Abstract
Burn sepsis is a leading cause of mortality and morbidity in patients with major burns. The use of topical anti-microbial agents has helped
improve the survival in these patients. There are a number of anti-microbials available, one of which, SilvazineTM (1% silver sulphadiazine
(SSD) and 0.2% chlorhexidine digluconate), is used only in Australasia. No study, in vitro or clinical, had compared SilvazineTM with
the new dressing ActicoatTM . This study compared the anti-microbial activity of SilvazineTM , ActicoatTM and 1% silver sulphadiazine
(FlamazineTM ) against eight common burn wound pathogens.
Methods: Each organism was prepared as a suspension. A 10 l inoculum of the chosen bacterial isolate (representing approximately
between 104 and 105 total bacteria) was added to each of four vials, followed by samples of each dressing and a control. The broths were
then incubated and 10 l loops removed at specified intervals and transferred onto Horse Blood Agar. These plates were then incubated
for 18 hours and a colony count was performed.
Results: The data demonstrates that the combination of 1% SSD and 0.2% chlorhexidine digluconate (SilvazineTM ) results in the most
effective killing of all bacteria. SSD and ActicoatTM had similar efficacies against a number of isolates, but ActicoatTM seemed only
bacteriostatic against E. faecalis and methicillin-resistant Staphylococcus aureus. Viable quantities of Enterobacter cloacae and Proteus
mirabilis remained at 24 h.
Conclusion: The combination of 1% SSD and 0.2% chlorhexidine digluconate (SilvazineTM ) is a more effective anti-microbial against
a number of burn wound pathogens in this in vitro study. A clinical study of its in vivo anti-microbial efficacy is required.
© 2003 Elsevier Ltd and ISBI. All rights reserved.
Keywords: Anti-microbial; Wound sepsis; Burns; Sulphonamides; Silver
10000000
Control
1000000
Acticoat
Colony Count
100000
Silvazine
Flamazine
Log10
10000
1000
100
10
1
0 4 8 12 16 20 24
Time (Hrs)
Fig. 1. Methicillin-resistant S. aureus viability curve induced by 1% silver sulphadiazine combind with 0.2% chlorhexidine digluconate (SilvazineTM ),
1% silver sulphadiazine (FlamazineTM ) and ActicoatTM dressing. Each point is the mean from three replicate experiments ± standard deviation.
10000000
Control
1000000 Acticoat
Silvazine
Colony Count
100000
Flamazine
Log10
10000
1000
100
10
1
0 4 8 12 16 20 24
Time (Hrs)
Fig. 2. Acinectobacter baumannii viability curve induced by 1% silver sulphadiazine combined with 0.2% chlorhexidine digluconate (SilvazineTM ), 1%
silver sulphadiazine (FlamazineTM ) and ActicoatTM dressing. Each point is the mean from three replicate experiments ± standard deviation.
10000000
Control
1000000 Acticoat
Silvazine
Colony Count
100000
Flamazine
Log10
10000
1000
100
10
1
0 4 8 12 16 20 24
Time (Hrs)
Fig. 3. Pseudomonas aeruginosa viability curve induced by 1% silver sulphadiazine combined with 0.2% chlorhexidine digluconate (SilvazineTM ), 1%
silver sulphadiazine (FlamazineTM ) and ActicoatTM dressing. Each point is the mean from three replicate experiments ± standard deviation.
38 J.F. Fraser et al. / Burns 30 (2004) 35–41
10000000
Control
1000000 Acticoat
Silvazine
Colony Count
100000
Flamazine
Lo g10
10000
1000
100
10
1
0 4 8 12 16 20 24
Time (Hrs)
Fig. 4. Escherichia Coli viability curve induced by 1% silver sulphadiazine combined with 0.2% chlorhexidine digluconate (SilvazineTM ), 1% silver
sulphadiazine (FlamazineTM ) and ActicoatTM dressing. Each point is the mean from three replicate experiments ± standard deviation.
10000000
Control
1000000 Acticoat
Silvazine
Colony Count
100000
Flamazine
Log10
10000
1000
100
10
1
0 4 8 12 16 20 24
Time (Hrs)
Fig. 5. Enterobacter cloacae viability curve induced by 1% silver sulphadiazine combined with 0.2% chlorhexidine digluconate (SilvazineTM ), 1% silver
sulphadiazine (FlamazineTM ) and ActicoatTM dressing. Each point is the mean from three replicate experiments ± standard deviation.
10000000
Control
1000000 Acticoat
Silvazine
Colony Count
100000
Flamazine
Log10
10000
1000
100
10
1
0 4 8 12 16 20 24
Time (Hrs)
Fig. 6. Staphylococcus aureus viability curve induced by 1% silver sulphadiazine combined with 0.2% chlorhexidine digluconate (SilvazineTM ), 1% silver
sulphadiazine (FlamazineTM ) and ActicoatTM dressing. Each point is the mean from three replicate experiments ± standard deviation.
