Arglaes leads way among silver dressings

Prevents infections, reduces risk of transmission

Dressings impregnated or coated with some form of silver are garnering a lot of attention these days, primarily because of their antimicrobial and antifungal properties. A slew of positive anecdotal reports aren’t hurting the reputation of such products. One of the chief applications for silver dressings has been burn care, but they’ve increasingly found favor for treating chronic wound patients as well.

For wound care, the more prominent of the two silver dressings currently on the market is Arglaes, manufactured by Maersk Medical UK and distributed in the United States by Medline Industries of Mundelein, IL. The other silver dressing available commercially is Acticoat, manufactured by Westaim Corp., Fort Saskatchewan, Canada. Silverlon, an emerging silver dressing manufactured by Argentum International LLC of Providence, RI, has received Food and Drug Administration marketing approval and is expected on the market this winter.

Though some attributes of these three dressings differ, they all are based on the same principle: They deliver silver ions to tissue at a steady rate for extended periods and are designed to prevent bacterial colonization in infection-prone areas.

"The physical characteristics of the dressings vary, but that’s not important to practitioners. They want to know how effective they are, how safe they are, and how much they cost," says Bart Flick, MD, an orthopedic surgeon who developed Silverlon and began investigating silver as an antimicrobial for wound care more than a decade ago.

Acticoat has been on the market for about a year. It was initially designed for preventing infection in burn patients and is still strongly identified with that niche. A company consultant told Wound Care that Westaim has begun to examine a larger role for Acticoat in chronic wound treatment.

Westaim focused first on burn care because it is "probably the most demanding area for high-performance infection control," according to company president Michael Raymont, whose office is in Exeter, NH. "Silver ions can wipe out any type of pathogenic bacteria considerably faster and at lower concentrations than conventional silver antimicrobials," he says.

Acticoat is described as a barrier dressing consisting of flexible, abrasion-resistant soluble silver films. Raymont says plans are under way for clinical trials to examine the use of Acticoat for donor sites, chronic wounds, and immunocompromised patients.

Silverlon consists of nylon fabric coated with a thin layer of 99% pure, 1% silver oxide.

"Silver has the capacity to reduce surface contamination," says Flick. "In many cases, that’s all that’s needed to enhance wound healing." He cautions that silver dressings may help reduce the bioburden of a seriously infected wound, but they will not eliminate an existing infection. "Appropriate medical treatment and surgery are needed for infected wounds," he explains. "There’s a lot of confusion over this. It’s a great mistake to think that silver alone can entirely rid the infection."

Arglaes more common in wound care

Silver dressings are easier to use than silver sulfadiazine cream. The cream, while easy to apply and less expensive than the newer silver-impregnated dressings, is messy and requires frequent applications and concurrent dressing changes because the silver in the cream is quickly neutralized after it comes into contact with bodily fluids. Dosing of silver sulfadiazine cream also is inexact, and depends greatly on how thickly the cream is applied; there is bound to be inter-clinician (and even intra-clinician) variability between applications.

Arglaes has seen substantially more clinical use in wound care than the other two products. Arglaes is available in two forms: a barrier film dressing designed for dry to lightly draining wounds, and an "island" dressing comprised of an alginate pad for moderately to heavily draining wounds.

The Arglaes film dressing releases silver ions at a relatively constant rate for as long as seven days, while the alginate pad does so for about five days, according to users who related their experiences to Wound Care. When water vapor from a wound reaches the silver-impregnated dressing, the material releases silver ions. According to Maersk, the discharge rate of silver ions remains the same regardless of the amount of liquid exuded by a wound. Arglaes can be applied in place of topical antibiotics for at-risk individuals, such as elderly patients, intensive care patients, diabetic patients, and immunosuppressed patients, Maersk researchers say. Many wound care professionals find the product extremely effective for treating patients with chronic wounds.

In one non-randomized study conducted at the Overton Brooks Veterans Administration Medical Center in Shreveport, LA, Arglaes was found to be 100% effective for suppressing bacteria at central line access sites. Common wound dressings demonstrated far less effectiveness.

High price, but reduced costs

The manufacturer claims that Arglaes, while relatively expensive (one user told Wound Care a 2" x 2" square of Arglaes cost more than $20), ultimately saves money by reliably preventing infections and reducing the risk of transferring infections to staff members or other patients — events that easily could result in costs greatly exceeding the price of several weeks’ worth of dressings and the concomitant staff time.

Stephen Colvin, MD, a cardiothoracic surgeon at the New York University School of Medicine, says the treatment leads to better outcomes for patients and shortens hospital stays. "They need fewer antibiotics and they are able to recover more quickly and completely," Colvin says. He uses Arglaes at the incision sites of his patients to reduce the risk of infection.

At Children’s Mercy Hospital in Kansas City, MO, clinicians have used Arglaes to help control infections in patients when prior measures failed. At a Florida hospital, clinicians report that a patient who developed a deep abscess on her buttock after a trauma could not be healed after antibiotic therapy and extensive operations and debridement. The wound became infected with methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci. Arglaes eventually was applied to the wound, and in one week wound depth had decreased by 50%.

John Macdonald, MD, medical director of the Wound Healing—Lymphedema Center in Fort Lauderdale, FL, has used Arglaes to treat about 50 chronic wound patients. "The basic premise for using silver is very good because it’s bactericidal and fungicidal, nothing is really resistant to it, and allergic reactions are rare," he says. Macdonald recalls during his residency a surgeon who used silver ointment on wounds long before silver had become a regular part of wound care.

"If all that the manufacturer is saying is correct, [silver] will be a great alternative to topical antibiotics, which many clinicians stay away from because of the risk of colonization and infection, allergy, and dermatitis," Macdonald adds.

He says he’s still getting used to Arglaes and is searching for the best methods of application. "We’re doing a lot of trial and error, and a lot of it is working."

He adds that the "jury is still out on some aspects" of Arglaes for chronic wounds.

Giving healing a jump-start

"One question is how much penetration of the skin there is with silver," says Macdonald. "How deep does it go and how much is absorbed? We’re seeing the effect, but we’d like to know more about how it works. One problem is that there’s not yet a lot of American literature on the use of [Arglaes].

"Where I’ve seen good results is when I see a wound that needs a quick jump-start of antibacterial or antifungal activity. We’ve had good luck clearing up peri-inflammation around wounds. In the very early stages of wound care, when we would often have used a topical antibiotic, Arglaes can be used to take care of a local infection." He says he often leaves the dressing in place for five or six days and has used it under an Unna Boot for treating venous stasis ulcers. Arglaes film is not appropriate for highly exudative wounds because the dressing acts as a barrier to exudate, Macdonald notes.

One nurse reports overcoming that limitation by actually cutting slits in the film dressing and placing an absorbent material over the Arglaes layer to absorb exudate that seeps through. The antimicrobial aspects of the dressing compensate for compromising the barrier, while the dressing combination still maintains a moist wound environment.

Macdonald predicts that over the next year, clinicians will define more "dos and don’ts" for the use of Arglaes. More clinical experience with silver dressings and consistent methods for measuring outcomes are still needed. As more dressings are used and information on their performance is gathered, judgments on the effectiveness of Arglaes under varying circumstances will grow clearer and show if the dressing — and others like it — can fulfill the promises of their manufacturers and marketers.