Table 1.

Summary of Silver Applications for Treatment of Infections

Modality	Pros	Cons	Cost effectiveness	Recommendation
Topical application for burns	• Several preparations available • Reduced infection rates • Prolonged silver ion release with some preparations • Potentially fewer dressing changes • Better wound healing and skin graft adherence	• Several preparations available • Concern about toxicity for host cells • Electrolyte leaching with silver nitrate	Favors use of prolonged-release silver, although no comparison of all products is available [53]	Difficult to compare wide variety of applications; recommended for initial/early decontamination of burn wounds
Topical application for ulcers	• Several preparations available • Potentially longer wear time for dressings • Reduction in wound size; less odor and exudate • Less pain	• Several preparations available • Potentially more frequent office visits and longer total duration of wound care • Several studies failed to show benefit in overall wound healing	Some studies favor use of silver-releasing foam dressing [55,60,62], whereas others show higher cost [59,61]	Current data do not support routine use of silver for this application
Surgical incisions	• Fewer surgical site infections in cardiac, colorectal, or lower extremity revascularizations • Shorter time to re-epithelialization of skin graft donor sites [69]	• Longer time to re-epithelialization of skin graft donor sites in one study [68] • Studies of silver-impregnated mesh or suture material are still in early phases	Cost comparison data not available	Current data do not support routine use of silver for this application
Blood stream infections	• Reduced catheter colonization and CR-BSI rates with CSS catheters (more so with second-generation catheters)	• Benefit may not be seen with low institutional baseline infection rates • Use of antibiotic-impregnated catheters may confer greater reduction of infections	Favors use of CSS and RM catheters in high-risk patients or with high baseline infection rates [96,97]	Recommended if elevated institutional CR-BSI rates despite a comprehensive control program
Urinary tract infections	• Reduced infection rates in some studies with use of silver-alloy catheters	• Studies are heterogeneous • Several large studies did not find benefit	Favors use of silver alloy catheters [109]	Recommended if baseline infection rates are high
Ventilator/ endotracheal tubes	• Lower incidence of VAP • Reduced mortality rate in patients with VAP	• Higher mortality rate in patients without VAP • Use of care bundles may negate contribution of silver-coated tubes	Favors use of silver-coated tubes [131]	Recommended if elevated institutional VAP rates despite a comprehensive control program
Orthopedic hardware	• Decreased bacterial adherence to silver-coated external fixation pins • Better cyto-compatibility • Fewer infections when combined with chlorhexidine for pin-site dressings • Lower infection rates with silver-coated implant devices	• Increased serum silver concentrations in one study • Early-phase studies only; need further investigation	Cost comparison data not available	Current data do not support routine use of silver for this application
Vascular prostheses	• Lowered rates of infection when used as primary prosthesis, although differing results have been reported	• Inconsistent data regarding risk of reinfection • May activate neutrophils and inhibit their antibacterial properties	Cost comparison data not available	Current data do not support routine use of silver for this application
Heart valves	• Low rates of recurrent endocarditis in early studies	• Higher rates of embolization • More moderate and severe paravalvular leaks • Substantial need for reoperation	No longer available	Not recommended

CR-BSI=catheter-related blood stream infection; CSS=chlorhexadine–silver sulfadiazine; RM=rifampicin–minocycline; VAP=ventilator-associated pneumonia.