The efficacy of silver dressings and antibiotics on MRSA

and MSSA isolated from burn patients

Steven L. Percival, PhD1,2; John G. Thomas, PhD1; Will Slone, MS1; Sara Linton, MS1; Linda Corum, MS1;
Tyler Okel, MS1
1. Department of Pathology, Biofilm Laboratory, Medical School, West Virginia University, Morgantown, West Virginia
2. Advanced Medical Solutions Ltd, Winsford, Cheshire, UK

Reprint requests:
Prof. S. L. Percival, Director Innovation
and Research,Advanced Medical Solutions
Ltd, Premier Park, Winsford Industrial
Estate, Winsford, Cheshire CW7 3PD, UK.
Tel: +44 01606 545634;
Fax: +44 01606 863600;
Email: steve.percival@admedsol.com
Manuscript received: March 23, 2011
Accepted in final form: September 8, 2011
DOI:10.1111/j.1524-475X.2011.00739.x

ABSTRACT
In this study our objectives were (1) to investigate whether meticillin-resistant
Staphylococcus aureus (MRSA) showed an increased tolerance to silver wound
dressings compared with meticillin-sensitive S. aureus (MSSA); and (2) to evaluate
the effects of bacterial phenotypic states of MRSA and MSSA, and pH, on the
activity of silver wound dressings and two antibiotics, ampicillin and clindamycin.
Twenty MRSA strains and 10 MSSA strains isolated from burns patients in South
Africa were evaluated for their susceptibility to a silver alginate and a silver carboxymethyl cellulose wound dressing, employing a corrected zone of inhibition
assay, conducted on Mueller Hinton agar and a poloxamer-based biofilm model.
When exposed to the two silver dressings, all 30 S. aureus strains showed susceptibility. Possible enhanced antimicrobial efficacy of the silver dressings occurred when
pH was lowered to 5.5, compared with a pH of 7.0. When all S. aureus were grown
in the biofilm phenotypic state and exposed to both silver dressings and antibiotics,
enhanced tolerance was noted. Susceptibility to silver was overall higher for MRSA
when compared with MSSA. This study showed that the effect of pH and bacterial
phenotypic state must be considered when the antimicrobial activity of silver wound
dressings is being investigated. It is evident from the data generated that both pH and
the bacterial phenotypic state are factors that induce changes that affect both antimicrobial performance and bacterial susceptibility.

Staphylococcus aureus is an opportunistic pathogen that has

the ability to survive in many adverse environments. It is able
to colonize many sites in and on the human body, including
the mouth, vagina, and skin, showing its resilience and ability
to withstand hostile conditions.1,2 S. aureus is one of the most
frequently isolated bacteria in burn wounds with resistance to
antibiotics a common occurrence.3,4 Consequently, it is very
important that antimicrobials, which are used both systemically and topically for the treatment of infected wounds,
remain efficacious on both resistant and nonresistant strains of
S. aureus.
The polymicrobial wound, bioburden, is composed of
microorganisms residing in both a non-biofilm (planktonic)
and biofilm phenotypic state.5,6 Biofilms, in particular, are
considered to have a fundamental role to play in delaying
wound healing and have recently been identified in burn
wounds.6 Biofilms are referred to as microorganisms attached
to each other or to a biotic or non-biotic surface, and encased
within polysaccharides, proteins, nucleic acids, and glycoproteins and are inherently tolerant to antimicrobials. Consequently, topical and systemic antimicrobials have to show
activity and efficacy on microorganisms residing not just in
the planktonic state but also on the more recalcitrant biofilm
state.69
Wound Rep Reg (2011) 19 767774 2011 by the Wound Healing Society

