Review: Diabetic Foot Ulcer Treatments Compared

Use of an antimicrobial dressing instead of a non-antimicrobial dressing may increase healing of diabetic foot ulcers over a medium-term follow-up period, according to a Cochrane Database of Systematic Reviews.

Topical antimicrobial preparations are often used on diabetic food ulcers, either to treat clinically infected wounds or to prevent infection in clinically uninfected wounds.

Dumville et al. conducted a review to evaluate the effects of treatment with topical antimicrobial agents on the resolution of signs/symptoms of infection, the healing of infected ulcers, and the prevention of infection and improving healing in uninfected ulcers.

They reviewed 22 randomized controlled trials (N=2310) that evaluated topical treatment with any type of solid or liquid antimicrobial agent, including antiseptics, antibiotics, and antimicrobial dressings, in people with diabetes mellitus who were diagnosed with an ulcer or open wound of the foot. Most of the studies had only a small numbers of participants (from 4 to 317) and relatively short follow-up periods (4 to 24 weeks). The included studies utilized several different types of topical antimicrobial treatments, including antimicrobial dressings (e.g. silver, iodides), super-oxidized aqueous solutions, zinc hyaluronate, silver sulphadiazine, tretinoin, pexiganan cream, and chloramine. 

The researchers conducted five different comparisons. A comparison of antimicrobial dressings to non-antimicrobial dressings (including pooled data from five trials, n=945 participants) suggested that more wounds may heal when treated with an antimicrobial dressing than with a non-antimicrobial dressing: (RR 1.28, 95% confidence interval (CI) 1.12 to 1.45). Participants in the antimicrobial-dressing treatment arm also experienced an additional 119 healing events. However, the researchers considered this “low-certainty evidence,” due to risk of bias.

In comparing antimicrobial topical treatments (non-dressings) to non-antimicrobial topical treatments (non-dressings), the researchers found evidence that was “generally of low or very low certainty.”

The researchers were unable to reach any conclusions regarding comparison of different topical antimicrobial treatments, as all comparisons across the eight qualifying trials were different and no data could be appropriately pooled.

Comparison of topical antimicrobials with systemic antibiotics yielded “uncertain” evidence regarding the relative effects on resolution of infection in infected ulcers and surgical resection (very low certainty). However, based on the four qualifying studies, they concluded that there was “probably little difference in the risk of adverse events between the compared topical antimicrobial and systemic antibiotics treatments: RR 0.91 (95% CI 0.78 to 1.06; moderate-certainty evidence).”

A comparison of topical antimicrobial agents compared to growth factor could not be adequately conducted, due to small sample size (40 participants).

“Given the high, and increasing, frequency of diabetic foot wounds, we encourage investigators to undertake properly designed randomized controlled trials in this area to evaluate the effects of topical antimicrobial treatments for both the prevention and the treatment of infection in these wounds and ultimately the effects on wound healing,” the authors concluded.

Reference

Dumville JC, Lipsky BA, Hoey C, Cruciani M, Fiscon M, Xia J. Topical antimicrobial agents for treating foot ulcers in people with diabetes. Cochrane Database Syst Rev. 2017 Jun 14;6:CD011038.