Cochrane reviews allow firm conclusions to be made about the effectiveness of various local and systemic treatments for wounds and ulcers
- Correspondence to
: Dr Katherine R Jones
School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4909, USA;
Implications for practice and research
Evidence-supported interventions to manage chronic wounds include elastic, high or multilayer compression and systemic pentoxifyllene for venous ulcers; hyperbaric oxygen and local hydrogels applied after debridement for diabetic ulcers; systemic prostanoids and spinal cord stimulation for arterial ulcers; and avoidance of local therapeutic ultrasound for healing pressure ulcers.
Evidence-supported interventions to prevent pressure ulcers include high-specification foam and low air-loss mattresses, and pressure-relieving overlays on operating room tables.
Evidence-supported interventions for acute wound healing include topical honey for burns, tap water for cleansing soft tissue injury, prophylactic antibiotics for hand bites and avoidance of silver sulfadiazine as a topical agent.
Many common wound care therapies have had no trials conducted to assess their effectiveness. More high-quality research studies are urgently needed to determine best practices for managing both acute and chronic wounds.
Acute and chronic wounds occur across healthcare settings, age groups and diagnoses. Skin breakdown prevalence will continue to increase as the population ages1 and contributes to the escalating costs of healthcare.2 Optimal wound care is essential to improve survival, quality of life, functioning and pain. Although the wound care literature is extensive, the majority of studies suffer from serious methodological shortcomings. Evidence-based treatments for patients with wounds are limited because of insufficient scientific evidence3 which results in wound care management based on tradition rather than evidence. This meta-review provides guidance to clinicians by summarising wound care best practices as determined by Cochrane Systematic Reviews.
The authors conducted a meta-review of 44 Cochrane Systematic Reviews focused on therapeutic and preventive interventions for acute and chronic wounds. Reviews were screened independently by two researchers, with a third resolving any disagreements. The reviews generated 109 evidence-based conclusions, categorised into five levels of evidence of effect based on: total number of studies and participants, consistency of results, and potential for pooling of results. Local, systemic and preventive measures for various wound types were considered.
Fifty-one conclusions had strong or fairly strong evidence of effect; 58 had no or insufficient evidence. Almost three-quarters of the conclusions related to chronic wounds, and most of these pertained to venous ulcers. Twelve treatment recommendations had the strongest levels of evidence (listed above). Negative findings were also noteworthy. None of 25 trials comparing routine use of antibiotics and antiseptics with standard care, other antibiotics or placebo provided strong evidence of quicker wound healing—antimicrobial drugs should only be used with evidence of colonisation or infection. No dressing type had an additional benefit over any other when applied under compression bandaging. The authors note that lack of evidence of benefit is not the same as evidence of lack of benefit. Potentially beneficial results can be achieved in the absence of robust evidence of effectiveness—but research is needed to ascertain whether an actual benefit exists.
Only Cochrane Systematic Reviews were included in this meta-review because they are considered the highest level of evidence for effectiveness in the hierarchy of study designs. Other potentially high-quality systematic reviews were excluded. Some interventions included in the meta-review are not considered first-line treatment options, such as prostanoids and pentoxifylline, owing to high cost and/or side effects. At the same time, some first-line treatment options such as compression therapy to prevent venous ulcer recurrence, lack clinical trials. The authors conclude that new research should reflect current clinical dilemmas rather than the interests of manufacturers, drug companies or researchers.
The authors grade the strength of evidence of effect largely based on a minimum sample size of 100 subjects. This may not be a suitable number for some interventions, depending on underlying power calculations. However, the authors did conduct a sensitivity analysis using alternative definitions of large sample. Additionally, systematic reviews are only as strong as the underlying research base. Publication and reporting bias may have been an issue. Additionally, some of the findings are difficult to interpret, owing to unclear or potentially inappropriate comparisons made in the underlying studies. For example, standard wound care is not further defined.
This meta-review confirms what is known about the wound care research base; it is extensive but not uniformly high quality. An urgent need exists for further research studies that have sufficient sample sizes, adequate follow-up periods, appropriate comparators, detailed descriptions of interventions and relevant primary and secondary outcomes. But clinician decision-making can be guided by these evidence-based recommendations for acute and chronic wound care.