4. Summary of secondary outcome data for comparisons.
| Study ID | Number participants/burns | Duration | Adverse events |
Pain Means (SD) |
Mortality | Quality of life |
Resource use Means (SD) |
Costs: Means (SD) Difference in means (95% CI) |
| Antiseptic versus topical antibiotic | ||||||||
| Silver versus SSD | ||||||||
| Abedini 2013 | Silver hydrofibre 35 SSD 34 |
Until healing | ‐ | Doses of fentanyl silver: 3.3 (1.9) SSD 10.3 (4.2) SD extrapolated from graph |
‐ | ‐ | ‐ | Costs of antibiotics, analgesics, dressings, accommodation, nursing/visiting (USD) Silver 26,000 (20,000) SSD 38,000 (30,000) Data extrapolated from graph MD ‐12,000 (‐24,065.99 to 65.99) |
| Caruso 2006 | Silver hydrofibre 42 SSD 40 |
21 days | All Silver 20 SSD 18 RR 1.06 (0.66 to 1.69) Serious Silver 8 SSD 8 RR 0.95 (0.40 to 2.29) |
Participants aged > 4 years (69%) VAS score during dressing changes Silver 3.63 SSD 4.77 P = 0.003 |
Silver 1 SSD 0 |
Dressing changes/day Silver 0.5 (0.1) SSD 1.2 (0.5) Total dressing changes Silver 7.7 (3.9) SSD 19.1 (13.2) MD ‐11.40 (‐15.66 to ‐7.14) |
Cost of nursing time (USD) Silver 14.30 SSD 21.90 Costs of study dressings Silver 684 SSD 398 Cost of all dressings (USD) Silver 845.5 SSD 759.6 Total care Silver 1040 (856.66) SSD 1180 (792.18) MD ‐140 (‐4.96.92 to 216.92) Cost effectiveness /patient healed (USD) Silver 1409.06 (1050.41‐1857.58) SSD 1967.95 (1483.06‐2690.22) MD ‐558.89 (‐1383.08 to 265.30) ICER ‐1019.21 (‐6320.59 to 4054.32) |
|
| Muangman 2010 | Silver hydrofibre 35 SSD 35 |
NR | ‐ | Pain during dressing Day 1: Silver 4.1 (2.1) SSD 6.1 (2.3) Day 3 Silver 2.1 ( 1.8) SSD 5.2 (2.1) Day 7 Silver 0.9 (1.4) SSD 3.3 (1.9) MD ‐1.42 (‐1.95 to ‐0.89) |
‐ | ‐ | ‐ | Total cost (USD) Silver 52 (29) SSD 93 (36) MD ‐ 41.00 (‐56.31 to ‐25.69) Hospital cost Silver 43 (28) SSD 57 (SD 25) Travel cost: Silver 9 (4) SSD 36 (SD 14) |
| Adhya 2015 | Silver hydrogel 84 SSD 79 analysed Silver 54 SSD 52 |
4 weeks/until healing | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Glat 2009 | Silver hydrogel 12 SSD 12 |
21 days+ | Silver 0 SSD 0 |
Pain during dressing changes (Wong‐Baker Faces Pain Scale observational pain assessment scale in infants or toddlers) Silver 2.33 (1.07) SSD 5.33 (1.44) ‐2.28 (‐3.35, ‐1.22) |
‐ | ‐ | Number of dressing changes (over 21 days) Silver 13.50 (4.70) SSD 13.42 (8.26) MD 0.08 (‐5.30 to 5.46) |
‐ |
| Gong 2009 | Silver hydrogel 52 SSD 52 |
21 days+ | During dressing: Silver no significant damage to granulation SSD damage to granulation |
Silver no pain during dressing SSD pain during dressing |
‐ | ‐ | ‐ | ‐ |
| Silverstein 2011 | Silver foam 50 SSD 51 |
21 days | 2 associated withdrawals in each group Other events reported Silver 16 SSD 10 RR 0.75 (0.48, 1.16) |
Dressing application (week 1) Silver 19.1 SSD 40.0 During wear silver 22.0 SSD 35.5 Dressing removal: reported as NS |
Silver 1 SSD 1 |
‐ | Mean number of dressing changes over 3 weeks (SD NR) Silver 2.24 (N = 47) SSD 12.4 Mean time to discharge Silver 5.62 d SSD 8.31 d |
Total costs (USD) Silver 309 (144) SSD 514 (282) Average C‐E Silver 395 (344‐450) SSD 776 (659‐892) ICER ‐1688 Based on 20 participants |