S. aureus that contains resistance genes to antibiotics have

shown increased tolerance to a number of antiseptics and
disinfectants including chlorhexidine, ethidium bromide,
quaternary ammonium compounds, acriflavine, benzalkonium
chloride, chlorhexidine digluconate, hexamidine diisethionate,
triclosan, and povidone-iodine.1016 Irizarry and colleagues17
reported from their studies that meticillin-resistant S. aureus
(MRSA) was less susceptible to antiseptics and disinfectants
than meticillin-sensitive S. aureus (MSSA). However, in studying Irizarry and colleagues study in more detail, McDonnell
and Russell18 concluded that similar susceptibilities were noted
for both the resistant S. aureus and nonresistant S. aureus.
Based on current available literature, controversy exists between
the presence of antibiotic-resistant genes and correlation to a
higher tolerance to antiseptics and disinfectants.
In this study, our objectives were to investigate whether
MRSA showed an increased tolerance to a silver alginate and
a silver carboxymethyl cellulose dressing compared with
MSSA. In addition, it has been documented that pH and
bacterial phenotypic can affect the activity and performance
of antimicrobials.19,20 Consequently, for both MRSA and
MSSA, we also wanted to evaluate the effect of pH and
bacterial phenotypic state on the activity of silver and antibiotics, ampicillin, and clindamycin.
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MATERIALS AND METHODS

up at 37 C for 24 hours. After incubation the corrected ZOI

(CZOI) was then taken for each bacteria tested.
The effects of pH on the antimicrobial activity of silver and
antibiotics were assessed using pH-adjusted (5.5 or 7) MHA.
Altering the pH of the media was achieved by the addition
of 2 M HCL or NaOH (the pH was checked before and after
incubation). All testing was done in triplicate.

Wound dressings

The two silver-containing wound dressings tested included

a carboxymethyl cellulose dressing containing silver (SCMCAquacelAg, ConvaTec, Skillman, NJ) and a silver alginate
(SA) dressing (Advanced Medical Solutions Ltd, Winsford,
UK). A non-SA dressing was used to represent a control. All
dressings were aseptically divided into 1 1 cm test squares
and stored (in the dark) until use.
Test microorganism

Twenty MRSA and 10 MSSA strains, which had been routinely isolated from burn wound patients, were kindly provided by Dr. Adriano Duse, National Health Laboratories,
South Africa. All S. aureus strains were cultured in tryptic
soy broth at 37 C for 24 hours. Following incubation, a
1 106 cfu (colony forming units)/mL inoculum of each bacteria was prepared in saline (0.85%) and then swabbed (using
a sterile cotton swab) onto Mueller Hinton Agar (MHA)
plates using Clinical Laboratory Standards Institute techniques.21 All inoculated plates were allowed 5 minutes for
drying prior to the addition of wound dressings or antibiotic
disks.
Antibiotic profiling for resistance classification

Antibiotic susceptibility testing of all S. aureus was determined using commercially available disks (BBL, BectonDickinson Microbiology Sys Inc., Cockeysville, MD)
following standard guidelines.21 The following panel of antibiotics was tested in the initial screening of all S. aureus
strains: vancomycin (30 mgVA30), oxacillin (1 mgOX1),
ciprofloxacin (5 mgCIP5), amikacin (30 mgAN30),
ceftazidime (30 mgCAZ30), synercid (15 mgSYN15),
clindamycin (CC22 mg), gentamicin (10 mgGM10), imipenem (10 mgIPM10), doxycycline (30 mgD30), and
aztreonam (30 mgATM30). To determine the effect of pH
and bacterial phenotype on antibiotic sensitivity, only the two
antibiotics AM10 (10 mg) and CC2 (2 mg) were employed.

Biofilm test method and procedure (poloxamer)

The set up of the biofilm test model employed in this study

can be located elsewhere.22 Essentially, poloxamer (F12730%) was incorporated into Mueller Hinton broth (MHB)
and refrigerated overnight (4 C). The liquefied poloxamer
mixture was added into Petri dishes and then incubated overnight at 37 C before inoculation with MRSA and MSSA
strains (1.0 106 cfu/mL). Test dressings and antibiotic disks
were placed onto the seeded plates. After overnight incubation at 37 C the CZOI (wound dressings) and ZOI (antibiotic
disks) were measured. All testing was done in triplicate.