J.F. Fraser et al. / Burns 30 (2004) 35–41 39
10000000
Control
1000000 Acticoat
Silvazine
Colony Count
100000
Flamazine
Log10
10000
1000
100
10
1
0 4 8 12 16 20 24
Time (Hrs)
Fig. 7. Enterococcus faecalis viability curve induced by 1% silver sulphadiazine combined with 0.2% chlorhexidine digluconate (SilvazineTM ), 1% silver
sulphadiazine (FlamazineTM ) and ActicoatTM dressing. Each point is the mean from three replicate experiments ± standard deviation.
10000000
Control
1000000 Acticoat
Silvazine
Colony Count
100000
Flamazine
Lo g10
10000
1000
100
10
1
0 4 8 12 16 20 24
Time (Hrs)
Fig. 8. Proteus mirabilis viability curve induced by 1% silver sulphadiazine combined with 0.2% chlorhexidine digluconate (SilvazineTM ), 1% silver
sulphadiazine (FlamazineTM ) and ActicoatTM dressing. Each point is the mean from three replicate experiments ± standard deviation.
studies with Proteus mirabilis and Enterobacter cloacae, ing in damage to cell walls, and at higher concentrations, to
increasing bacterial survival was seen in the ActicoatTM the intracellular contents. Damage occurs to the cell walls,
assays between 8 and 24 hours, consistent with increased and at higher concentrations, to the intracellular contents.
bacterial survival in the broth mixture. The majority of bacteria and yeast, with the exception of
mycobacteria, are sensitive to chlorhexidine. Hence, it is to
be expected that the addition of chlorhexidine substantially
4. Discussion improves the potency of the SSD.
A number of previous studies have examined TAA ef-
Silver in its numerous forms has been used for over 200 ficacy using zone of inhibition. Clinically, however, any
years in the treatment of burn injury [22]. The alteration of skin that is susceptible to infection is covered with TAA,
the physical form and the addition of co-molecules signifi- rendering the zone distal to the TAA irrelevant in a clinical
cantly alters the anti-microbial activity of silver. This is the context. The question that our study addressed is, ‘how po-
first in vitro comparison between the most commonly used tent an anti-microbial action does the TAA have in optimal
TAA in Australasia and ActicoatTM . The data is very clear in growing conditions for bacteria?’ The burn wound, with
the superior killing effect of the SilvazineTM over the other its high protein content and limited immune system due
dressings. The only difference between SilvazineTM and to local reduction of blood supply and systemic immuno-
FlamazineTM is the addition of 0.2% chlorhexidine diglu- suppression represents such an area. The broth inoculation
conate. This water-soluble biguanide is a potent bactericidal method allows for optimal bacterial growth. In agitating
agent in its own right. Its activity is concentration and pH the broths, which contain the TAA, the surface area of the
dependant, and peak effect occurs within 20 seconds result- creams (SilvazineTM and FlamazineTM ) may be larger as
40 J.F. Fraser et al. / Burns 30 (2004) 35–41
they are broken into smaller particles. However, SSD is show that SilvazineTM is a much more potent TAA against
relatively water insoluble. As has been mentioned earlier, all isolates tested. FlamazineTM and ActicoatTM have sim-
chlorhexidine is water soluble, and this may partly explain ilar efficacy in a number of isolates, but FlamazineTM is
the very rapid kill curve obtained consistently with Sil- superior to ActicoatTM in others, in particular S. aureus. The
vazine. Our group also investigated these agents, using a most potent agent was a combination of 1% silver sulpha-
zone of inhibition method, and chlorhexidine leached out diazine/0.2% chlorhexidine digluconate. A clinical study
of the cream, resulting in similar results. comparing the efficacy of ActicoatTM and SilvazineTM in
Of interest is the relative efficacy of ActicoatTM and the prevention of burn wound sepsis is required.
FlamazineTM . FlamazineTM was included in this study
to identify the relative efficacy of SilvazineTM and
FlamazineTM , and hence demonstrate the importance of Acknowledgements
the chlorhexidine digluconate. However, the comparison of
ActicoatTM and FlamazineTM show significantly different The authors acknowledge Miss Leila Cuttle (B.Sc.) and
results to the published literature. This may be due to the Ms. Margit Kempf for their comments on the manuscript.
differing study methods. Whilst there are pros and cons Smith and Nephew (Australia) provided the dressings free
of all study methods, none truly reflect clinical practice, of charge.
and it is an important finding of this study that ActicoatTM
does not perform so well under these laboratory conditions.
However, it must be born in mind that the graphs represent References
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