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Module 4.4: Infection
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Antimicrobial Dressings

Antimicrobial dressings have differing active ingredients and modes of action. They may kill or inhibit bacteria actively within the wound bed, or some dressings control bacteria passively by removing and binding the bacteria to the dressing. (Mahoney, 2015)

Because the characteristics of topical antimicrobial dressings vary, when choosing a product, the clinician should also take the following into consideration:

  • Wound type, aetiology, anatomical location and visible structures
  • Risk of wound infection
  • Any signs and symptoms of local wound infection or spreading infection
  • Patient factors (e.g. comorbidities, allergies and level of pain)
  • Compatibility with dressings
  • Clinical efficacy and sensitivities
  • Colonisation with multidrug-resistant organisms
  • Goals of treatment
  • Cost-effectiveness
  • Antiseptic presentation (e.g. gel, solution, spray, dressing, etc.)
  • Local policies, resources and availability
  • Ability to kill or inhibit bacteria
  • Mode of action
  • Potential cell toxicity
  • Has the wound been debrided?
  • Is exudate controlled?
  • Is there odour?
  • Are there any contraindications?
  • Is pain a consideration?
  • Is the dressing selected acceptable to the patient?
  • Wear time
  • Dressing presentation

(Wounds UK, 2013; Mahoney, 2015; Nair et al., 2023)

Antimicrobials should only be used when signs and symptoms suggest that the wound bioburden is interfering with healing.

  • Prevention of infection in individuals who are considered to be at an increased risk
  • Treatment of localised wound infection
  • Local treatment of wound infection in cases of local spreading or systemic wound infection using antiseptics, in conjunction with systemic antibiotics.

Antimicrobial dressings should not be used routinely on wounds that are proceeding along the healing continuum (International Consensus, 2016; Edwards–Jones et al., 2019)

Types of antimicrobial agents

Antimicrobial agent Information Contraindications
Enzyme Alginogel
  • Alginate gel with two enzymes: lactoperoxidase and glucose oxidase
  • Broad spectrum activity against Gram-negative and Gram-positive
  • Low cytotoxicity
  • Should not be used where patients have a previous sensitivity reaction to alginate dressings or to polyethylene glycol
Iodine (povidone, cadexomer)
  • Broad spectrum activity against Gram-negative and Gram-positive bacteria, fungi, spores, protozoa and viruses
  • Reduced selection for bacterial resistance
  • Neonates, iodine sensitivity, thyroid and/or renal disorders
  • Children below 12 years
  • Pregnancy and breastfeeding
  • Rapid release formulas may require 2-3 daily applications for optimal effect
Polyhexamethylene biguanide (PHMB)
  • Efficacious against Gram-positive bacteria, Gram-negative bacteria, fungi and viruses
  • Available in gel, irrigation and surfactant preparations as well as wound dressings
  • Does not promote bacterial resistance
  • Low cytotoxicity in vitro
  • Known sensitivity or allergy to PHMB or components of the dressing used
Octenidine dihydro-chloride (OCT)
  • Broad spectrum action against Gram-positive and Gram-negative bacteria, MRSA and fungi
  • Available in gel, irrigation and surfactant preparations
  • Does not promote bacterial resistance
  • Individuals who have any sensitivity or known allergic reactions to Octenidine dihydro-chloride
Honey (medical grade)
  • Effective against Gram-positive and Gram-negative bacteria including E. coli, P. aeruginosa, S. aureus, Acinetobacter, Stenotrophomonas, MRSA and vancomycin-resistant enterococci (VRE)
  • Promotes autolytic debridement
  • Allergy to bee venom
  • Known sensitivity to honey
  • Individuals with diabetes should be monitored for changes in blood-glucose concentrations during treatment with topical honey or honey-impregnated dressings
Silver (Elemental -metal and nanocrystalline)
  • Broad-spectrum activity against Gram-negative and Gram-positive bacteria, including P. aeruginosa, E. coli and S. aureus
  • Available in a variety of wound dressings
  • Individuals with a known sensitivity to silver
  • Some dressings may require removing before undergoing examinations such as X-ray, ultrasound, diathermy or magnetic resonance imaging
  • Ulcers resulting from infection such as tuberculosis, syphilis, or deep fungal infections; third-degree burns
Silver (salts and compounds, including sulphadiazine, oxides, phosphate, sulphates and chlorides)
  • Concentration dependent effect in eradicating mature P. aeruginosa and S. aureus biofilm
  • Silver dressings/slow-release ions have broad-spectrum activity, including against MRSA and VRE
  • Microbial resistance appears uncommon
  • Available as ointment, gel and wound dressing
  • Known allergy or sensitivity to silver
  • Some dressings may require removing before undergoing examinations such as X-ray, ultrasound, diathermy or magnetic resonance imaging
  • Silver sulfadiazine is contra-indicated in neonates, pregnancy, and individuals with significant renal or hepatic impairment, sensitivity to sulphonamides, or G6PD deficiency
  • Ulcers resulting from infection such as tuberculosis, syphilis, or deep fungal infections; third-degree burns

Adapted from (Swanson et al., 2014; IWII, 2022)

Silver contraindication link BNF: Silver

Iodine contraindication link BNF: Iodine

Honey contraindication link BNF: Honey

See Module Five Dressing Selection chapter for information on Larval Therapy.