| Tang 2015 | Silver foam 71 SSD 82 |
4 weeks | Silver 4 participants with 5 events SSD 7 participants with 7 events RR 0.66 (0.20, 2.16) |
Baseline Silver 35.3 (22.4) SSD 42.9 (25.8) Week 4 Before dressing removal silver 6.78 (12.95) SSD 11.0 (17.3) MD ‐4.22 (‐9.03 to 0.59) During dressing removal silver 9.23 (13.61) SSD 19.1 (23.9) After dressing removal silver 9.41 (17.33) SSD 15.8 (19.7) MD ‐6.39 (‐12.26 to ‐0.52) |
‐ | ‐ | Total number of dressing changes silver 3.06 SSD 14.0 Per week silver 1.36 SSD 5.67 SD NR |
‐ |
| Yarboro 2013 | Silver foam SSD 24 participants randomised; group allocation unclear |
NR | ‐ | Mean after each treatment Silver 2.92 (1.12) SSD 4.70 (2.22) MD ‐0.98 (‐1.83 to ‐0.12) |
‐ | ‐ | Number of treatments required: Silver 4.10 (1.38) SSD 10.27 (7.46) MD ‐6.17 (‐10.46 to ‐1.88) |
‐ |
| Zhou 2011 | Silver foam SSD 40 participants; part of each burn randomised to each treatment |
14 days | No serious events | ‐ | ‐ | ‐ | ‐ | ‐ |
| Chen 2006a (nanoparticle) | Silver nanoparticle) 65 SSD 63 Vaseline gauze 63 |
Until healing | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Huang 2007 | 98 participants with 166 burns Nanocrystalline silver 83 burns SSD 83 burns |
20 days | No local allergic or systemic symptoms. No side effects related to silver dressing | ‐ | ‐ | ‐ | ‐ | ‐ |
| Muangman 2006 | Nanocrystalline silver 25 SSD 25 |
NR | ‐ | Silver 4 (± 0.6) SSD 5 (± 0.7) MD ‐1.51 (‐2.14 to ‐0.88) |
Silver 0 SSD 0 |
‐ | ‐ | ‐ |
| Varas 2005 | Nanocrystalline silver SSD 14 participants with 2 burn areas; 14 burn areas/group |
NR | Withdrawals due to pain/infection silver 0 SSD 5/10 after 4.8 d (0‐8) |
Silver 3.2 (2.68) SSD 7.9 (2.65) Paired data for 10 participants ‐1.69 (‐2.74 to ‐0.64) |
‐ | ‐ | ‐ | ‐ |
| Liao 2006 | Silver nitrate SSD 120 participants with 2 burns; 120 burns/ group |
Until healing | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Opasanon 2010 | Silver alginate 30 SSD 35 |
NR | ‐ | Silver 2.23 (1.87) SSD 6.08 (2.33) MD ‐1.79 (‐2.37 to ‐1.20) |
‐ | ‐ | Nursing time (min) Silver 8.47 (6.16) SSD 13.29 (4.19) Dressing changes Silver 2.93 (1.17) SSD 14.00 (4.18) MD ‐11.07 (‐12.52 to ‐9.62) |
‐ |
| Honey versus topical antibiotics | ||||||||
| Baghel 2009 | Honey 37 SSD 41 |
NR (2 months' follow‐up) | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Bangroo 2005 | Honey 32 SSD 32 |
21 days | Contractures or over‐granulation reported in 3 vs 5 cases | Pain reported as "worse" for honey group | ‐ | ‐ | ‐ | ‐ |
| Malik 2010 | Honey SSD 150 participants with 2 burns; 150 burns/group |
24 days | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Mashhood 2006 | Honey 25 SSD 25 |
6 weeks | Honey no allergy or side effects SSD 2 participants irritation/burning (mild) |
Pain free 1 week honey 9 SSD 4 2 weeks honey 20 SSD 11 3 weeks honey 25 SSD 18 4 weeks honey 25 SSD 25 |
‐ | ‐ | ‐ | Cost per % of TBSA affected Honey 0.75 Rupees for 5 mL SSD 10 Rupees for 2 g ointment SD NR |
| Memon 2005 | Honey 40 SSD 40 |
46 days | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Subrahmanyam 1991 | Honey 52 SSD 52 |
15 days | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Subrahmanyam 1998 | Honey 25 SSD 25 |