Measurement of the corrected CZOI

The CZOI was determined by measuring the zone of clearing

across one direction of the dressing and subtracting the width
of the dressing. The measurement was done in two different
perpendicular directions (vertically and horizontally) across
the dressing. The resulting measurement was averaged to
yield the CZOI. The CZOI reflected only the width of the
zone of clearing surrounding the dressing and was corrected
for variances in both dressing size and shrinkage.

Statistical analysis

For two-group comparisons, statistical analysis for significance was determined using a two-tailed t-test, with p 0.05
considered to be significant. All data were analyzed using
MicrosoftTM Excel (Redmond, WA).

RESULTS
Antibiotic susceptibility test

Antibiotic disks were aseptically placed onto the inoculated

MHA plates. All plates were then incubated at 37 C for 24
hours. After incubation, antibiotic sensitivity patterns of
respective MRSA and MSSA strains were identified by measuring a zone of inhibition (ZOI). If the bacteria were susceptible to a particular antibiotic, an area of clearing surrounded
the antibiotic disk where bacteria were not capable of
growing. This area is called the ZOI. The results were interpreted according to the recommendations of the National
Committee for Clinical Laboratory Standards.20 Zone diameter around the antibiotic disks was measured in millimeters.
All testing was done in triplicate.
Quasi/non-biofilm plating procedure (agar)

Each silver and control dressing was added to an inoculated

MHA plate (pH 5.5 and 7.0). All plates were incubated face
768

Antibiotic sensitivity testing

All S. aureus strains isolated from burn patients in South

Africa were exposed to a range of antibiotics to establish an
antibiogram according to standard guidelines. All 20 MRSA
strains were found to be resistant to oxacillin, ceftazidime,
aztreonam, and imipenem (Table 1). Poor antibiotic effectiveness on MRSA strains was evident with ciprofloxacin,
amikacin, gentamicin, and doxycycline with the numbers
of resistant strains being 19, 19, 19, and 17, respectively.
Vancomycin was found to be the most effective antibiotic on
all MRSA strains. However, synercid was also effective on 18
MRSA strains and clindamycin on 14 MRSA strains.
All MSSA strains were found to be sensitive to the majority
of the antibiotics with resistance to gentamicin being detected
in only one strain (Table 1). Four MSSA strains showed resistance to doxycycline. All MSSA strains were found to be
resistant to aztreonam.
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Percival et al.

Antimicrobial efficacy of wound dressings

Table 1. Efficacy of antibiotics on meticillin-resistant Staphylococcus aureus (MRSA) and meticillin-sensitive S. aureus (MSSA)
MRSA (ZOI, mm)

Antibiotic

Mean

SD

Range (mm)

17.9
0
1.2

0.9
0
5.4

16.519.0
0
023.5

7.5

5.7

020.0

Ceftazidime (CAZ30)
Synercid (SYN15)

0
22.8

0
4.4

0
1026.0

Clindamycin (CC2)

18.9

12

029.0

Gentamicin (GM10)

1.4

4.7

020.0

Imipenem (IPM10)
Doxycycline (D30)

4.9
12.3

4.2
6.8

010.5
028.5

Aztreonam (ATM30)

Vancomycin (VA30)
Oxacillin (OX1)
Ciprofloxacin (CIP5)
Amikacin (AN30)

MSSA (ZOI, mm)

Sensitivity/
resistance
All sensitive
All resistant
One sensitive,
19 resistant
One sensitive,
19 resistant
All resistant
18 sensitive,
two resistant
14 sensitive,
six resistant
One sensitive,
19 resistant
All resistant
Three sensitive,
17 resistant
All resistant

Sensitivity/
resistance

Mean

SD

Range (mm)

17
16.2
25

0.7
2.6
1.8

16.018.5
11.521.5
22.027.0

All sensitive
All sensitive
All sensitive

19.8

0.63

18.521.0

All sensitive

17.7
23.8

1.4
1.3

16.020.0
22.025.5

All sensitive
All sensitive

25

1.5

23.028.0

All sensitive

18.6

2.5

12.020.5

46.3
20

1.1
6.9

45.048.0
11.027.0

One resistant,
nine sensitive
All sensitive
Four resistant,
six sensitive
All resistant

SD, standard deviation; ZOI, zone of inhibition.

