I have a patient who had a failed mesh placement and a panniculectomy and who has developed at least three separate fistulas with a very large amount of output (3-4 L/24 hrs). Any suggestions? I am using an Eakin wound management pouch hooked up to wall suction.
A Scientific Perspective on the Use of Topical Silver Preparations
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T he use of silver as an antimicrobial agent reaches back into antiquity, when people first learned that water stored in silver vessels kept better than water stored in other types of containers. Those who settled the American west placed silver dollars in their wooden water barrels to preserve the water. Such occurrences predate Pasteur's Germ Theory of Disease (published in 1877) and knowledge of the role that micro-organisms play in disease.
In 1884, Crede started using a 1% silver nitrate solution on neonates to prevent ocular infections.1 This was followed by Von Behring's work in 1887, where he showed that 0.25% and 0.01% silver nitrate solutions were effective against typhoid and anthrax bacilli, respectively.1 In 1893, von Nageli coined the term oligodynamic to describe the high level of antibacterial activity that was generated from relatively small amounts of silver and other heavy metals.1 Silver in the form of hammered foils and colloidal silver was used to treat indolent wounds in the early 1900s. During these treatments, a decrease in rubor often was noted, suggesting that the wounds were changing from an inflamed state to a non-inflamed healing state. In the 1920s, the US Food and Drug Administration accepted colloidal silver as a wound treatment.2
In the 1940s, with the advent of antibiotics, research on medical applications of silver declined dramatically. Not until the 1960s when Moyer and Monafo3 and Burke4 started using 0.5% silver nitrate solutions on burn wounds were research interests rekindled. In 1968, Fox5 introduced 1% silver sulfadiazine cream, which has become one of the leading topical agents used to treat burn wounds over the last 35 years.
Characteristics
Antimicrobial activity. Silver is effective against a broad range of aerobic, anaerobic, Gram-negative and Gram-positive bacteria, yeast, filamentous fungi, and viruses.1,6-8 In combination with its broad antimicrobial properties, silver also appears to have other prohealing or anti-inflammatory properties as suggested by the loss of rubor in chronic wounds treated with silver.2
The concentrations of silver that are needed to create a biological effect are dependent upon the local environment. In a pristine aqueous system, concentrations as low as 10 ug/L are effective in controlling bacteria, while in complex organic media, the minimum inhibitory concentration (MIC) increases 2,000-fold to the 20 to 40 ug/mL concentration reported by Ricketts et al.9 Yin et al6 determined MICs for five clinically relevant bacteria in Mueller-Hinton broth, a complex organic growth medium. The MIC values ranged from 5 to 12.5 ug Ag/mL.
Lack of toxicity. Few reported cases of silver toxicity exist in the medical literature. This suggests a low mammalian cell toxicity. Although cases of silver sensitivity (allergic responses) have occurred, no other pathological conditions have been noted despite large exposures to silver in burn wound treatment. Silver nitrate is typically applied 12 times per day in the treatment of serious burns. In 1 mL of absorptive capacity of dressing (about 1 square inch depending upon number of plies), the wound is treated (12 mL/day x 3,176 ug Ag+/mL) with 38,112 ug of silver per day or 533,568 ug of silver per 14 days. Silver sulfadiazine is typically applied twice daily on serious burns at a thickness of about 4 mm. This translates into about 2.6 grams of SSD per square inch (2.6 g x 3,000 ug Ag+/g SSD) or 7,800 ug of silver applied twice daily for a total of 15,600 ug of silver per day. This equates to 218,400 ug of silver per 14 days - about 41% of the silver applied through silver nitrate treatments. This reduction in silver usage was achieved by using the sulfadiazine moiety to control the release of silver and was considered a significant improvement in silver delivery.
References:
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3. Monafo W, Moyer C. The treatment of extensive thermal burns with 0.5% silver nitrate solution in early treatment of severe burns. Ann NY Acad Sci. 1968;150:937.
4. Burke, J. Personal communication.
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