21 days | SSD 4 participants required skin grafting | ‐ | ‐ | ‐ | ‐ | ‐ |
| Subrahmanyam 2001 | Honey 50 SSD 50 |
21 days | No irritation allergy or other side effects. Need for skin grafting Honey 4 SSD 11 |
Subjective relief of pain better in honey group | Hospital stay days Honey 22.0 (1.2) SSD 32.3 (2.0) |
|||
| Sami 2011 | Honey 25 SSD 25 |
60 days | ‐ | Time to complete relief of pain (mean) Honey 12 days SSD 16.8 days Up to 5 days Honey 9 SSD1 6‐12 days Honey 9 SSD 11 13‐21 days Honey 7 SSD 11 22‐26 days Honey 0 SSD 2 |
Amount used per dressing per % burn Honey 5 gm (sic) SSD 2 gm (sic) Based on adult participants |
Cost per dressing per % burn Honey 2.40 Rs SSD 4.92 Rs |
||
| Maghsoudi 2011 | Honey 50 Mafenide acetate 50 |
30 days | Honey 0 Mafenide 0 |
‐ | ‐ | ‐ | ‐ | ‐ |
| Zahmatkesh 2015 | Honey (olea) 10 Mafenide acetate 20 |
20 days | Need for surgical debridement Honey 0/10 Mafenide 13/20 |
‐ | ‐ | ‐ | ‐ | ‐ |
| Aloe Vera versus topical antibiotics | ||||||||
| Khorasani 2009 | Aloe Vera 30 SSD 30 |
24 days | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Panahi 2012 | Aloe Vera 60 SSD 60 |
14 days | ‐ | Changes from baseline Day 2 Aloe Vera 2.61 (1.55) SSD 1.19 (2.25) Day 7 Aloe Vera 5.13 (2.82) SSD 3.78 (2.83) Day 14 Aloe Vera 5.68 (3.2) SSD 4.54 (2.83) MD 1.14 (0.02 to 2.26) |
‐ | ‐ | ‐ | ‐ |
| Shahzad 2013 | Aloe Vera 25 SSD 25 |
Until healing/ 2 months |
‐ | Time to being pain free reported differently for groups | ‐ | ‐ | ‐ | Cost/%TBSA Aloe Vera 2.40 Rs SSD 4.92 Rs SD NR |
| Thamlikitkul 1991 | Aloe Vera 20 SSD 18 |
26 days | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Akhtar 1996 | Aloe Vera 50 Framycetin 50 |
NR | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Iodine versus SSD | ||||||||
| Homann 2007 | Povidone iodine Hydrogel SSD 43 participants each with 2 comparable burns; 43 burns in each group |
21 days | 20 participants with events. 6 systemic and considered unrelated to study interventions Iodine 6 (5 pain) SSD 7 (5 pain) |
‐ | ‐ | ‐ | ‐ | ‐ |
| Li 1994b | MEBO 31 Iodophor 24 Ethacridine lactate 22 SSD 38 |
Until healing | ‐ | ‐ | ‐ | ‐ | ‐ | All RMB (Chinese Yuan) MEBO 1836 (542.35) Iodophor 621 (130.83) Ethacridine 598 (125.43) SSD 674 (191.50) Ethacridine vs SSD MD ‐76.00 (‐1.56.34 to 4.34) Iodophor vs Ethacridine MD 23 (‐51.07 to 97.07) Ethacridine vs MEBO MD ‐1238 (‐1435.98 to ‐1040.02) Iodophor vs SSD MD ‐53.00 (‐133.29 to 27.29) Iodophor vs MEBO MD ‐1215 (‐1412.96 to ‐1017.04) |
| Other antiseptics versus topical antibiotics | ||||||||
| Ning 2008 | 20 participants with 2 burns (20 burns/group) | 28 days | No serious events in either group. | ‐ | ‐ | ‐ | ‐ | ‐ |
| Radu 2011 | Octenidine SSD 30 participants with 2 burn areas; 30 burns in each group |
24 hours | ‐ | Median VAS Octenidine 3 (1‐6) SSD 6 (3‐8) |
‐ | ‐ | ‐ | ‐ |
| Piatkowski 2011 | Polyhexanide 30 with 38 burns SSD 30 with 34 burns |