Efficacy of silver dressings on S. aureus grown in the

quasi/non-biofilm state

The activity of the SA and the SCMC dressings on MRSA

strains grown in the quasi/non-biofilm state was investigated
using CZOI measurements on agar. Both silver dressings
were found to be very effective in inhibiting the growth of all
MRSA strains at a pH of 7 (Figure 1). The mean CZOI for
the SA dressing was 6.7 mm compared with 8.8 mm for the
SCMC dressing. This effect was found to be significant
(p < 0.05). Interestingly the mean corrected zone of inhibition for the SCMC dressing at a pH of 5.5 was not significantly (p < 0.05) larger on MRSA when compared with the
SA dressing.
By reducing the pH of the agar to 5.5, the CZOI significantly increased in the MRSA strains (p < 0.05) following
exposure to the silver dressings, when compared with the
mean CZOI at pH 7. For the SA dressing, the CZOI increased
from a range of 4.57.7 mm, at pH 7, to 8.214.0 mm at pH
5.5. The mean CZOI was significantly (p < 0.05) larger when
grown at a pH of 5.5 compared with 7.0. For the SCMC
dressing, lowering pH to 5.5 also significantly increased
(p < 0.05) the mean CZOI.
All MSSA strains were found to be sensitive to both silver
dressings when grown in the quasi/non-biofilm phenotypic
state. However, the SCMC dressing was found to be more
effective at inhibiting the growth of MSSA strains when compared with the SA dressing at a pH of 7.0. This result was
found not to be significant (p < 0.05). At a pH of 5.5, the
CZOI around each silver dressing was larger than at a pH of
7, more so for the SA dressing than the SCMC dressing. For
the SCMC dressing, lowering pH to 5.5 resulted in a signifiWound Rep Reg (2011) 19 767774 2011 by the Wound Healing Society

cant larger mean CZOI, compared with pH 7.0. For the SA

dressing, the mean CZOI was found to be significantly
(p < 0.05) larger at pH 5.5 compared with a pH of 7.0.
For MSSA strains, there was no significant difference
(p < 0.05) shown between mean CZOIs when a comparison
was made between each silver dressing at a pH of 5.5.
Overall, at a pH of 5.5 and 7, all MRSA strains were found
to be more sensitive to both silver dressings compared with
the MSSA isolates.
Antimicrobial efficacy of silver dressings on
S. aureus in the biofilm state

The mean CZOI following exposure to the SA dressing on

MRSA and MSSA grown in the biofilm state was significantly
lower (p < 0.05) when compared with the quasi/non-biofilm
grown MRSA strains (Figure 2). For the SCMC dressing, a
similar significant effect to silver was also found (p < 0.05).
The SA dressing demonstrated overall a higher efficacy on
MRSA biofilms than the SCMC dressing. This results,
however, were not statistically significant. It was found that
the SA dressing was significantly (p < 0.05) more effective
on the biofilm-grown MSSA compared with the SCMC
dressing.
Antibiotic sensitivity and effect of pH and
bacterial phenotype

The effects of pH on the activity of ampicillin and clindamycin against MRSA and MSSA strains are represented in
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Percival et al.

