Review: evidence for use of systemic antibiotics and topical antiseptics for venous leg ulcers is insufficient.

QUESTIONAre systemic antibiotics and topical antibiotics and antiseptics effective for treatment of venous leg ulcers?REVIEW SCOPEStudies selected compared systemic antibiotics or topical antibiotics or antiseptics with placebo, no treatment, usual care, another antibiotic or antiseptic, or another treatment in patients with venous leg ulcers. Studies involving topical silver-based preparations or honey were excluded. Outcomes were objective measures of wound healing (time to healing, proportion of ulcers completely healed, change in ulcer size, or healing rate).REVIEW METHODSCochrane Wounds Group Specialised Register, Medline, CINAHL, and EMBASE/Excerpta Medica (to Oct 2007); Cochrane Central Register of Controlled Trials (Issue 4, 2007); and reference lists were searched for randomised controlled trials (RCTs). 22 RCTs met the selection criteria; treatments assessed were systemic antibiotics (5 RCTs, n = 232), cadexomer iodine (10 RCTs, n = 645), povidone iodine (2 RCTs, n = 300), peroxides (3 RCTs, n = 83), and miscellaneous topical preparations (2 RCTs, n = 283). Median duration of follow-up was 6 weeks (range 10 d to 24 wk). 3 trials reported a satisfactory randomisation method, 2 used adequate allocation concealment, and 11 had blinded outcome assessment.MAIN RESULTSSystemic antibiotics. In 1 trial (n = 59), complete ulcer healing at 20 weeks occurred more frequently with systemic levamisole than with placebo (100% v 76%). In the other 4 trials (n = 26-63), systemic antibiotics did not differ from placebo, standard care alone, povidone iodine, or another systemic antibiotic. Only 1 trial used compression in both groups.Cadexomer iodine. 3 trials compared cadexomer iodine with standard care that did not reflect current best practice and reported complete healing rates. Cadexomer iodine improved complete healing rates (53% v 23%) in 1 RCT (n = 60) that involved 6 weeks of hospital bed rest and daily dressing changes; it did not differ from standard care in the other 2 trials (n = 25 and 60) done in outpatient or community settings. Meta-analysis of 2 trials (n = 57 and 72) showed that cadexomer iodine plus compression improved complete healing more than standard care plus compression (22% v 3.3%). Complete healing rates did not differ for cadexomer iodine and dextranomer (1 RCT, n = 21) or for cadexomer iodine and hydrocolloid or paraffin gauze (1 RCT, n = 153).Other topical treatments. Povidone iodine increased time to healing compared with dextranomer (1 RCT, n = 100) and did not increase complete healing rates compared with hydro-colloid (1 RCT, n = 200, compression used in both groups). Peroxide topical treatments (3 RCTs, n = 20-40; compression used in both groups in 2 RCTs) and ethacridine lactate lotion (1 RCT, n = 241; compression used in both groups) reduced ulcer surface area more than placebo. Mupirocin in paraffin did not differ from paraffin alone for complete healing (1 RCT, n = 30; compression used in both groups).CONCLUSIONSThere is insufficient evidence to support or refute routine use of systemic antibiotics for venous leg ulcers. Evidence on effectiveness of topical treatments is conflicting or insufficient.