NR | ‐ | Graph data Baseline Polyhexanide Change 7.8 Between 1.2 SSD Change 8 Between 3 Day 1 Polyhexanide Change 4.2 Between 0.8 SSD Change 6 Between 2.6 Day 3 Polyhexanide Change 2.2 Between 0.2 SSD Change 5 Between 1.8 Day 5 Polyhexanide Change 1.4 Between 0.1 SSD Change 4 Between 1 Day 7 Polyhexanide Change 0.8 Between 0.1 SSD Change 3 Between 0.8 Day 10 Polyhexanide Change 0.2 Between 0.5 SSD Change 2 Between 0.5 Day 14 Polyhexanide Change 0 Between 0 SSD Change 1.4 Between 0 SD NR |
‐ | ‐ | ‐ | Costs/day (EUR) Materials Polyhexanide 5.14 SSD 6.96 Personnel Polyhexanide 9.63 SSD 9.63 Total Polyhexanide 14.77 SSD 16.59 SD NR |
| Nasiri 2016 |
Arnebia euchroma SSD 49 participants with 2 burns; 49 burns in each group |
36 days but up to 10 days for secondary outcomes | Specific complications such as burning, pain, itching, warming , allergic reactions and requiring skin graft. Scores reported for itching and warming. Skin graft risk A euchroma 2.2% (2.2 to 6.7) SSD 6.7% (0.9 to 14.3) |
Pain scores reported graphically for days 1, 3, 5 and 10 for minutes 1, 5 and 15 after dressing. Graphs appeared to show overlapping CI but P reported < 0.05 (CI could not be extracted) | ‐ | ‐ | ‐ | ‐ |
| Antiseptics versus alternative antiseptics | ||||||||
| Han 1989 | Iodine 111 Chlorhexidine 102 |
NR | ‐ | Pain at rest Iodine (N = 84) 9.18 (15.11) Chlorhexidine (N = 78) 11.44 (14.27) MD 2.26 (‐2.26 to 6.78) Pain on dressing removal Iodine (N = 92) 6.66 (11.06) Chlorhexidine (N = 84) 8.75 (15.84) MD 2.09 (‐2.00 to 6.18) |
‐ | ‐ | Number hospital visits (N unclear) Iodine 2.64 (1.45) Chlorhexidine 3.03 (1.62) MD 0.25 (‐.0.02 to 0.52) |
‐ |
| Antispetic versus non‐antibacterial treatment | ||||||||
| Jiao 2015 | Nanocrystalline silver 38 Vaseline gauze 38 |
30 days | Scar hyperplasia reported; no other data | ‐ | ‐ | ‐ | ‐ | ‐ |
| Healy 1989 | Silver xenograft 16 Petroleum gauze 16 |
14 days | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Subrahmanyam 1993b | Honey 46 Polyurethane film 46 |
NR | Honey 4 noted Polyurethane 6 noted Not clear all events were reported/basis of reported events |
‐ | ‐ | ‐ | ‐ | ‐ |
| Subrahmanyam 1994 | Honey gauze 40 Amniotic membrane 24 |
30 days | Honey 4/40 Amniotic 5/24 Not clear all events were reported/basis of reported events |
Numbers with pain evaluated with 4‐point scale None/mild Honey 33/40 Amniotic 13/24 Moderate/severe Honey 7/40 Amniotic 11/24 |
‐ | ‐ | ‐ | ‐ |
| Subrahmanyam 1996a | Honey 50 Potato peel 50 |
21 days | "Allergy or other side effects were not observed in any patient of either group" | "Subjective relief of pain was the same in both groups" | ‐ | ‐ | ‐ | ‐ |
| Subrahmanyam 1996b | Honey 450 "Conventional dressing" 450 |
NR | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Inman 1984 | SSD + chlorhexidine 54 assessed SSD only 67 assessed Unclear if additional post‐randomisation exclusions |
Until healing (26 days) | ‐ | Pain sufficient to stop treatment Chlorhexidine 1/54 SSD alone 0/67 |
Chlorhexidine 3/54 SSD alone 4/67 RR 0.93 (0.22 to 3.98) Infection‐related chlorhexidine 3/54 SSD alone 0/67 |
‐ | ‐ | ‐ |
| Neal 1981 | Chlorhexidine 25 Polyurethane 26 |
30 days | ‐ | Qualitative data only (chlorhexidine perceived as more painful) | ‐ | ‐ | ‐ | ‐ |
| Phipps 1988 | Chlorhexidine 104 Hydrocolloid 92 |