Figure 1. Corrected zone of inhibition (CZOI) (mm) of a silver carboxymethyl cellulose (SCMC) and a silver alginate (SA) dressing
on meticillin-resistant Staphylococcus aureus MRSA and meticillin-sensitive S. aureus (MSSA) at pH 7 and 5.5 (quasi/non-biofilm
state). 1*SCMC: The mean CZOI was found to be signficantly larger at pH 5.5 compared with pH 7 following a paired t-test analysis
(95% confidence level). 2*SA: The mean CZOI was found to be signficantly larger at pH 5.5 compared with pH 7 following a paired
t-test analysis (95% confidence level). 3*SCMC: The mean CZOI was found to be signficantly larger at pH 5.5 compared with pH
7 following a paired t-test analysis (95% confidence level). 4*SA: The mean CZOI was found to be signficantly larger at pH 5.5
compared with pH 7 following a paired t-test analysis (95% confidence level).

Figure 2. Corrected zone of inhibition (CZOI) (mm) of a silver alginate (SA) and a silver carboxymethyl cellulose (SCMC) dressing
on meticillin-resistant Staphylococcus aureus (MRSA) and meticillin-sensitive S. aureus (MSSA) grown in the quasi/non-biofilm
and biofilm state. 1*SCMC: The mean CZOI was found to be signficantly larger on quasi/non-biofilm compared with biofilm grown
MRSA following a paired t-test analysis (95% confidence level). 2*SA: The mean CZOI was found to be signficantly larger on
quasi/non-biofilm compared with biofilm grown MRSA following a paired t-test analysis (95% confidence level). 3*SCMC: The
mean CZOI was found to be signficantly larger on quasi/non-biofilm compared with biofilm grown MSSA following a paired t-test
analysis (95% confidence level). 4*SA: The mean CZOI was found to be signficantly larger on quasi/non-biofilm compared with
biofilm grown MSSA following a paired t-test analysis (95% confidence level).

770

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Antimicrobial efficacy of wound dressings

Table 2. Zone of inhibition (mm) of antibiotics (clindamycin [CC2-2 mg] and ampicillin [AM10-10 mg]) against meticillin-resistant
Staphylococcus aureus (MRSA) and meticillin-sensitive S. aureus (MSSA) at a pH of 7 and 5.5
CZOI (mm)
Bacteria
MRSA

Number
20

Antibiotic
CC2
AM10

MSSA

10

CC2
AM10

pH

Mean

Standard Error

Range

7
5.5*
7
5.5
7
5.5*
7
5.5*

17.9
15.2
0
11.9
18.1
25.6
28.7
21.7

3.5
2.6
0
1.0
3.0
1.9
0.3
0.2

032
028
0
017.5
038.5
2041.5
28.530.0
21.023.0

*Comparison between pH 5.5 and 7 was statistically significant (p < 0.05).

CZOI, corrected zone of inhibition.

Table 2. Overall, all MRSA strains were found to be resistant

to ampicillin at a pH of 7. At a pH of 5.5, the ZOI around the
antibiotic disk increased to a mean ZOI of 11.9 mm. At a pH
of 7, the mean ZOI for CC2 was 17.9 mm compared with
15.2 mm at pH 5.5. A reduced ZOI for CC2 at a lower pH was
significant (p > 0.05) compared with the ZOI at a pH of 7.0.
All MSSA were sensitive to AM10. By lowering pH to 5.5,
a decrease in the CZOI was found when compared with the
CZOI at pH 7.0. The performance of clindamycin in a slightly
acidic environment was enhanced against MSSA compared
with a pH of 7. This was found to be statistically significant
(p < 0.05).
Resistance to ampicillin was found in all MRSA strains
when grown as a biofilm (Table 3). All MRSA strains also
showed increased tolerance to CC2 when grown in a biofilm
compared with the quasi/non-biofilm state (p < 0.05). For
MSSA strains, increased tolerance to AM10 and CC2 was
also shown when grown in the biofilm phenotypic state
(Table 3).

