SSD wounds and burns:
For me, one of the most fascinating uses of UpToDate is to compare it to evidence-based recommendations. In my circle of afficionados of evidence-based medicine, there is a tendency to believe that UpToDate’s recommendations are ‘evidence-based.’ If you read UpToDate regularly, you will find out that it is indeed somewhat better than conventional textbooks, but still has a long way to go before it could be remotely considered evidence-based.
For example, consider the chapter on treatment of burns (a topic very much on the mind of people who work in resource-limited settings). There is strong belief in Mozambique where I work that prophylactic antibiotics are effective in preventing infections. UpToDate clearly dispels that myth by saying: “There is no role for prophylactic IV antibiotics” in burn management.” (Section: “Emergency care of moderate and severe thermal burns in adults”)
However, in the sections on topical treatment of burns, UpToDate is at marked variance with the Cochrane review on the subject.
The Cochrane review (accessed 4 Feb, 2013) states that: “This review highlights the lack of conclusive evidence on the effects of silver-containing dressings or agents to prevent wound infection and to promote wound healing. In particular, there was no evidence to support the use of silver sulphadiazine (SSD) for prevention of wound infection in patients with partial-thickness burns. None of the trials indicated a beneﬁcial effect for SSD for other outcomes when compared with other silver-containing or non-silver dressings. Furthermore, there was evidence that SSD may delay wound healing, may be more expensive, and may be more painful when applied to burns. The few trials on full-thickness burns and acute, chronic, or mixed wounds showed insufﬁcient evidence for a beneﬁcial effect of silver-containing dressings to decrease infection rates and to aid wound healing.”
Contrast the Cochrane review (our “Best Evidence”) to the UpToDate text on burn treatment. In the section on “Local treatment of burns: Topical antimicrobial agents and dressings” UpToDate states:
“ Local treatment of burns includes cleansing and debridement, topical antimicrobial agents, and dressings….. The use of topical antimicrobial agents and aggressive wound care has reduced the incidence of invasive wound infections for superficial partial-thickness burns devoid of epithelium, superficial full-thickness burns, and deeper burns.”
“The selection and application of topical antimicrobials are to a great degree reflected in the art of the science.”
Summary: “We suggest using a topical antimicrobial agent or bismuth-impregnated petroleum based gauze (eg, Xeroform) as the initial burn wound coverage for superficial partial-thickness burns devoid of epithelium and deeper burns (Grade 2C). These agents provide a moist environment conducive to wound healing. Commonly used topical antimicrobial agents include silver sulfadiazine, combination antibiotics, and chlorhexidine.”
“Silver sulfadiazine cream (SSD 1 percent) is the most commonly used burn wound dressing. This thick white cream is applied once or twice daily, and can be soothing.”
However, in the Section on “Treatment of minor thermal burns”, UpToDate states:
“Silver sulfadiazine (SSD) is commonly used for prophylaxis against infection but is generally not used for superficial burns. Treatment with SSD may slow wound healing and increases the frequency of dressing changes, resulting in increased pain.”
Thus, even within UpToDate, one section says that SSD is “soothing” and another says that it “increased pain.” The scientific evidence, as in Cochrane text above, shows that SSD increases pain.
What do other readers think about UpToDate’s evidence-base in your area of expertise?