NR | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Thomas 1995c | Chlorhexidine tulle‐gras 18 Hydrocolloid 16 Hydrocolloid + SSD 16 |
NR | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Wright 1993 | Chlorhexidine 49 Hydrocolloid 49 |
NR | Chlorhexidine 1 Hydrocolloid 5 Denominator unclear |
VAS (summed for each visit) Chlorhexidine (N = 31) Hydrocolloid (N = 36) P = 0.284 |
‐ | ‐ | Number dressings Chlorhexidine 2.8 Hydrocolloid 2.61 SD NR |
‐ |
| Carayanni 2011 | Povidone iodine + Bepanthenol 107 MEBO 104 |
18 days | "Complications" Iodine 8 MEBO 11 RR 1.30 (0.47 to 3.61) |
Median pain scores reported graphically. Analgesia requirements also reported | ‐ | ‐ | Reduction of hospital stay (subtracted from a standard length of stay (10 days)) Iodine ‐3.01 (2.02) MEBO ‐3.63 (2.19) MD 0.62 (0.05 to 1.19) |
Costs of hospital stay including medicines and examinations and the visits and treatments after discharge 2006 (EUR) Total MEBO 529.66 (172.75) Total iodine 566.21 (151.45) MD 36.55 (‐7.33 to 80.43) ICERs reported per day of hospitalisation and per day of recovery gained. Total/hospitalisation day gained ‐58.95E (‐63.10, ‐55.09) (favours MEBO) |
| Li 2006 | Iodine gauze 74 Superficial 16 Deep 32 Residual 26 Carbon‐fibre dressing 203 Superficial 46 Deep 89 Residual 68 |
NR | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
| Yang 2013 | 60 participants with burn wounds; 60 burn areas/group (Iodophor gauze/ hydrogel) |
14 days | ‐ | Dressing change pain Iodophor 43 wounds caused evident pain (VAS score 3‐6) Hydrogel 37 wounds caused mild pain (VAS 1‐3) |
‐ | ‐ | ‐ | ‐ |
| De Gracia 2001 | Cerium nitrate + SSD 30 SSD 30 |
Until healing/ readiness for grafting |
‐ | ‐ | CN + SSD 1/30 SSD 4/30 RR 0.25 (0.03 to 2.11) |
‐ | Days of hospitalisation CN + SSD 23.3 (11.4) SSD 30.7 (22.7) MD ‐7.40 (‐16.49 to 1.69) |
‐ |
| Oen 2012 | Cerium nitrate + SSD 78 SSD 76 |
21 days | ‐ | Mean (SEM) CN + SSD 0.6 (0.2) SSD 1.2 (0.4) MD Procedural Mean (SEM) CN + SSD 1.3 (0.3) SSD 1.6 (0.5) MD ‐0.60 (‐0.70 to ‐0.50) |
CN SSD 1 SSD 5 RR 0.19 (0.02 to 1.63) |
‐ | ‐ | ‐ |
| Piccolo‐Daher 1990d | Multiple comparisons Merbromin 25 Sodium salicylate 25 Zinc sulfadiazine 25 Sodium salicylate + zinc sulfadiazine 25 Collagenase + chloramphenicol 25 |
NR | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ |
C‐E: cost‐effectiveness; CN: cerium nitrate; ICER: incremental cost‐effectiveness ratio; MEBO: moist exposed burn ointment; NR: not reported; NS: not significant; SD: standard deviation; SEM: standard error of mean; SSD: silver sulfadiazine; TBSA: total body surface area; VAS: visual analogue scale
aChen 2006 also assessed a relevant comparison between antiseptic (silver) and non‐antibacterial (Vaseline gauze)
bLi 1994 also assessed relevant comparisons between two antiseptics (ethacridine lactate and iodophor), between ethacridine lactate and a non‐antibacterial treatment (MEBO) and between iodophor and MEBO. cThomas 1995 also assessed a relevant comparison between antiseptic (chlorhexidine) and topical antibiotic (silver sulfadiazine). dPiccolo‐Daher 1990 also assessed a relevant comparison between an antiseptic and topical antibiotic (zinc sulfadiazine).