DISCUSSION
The antimicrobial properties of silver-impregnated wound
dressings against Gram-positive and Gram-negative bacteria
have been shown in several in vivo studies.23,24 Silver plays an
important role in the management of burn wounds with its
main role being to reduce the microbial growth within a
wound dressing and wound bed. For silver to be effective on
microorganisms, it must convert, via oxidation, to the ionic
form Ag+ (ionic silver). The concentration and availability
of ionic silver in a wound is very important to the antimicrobial performance of a silver-impregnated wound dressing.
However, both the concentration and availability of ionic
silver can be affected by the presence of proteins and polysaccharides, the carrier vehicle (dressing), the phenotypic state
of the microorganisms, and the pH. In particular, the pH has
been shown to affect antimicrobial activity.25 For example, the
activity of the antiseptics chlorhexidine and quaternary
ammonium compounds are significantly enhanced at an alka-

Table 3. Zone of inhibition (mm) of antibiotics (clindamycin [CC2-2 mg] and ampicillin [AM10-10 mg]) against meticillin-resistant
Staphylococcus aureus (MRSA) and meticillin-sensitive S. aureus (MSSA) grown in the non-biofilm and biofilm state (pH 7.0)
CZOI (mm)
Bacteria
MRSA

Number
20

Antibiotic

Phenotype

Mean

Standard Error

Range

CC2

Non-biofilm
Biofilm*
Non-biofilm
Biofilm
Non-biofilm
Biofilm*
Non-biofilm
Biofilm*

17.9
11.7
0
0
18.1
16.1
28.7
10.9

3.5
1.7
0
0
3.0
0.4
0.3
2.3

032
018.5
0
0
038.5
14.518
28.530.0
026

AM10
MSSA

10

CC2
AM10

*Comparison between non-biofilm and biofilm was statistically significant (p < 0.05).
CZOI, corrected zone of inhibition.
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Antimicrobial efficacy of wound dressings

line pH.19 Contrary to this, hypochlorites are more active at an

acid pH.19 Antibiotic performance has also been shown to be
affected by pH. Within an acidic environment, the activity of
beta-lactams and fluoroquinolones has been shown to
increase.26,27 However, antibiotics such as gentamicin are
impaired from being transported into bacteria in an acidic
environment.28 This is probably because of a larger ionization
at a more acidic pH compared with a neutral pH.
Within this study, the main goal was to compare the performance of an SA and SCMC against MRSA and MSSA
strains isolated from burn wounds using the CZOI assay.
Each silver dressing was found to have activity against all
quasi/non-biofilm grown isolates at a pH of 7.0 and 5.5. The
antimicrobial performance of both silver dressings was,
overall, significantly enhanced at a pH of 5.5 compared with
a pH of 7.0.29 Interestingly, the MSSA strains showed a
slightly reduced susceptibility to silver when compared with
MRSA strains. Silver acts through an array of actions including damaging proteins, deoxyribose nucleic acid, enzymes,
and outer cell walls/membranes.30 It is possible the MSSA
strains have specific inherent characteristics that help to
reduce the effects of ionic silver. The outermost layers of
microbial cells can affect bacterial susceptibility (or insusceptibility) to antiseptics. For an antiseptic molecule to reach
its sites of action, in general, the outer layers of a cell must
be crossed. The nature and composition of these outer layers
will be dependent on the genera and species of bacteria and
may act as a permeability barrier, reducing uptake. MSSA
may exist as mucoid strains, with the cells surrounded by an
extracellular slime layer. In general non-mucoid strains are
killed more rapidly than mucoid strains. This has been
shown for an array of antiseptics including chloroxylenol,
cetrimide, and chlorhexidine.31 High quantities of extracellular slime are known to sequester metal ions, such as silver,
therefore reducing their availability for bacterial penetration.
In addition, bacterial growth rate and any growth-limiting
nutrient will affect the physiological state of bacterial cells
and, therefore, antimicrobial efficacy. For MSSA, the thickness and degree of cross-linking of peptidoglycan in the cell
wall are likely to be modified, and hence, the cellular sensitivity to silver will be altered when compared with MRSA.
Despite these hypotheses, there is an array of reasons as to
why a slightly enhanced tolerance to silver in MSSA occurs
when compared with MRSA. We are presently investigating
the effects of antimicrobials on mucoid and non-mucoid
grown S. aureus.
In other studies, it has been found that no differences
in susceptibilities to antiseptics occur between MRSA and
MSSA.32,33 Contrary to this, some studies have shown an
enhanced tolerance to antiseptics in MRSA strains compared
with MSSA strains.17,34,35
The study has also highlighted the effect that pH can
have on antibiotic performance. For example, ampicillin was
shown to be ineffective on MRSA strains in the quasi/nonbiofilm phenotypic state at a pH of 7 and at pH 5.5, whereas
all MSSA strains were found to be sensitive to ampicillin at
both pH 5.5 and 7.0. Clindamycin was found to be much more
effective on many of the MSSA strains at a pH of 5.5 compared with a pH of 7. The opposite was found to be true for the
MRSA strains.
Another important goal of our study was to investigate the
effect of the biofilm phenotypic state on antimicrobial performance. The phenotypic state of microorganisms is clinically
772

