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Adding an Antimicrobial With Silver to Your Wound Care Armamentarium

Wound Care in the First Person

Adding an Antimicrobial With Silver to Your Wound Care Armamentarium

Index: Ostomy Wound Manage. 2018;64(8):14,16.

Chronic wounds are associated with a high incidence and degree of microbial colonization,1,2 where microorganisms are present in the wound and proliferating. These microbes can make wounds harder to heal, present higher risk of infection, and decrease patient quality of life3 through pain, impaired mobility, and wound malodor.4,5 Additionally, contaminated wound dressings present risks to wound care practitioners and the clinical environment because microbial aerosols can contaminate personnel and environmental surfaces with potential pathogens.6,7 Antimicrobial technologies that protect from microbial contamination have become part of the modern wound care tool kit; when incorporated into dressings, they can reduce the risk that the dressing becomes a focal point for wound infection, potentially leading to systemic infection.8-10

In our practice, we have found the use of Endoform Natural Dermal Template (manufactured by Aroa Biosurgery Limited, Auckland, New Zealand, and distributed by Appulse; enables us to intervene from day 1 of care using an aggressive and proactive strategy.11 Endoform is a collagen dressing that features an extracellular matrix (ECM) that provides a cell scaffolding during wound repair. Endoform mimics the ECM found in tissues; it provides secondary molecules (eg, laminin, fibronectin, and glycosaminoglycans) that are important for healing.12 Additionally, Endoform has been shown to modulate some of the critical wound proteases implicated in wound chronicity and to restore the prohealing wound environment. The clinical benefits of Endoform are reflected in the widespread adoption of this advanced wound technology.13-17

Recently, Endoform Antimicrobial Dermal Template was introduced to our wound care clinic. This new product utilizes the same ECM technology with the addition of 0.3% ionic silver to provide antimicrobial protection. Silver formulations have a long history in wound care, particularly in combination with dressings to protect from microbial contamination.18 Silver works as an antimicrobial via several mechanisms, most notably by binding to and disrupting the microbial cell wall19; ionic silver (Ag+) is the active antimicrobial form of silver. It is more advantageous to use ionic silver rather than elemental silver (eg, nanocrystalline silver) because ionic silver does not need to undergo chemical reduction in order to become activated. The risk of microbial resistance developing toward silver is extremely low because silver has multiple mechanisms of action, and repeated exposure to sublethal concentrations of silver are required for selective pressure toward resistance development. Silver dressings, including Endoform Antimicrobial, deliver a lethal dose of silver, rendering organisms nonviable and therefore unable to produce the offspring required for the development of resistance.

Endoform Antimicrobial dressings can be worn up to 7 days; the dressings can be applied as often as daily or as infrequently as weekly with the assurance that the device is protected from a range of clinically relevant microbes for up to 7 days. Some silver dressings are only antibacterial, but Endoform Antimicrobial has broad-spectrum antimicrobial effectiveness not only toward bacteria, but also toward yeast and mold, including drug-resistant strains. In vitro testing has shown Endoform Antimicrobial reduced cell toxicity relative to other silver dressings, an issue that has plagued the day-to-day use of many silver-containing wound dressings.20

This addition of an antimicrobial to the Endoform product line enables us to continue to intervene early in wound management, knowing the ECM is protected from microbial contamination. This is especially useful during the early phases of healing where the wound and dressing are at greater risk of microbial contamination. We see Endoform Antimicrobial and Endoform Natural as complementary technologies that can be used across all phases of wound healing. The availability of both products enables us to be conservative in our use of silver; in this regard, we can adhere to best antimicrobial stewardship practice.18

Case Study

A patient with diabetes presented with a wound to the third toe of the left foot (measuring 1.5 cm x 1.5 cm x 0.4 cm (see Figure 1). The injury had caused exposure of the tendon. The patient was neuropathic and had previously had a left second toe amputation due to osteomyelitis. One (1) day after the injury, the wound underwent sharp debridement and Endoform Antimicrobial was applied. After 1 week, the tendon was partially covered and the wound progressed, with granulation present in the third week and wound dimensions of 1.0 cm x 1.0 cm x 0.3 cm (see Figure 2). Endoform was applied every 3 to 7 days, and ECM application was managed by the patient and her support network between visits. The patient has not noted any changes in pain, comfort, or malodor, and the wound bed was not discolored as might be expected from other silver-based dressings. We will continue to manage this wound with Endoform Antimicrobial; alternatively, we can switch to Endoform Natural now that the wound has stabilized and is progressing toward closure. 


Wound Care in the First Person is made possible through the support of Appulse ( The opinions and statements of the clinicians providing Wound Care in the First Person are specific to the respective authors and not necessarily those of Appulse, OWM, or HMP. This article was not subject to the Ostomy Wound Management peer-review process.