Westby MJ, Dumville JC, Soares MO, Stubbs N, Norman G, et al.
The Cochrane database of systematic reviews. Date of publication 2017 Jun 22;volume 6():CD011947.
1. Cochrane Database Syst Rev. 2017 Jun 22;6:CD011947. doi:
10.1002/14651858.CD011947.pub2.
Dressings and topical agents for treating pressure ulcers.
Westby MJ(1), Dumville JC, Soares MO, Stubbs N, Norman G.
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: Pressure ulcers, also known as bedsores, decubitus ulcers and
pressure injuries, are localised areas of injury to the skin or the underlying
tissue, or both. Dressings are widely used to treat pressure ulcers and promote
healing, and there are many options to choose from including alginate,
hydrocolloid and protease-modulating dressings. Topical agents have also been
used as alternatives to dressings in order to promote healing.A clear and current
overview of all the evidence is required to facilitate decision-making regarding
the use of dressings or topical agents for the treatment of pressure ulcers. Such
a review would ideally help people with pressure ulcers and health professionals
assess the best treatment options. This review is a network meta-analysis (NMA)
which assesses the probability of complete ulcer healing associated with
alternative dressings and topical agents.
OBJECTIVES: To assess the effects of dressings and topical agents for healing
pressure ulcers in any care setting. We aimed to examine this evidence base as a
whole, determining probabilities that each treatment is the best, with full
assessment of uncertainty and evidence quality.
SEARCH METHODS: In July 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 Plus. We also searched clinical trials registries for ongoing and
unpublished studies, and scanned reference lists of relevant included studies as
well as reviews, meta-analyses, guidelines and health technology reports to
identify additional studies. There were no restrictions with respect to language,
date of publication or study setting.
SELECTION CRITERIA: Published or unpublished randomised controlled trials (RCTs)
comparing the effects of at least one of the following interventions with any
other intervention in the treatment of pressure ulcers (Stage 2 or above): any
dressing, or any topical agent applied directly to an open pressure ulcer and
left in situ. We excluded from this review dressings attached to external devices
such as negative pressure wound therapies, skin grafts, growth factor treatments,
platelet gels and larval therapy.
DATA COLLECTION AND ANALYSIS: Two review authors independently performed study
selection, risk of bias assessment and data extraction. We conducted network
meta-analysis using frequentist mega-regression methods for the efficacy outcome,
probability of complete healing. We modelled the relative effectiveness of any
two treatments as a function of each treatment relative to the reference
treatment (saline gauze). We assumed that treatment effects were similar within
dressings classes (e.g. hydrocolloid, foam). We present estimates of effect with
their 95% confidence intervals for individual treatments compared with every
other, and we report ranking probabilities for each intervention (probability of
being the best, second best, etc treatment). We assessed the certainty (quality)
of the body of evidence using GRADE for each network comparison and for the
network as whole.
MAIN RESULTS: We included 51 studies (2947 participants) in this review and
carried out NMA in a network of linked interventions for the sole outcome of
probability of complete healing. The network included 21 different interventions
(13 dressings, 6 topical agents and 2 supplementary linking interventions) and
was informed by 39 studies in 2127 participants, of whom 783 had completely
healed wounds.We judged the network to be sparse: overall, there were relatively
few participants, with few events, both for the number of interventions and the
number of mixed treatment contrasts; most studies were small or very small. The
consequence of this sparseness is high imprecision in the evidence, and this,
coupled with the (mainly) high risk of bias in the studies informing the network,
means that we judged the vast majority of the evidence to be of low or very low
certainty. We have no confidence in the findings regarding the rank order of
interventions in this review (very low-certainty evidence), but we report here a
summary of results for some comparisons of interventions compared with saline
gauze. We present here only the findings from evidence which we did not consider
to be very low certainty, but these reported results should still be interpreted
in the context of the very low certainty of the network as a whole.It is not
clear whether regimens involving protease-modulating dressings increase the
probability of pressure ulcer healing compared with saline gauze (risk ratio (RR)
1.65, 95% confidence interval (CI) 0.92 to 2.94) (moderate-certainty evidence:
low risk of bias, downgraded for imprecision). This risk ratio of 1.65
corresponds to an absolute difference of 102 more people healed with protease
modulating dressings per 1000 people treated than with saline gauze alone (95% CI
13 fewer to 302 more). It is unclear whether the following interventions increase
the probability of healing compared with saline gauze (low-certainty evidence):
collagenase ointment (RR 2.12, 95% CI 1.06 to 4.22); foam dressings (RR 1.52, 95%
CI 1.03 to 2.26); basic wound contact dressings (RR 1.30, 95% CI 0.65 to 2.58)
and polyvinylpyrrolidone plus zinc oxide (RR 1.31, 95% CI 0.37 to 4.62); the
latter two interventions both had confidence intervals consistent with both a
clinically important benefit and a clinically important harm, and the former two
interventions each had high risk of bias as well as imprecision.
AUTHORS' CONCLUSIONS: A network meta-analysis (NMA) of data from 39 studies
(evaluating 21 dressings and topical agents for pressure ulcers) is sparse and
the evidence is of low or very low certainty (due mainly to risk of bias and
imprecision). Consequently we are unable to determine which dressings or topical
agents are the most likely to heal pressure ulcers, and it is generally unclear
whether the treatments examined are more effective than saline gauze.More
research is needed to determine whether particular dressings or topical agents
improve the probability of healing of pressure ulcers. The NMA is uninformative
regarding which interventions might best be included in a large trial, and it may
be that research is directed towards prevention, leaving clinicians to decide
which treatment to use on the basis of wound symptoms, clinical experience,
patient preference and cost.
DOI: 10.1002/14651858.CD011947.pub2
PMID: 28639707 [Indexed for MEDLINE]