Percival et al.

relevant as microorganisms within a wound are known to exist

in the planktonic, or quasi/non-biofilm, and biofilm phenotypic states.36 The biofilm mode of growth has been shown
to significantly reduce the effectiveness of antimicrobials.36
Microorganisms, which reside in the biofilm phenotypic state,
differ significantly from their planktonic/quasi/non-biofilm
counterparts both in terms of growth rate, gene transcription,
and antimicrobial sensitivity.36 The majority of studies that
have evaluated the antimicrobial performance of silverimpregnated wound dressings have, in general, only investigated the dressings ability to kill quasi/non-biofilm or
planktonic microorganisms only and not microbial biofilms.
The in vitro models that have been employed to assess the
effect of antimicrobial wound dressings on biofilms have
included a chambered slide biofilm model,37 a perfusion
chamber model,38 a constant depth film fermenter model,25
and a poloxamer-based biofilm model.22 The model chosen in
this study employed the use of the biofilm inducing agent
poloxamer.7,22 In a study conducted by Wirtanen and colleagues, it was found that bacteria, which grew in poloxamer,
had biofilm properties and associated enhanced biocide
resistance.39,40
When the antimicrobial performance of each silver wound
dressing was investigated on MSRA and MSSA strains grown
in the biofilm phenotypic state, both dressings remained
effective. The SA dressing showed a slightly superior antimicrobial activity on both MRSA and MSSA strains when
grown as a biofilm compared with the activity of the SCMC.
An increased tolerance to antimicrobials, when bacteria are
grown as a biofilm, has been documented elsewhere.25
Despite the findings in this paper, the use of in vitro models
does come with a cautionary note specifically because of their
lack of ability to evaluate immunological effects. Additionally, experimental conditions often chosen for in vitro studies
do not mimic the chronic wound environment as closely as
they should.
In conclusion, both silver-containing wound dressings in
this study showed potent antimicrobial activity against MRSA
and MSSA strains when grown in the quasi/non-biofilm and
biofilm phenotypic states. Both silver dressings exhibited an
overall enhanced activity at a pH of 5.5, compared with pH 7.
Despite the models and conditions employed in this study,
being remote from those prevailing in a patient with a burn
wound, our data, nevertheless, may help to further enhance
present understanding of how the activity of silver wound
dressings and antibiotics could be improved in the clinical
environment. Strategies used presently to increase the efficacy
of antimicrobials, specifically silver, on the microbial bioburden in wound dressings and the wound bed, are warranted.
Based on the initial findings in this study, it would appear that
better and more appropriate usage of silver wound dressings
could be achieved by adopting more robust in vitro biofilm
models, more appropriate to the clinical situation, and investigating the variables that affect antimicrobial performance,
namely, pH and bacterial phenotype. However, further studies
are needed to confirm and enhance on our initial findings in
this paper.

ACKNOWLEDGMENT
The funding for this study was provided by Advanced
Medical Solutions Ltd.
Wound Rep Reg (2011) 19 767774 2011 by the Wound Healing Society

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Antimicrobial efficacy of wound dressings

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