants) and may, on average, reduce mean
time to healing (difference in means -3.33 days; 95% CI -4.96 to -1.70; I2 = 87%;
10 studies; 979 participants).There is moderate certainty evidence that, on
average, burns treated with honey are probably more likely to heal over time
compared with topical antibiotics (HR 2.45, 95% CI 1.71 to 3.52; I2 = 66%; 5
studies; 140 participants).There is low certainty evidence from single trials
that sodium hypochlorite may, on average, slightly reduce mean time to healing
compared with SSD (difference in means -2.10 days, 95% CI -3.87 to -0.33, 10
participants (20 burns)) as may merbromin compared with zinc sulfadiazine
(difference in means -3.48 days, 95% CI -6.85 to -0.11, 50 relevant
participants). Other comparisons with low or very low certainty evidence did not
find clear differences between groups.Most comparisons did not report data on
infection. Based on the available data we cannot be certain if antiseptic
treatments increase or reduce the risk of infection compared with topical
antibiotics (very low certainty evidence). Antiseptics versus alternative
antisepticsThere may be some reduction in mean time to healing for wounds treated
with povidone iodine compared with chlorhexidine (MD -2.21 days, 95% CI 0.34 to
4.08). Other evidence showed no clear differences and is of low or very low
certainty. Antiseptics versus non-antibacterial comparatorsWe found high
certainty evidence that treating burns with honey, on average, reduced mean times
to healing in comparison with non-antibacterial treatments (difference in means
-5.3 days, 95% CI -6.30 to -4.34; I2 = 71%; 4 studies; 1156 participants) but
this comparison included some unconventional treatments such as amniotic membrane
and potato peel. There is moderate certainty evidence that honey probably also
increases the likelihood of wounds healing over time compared to unconventional
anti-bacterial treatments (HR 2.86, 95% C 1.60 to 5.11; I2 = 50%; 2 studies; 154
participants).There is moderate certainty evidence that, on average, burns
treated with nanocrystalline silver dressings probably have a slightly shorter
mean time to healing than those treated with Vaseline gauze (difference in means
-3.49 days, 95% CI -4.46 to -2.52; I2 = 0%; 2 studies, 204 participants), but low
certainty evidence that there may be little or no difference in numbers of
healing events at 14 days between burns treated with silver xenograft or paraffin
gauze (RR 1.13, 95% CI 0.59 to 2.16 1 study; 32 participants). Other comparisons
represented low or very low certainty evidence.It is uncertain whether infection
rates in burns treated with either silver-based antiseptics or honey differ
compared with non-antimicrobial treatments (very low certainty evidence). There
is probably no difference in infection rates between an iodine-based treatment
compared with moist exposed burn ointment (moderate certainty evidence). It is
also uncertain whether infection rates differ for SSD plus cerium nitrate,
compared with SSD alone (low certainty evidence).Mortality was low where
reported. Most comparisons provided low certainty evidence that there may be
little or no difference between many treatments. There may be fewer deaths in
groups treated with cerium nitrate plus SSD compared with SSD alone (RR 0.22, 95%
CI 0.05 to 0.99; I2 = 0%, 2 studies, 214 participants) (low certainty evidence).
AUTHORS' CONCLUSIONS: It was often uncertain whether antiseptics were associated
with any difference in healing, infections, or other outcomes. Where there is
moderate or high certainty evidence, decision makers need to consider the
applicability of the evidence from the comparison to their patients. Reporting
was poor, to the extent that we are not confident that most trials are free from
risk of bias.
DOI: 10.1002/14651858.CD011821.pub2
PMID: 28700086 [Indexed for MEDLINE]
