Topical antimicrobial dressings for locally infected leg ulcers: late-stage assessment

  • Health technology evaluation
  • HTE27
  • Published: 

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1 Recommendations

1.1

There is not enough evidence to determine whether price variations are justified between different antimicrobial agents in topical antimicrobial dressings for locally infected leg ulcers.

1.2

NHS trusts should provide access to a range of different types of antimicrobial dressings, so that a product that is clinically appropriate and meets people's needs is available for everyone with locally infected leg ulcers.

1.3

A healthcare professional and the person with the leg ulcer should decide together which dressing to use (see the NICE page on shared decision making). Decisions should take into account how the choice of dressing might affect the person's quality of life, including:

  • physical health

  • mental health and wellbeing

  • relationships with others

  • ability to complete activities of daily living.

1.4

If an antimicrobial dressing is needed to treat a locally infected leg ulcer, use a clinically appropriate dressing that meets the needs and preferences of the person with the leg ulcer, and if more than 1 is appropriate, choose the least expensive option. Include the following factors when choosing a dressing:

  • the cost of the primary dressing

  • the need for and cost of additional products

  • the frequency of dressing changes needed

  • if a person can change their own dressing or if a visit by a healthcare professional is needed.

What information is needed

More information is needed to determine whether price variations are justified between different antimicrobial agents in topical antimicrobial dressings for locally infected leg ulcers. Evidence should compare agents with each other and in similar dressing types. Evidence should be statistically powered, report details of concomitant treatments and ideally be done in a community setting in the NHS.

Key outcomes that should be captured include:

  • clinical performance outcomes of the dressings to evaluate clinical and cost effectiveness, including:

    • health-related quality of life

    • time taken to clear signs and symptoms of wound infection

    • time to complete wound healing

    • duration of antimicrobial dressing use and any other leg ulcer treatments

    • short- and long-term toxicity of the antimicrobial agents in the dressings

    • other adverse events or sensitivities to the dressing, including the number of people who have contraindications to particular antimicrobial agents

    • infection load and the type of bacteria killed or removed by the dressing

    • the number of people progressing to escalation of care and any associated resource costs

  • healthcare professional preferences, including:

    • dressing conformability

    • ease of application

    • ease of removal.

What this means in practice

Considerations for procurement and commissioning

  • Leg ulcers are the most common chronic wound in the UK. Estimates of the associated healthcare costs range from £102 million (Urwin et al. 2022) to £3.2 billion per year (Guest et al. 2020). The annual amount of NHS resource spent on dressings for venous leg ulcers was estimated at nearly £80 million (Guest et al. 2020).

  • Many factors can influence which type of topical antimicrobial dressing is best to treat a locally infected leg ulcer. Commissioners and procurement specialists should work with healthcare professionals in NHS trusts to ensure access to an appropriate range of topical antimicrobial dressings.

  • If a company introduces a new antimicrobial dressing or a new dressing feature with a higher price to market, they should provide evidence to justify price variation.

Considerations for wound management formulary groups

  • These recommendations are not intended to restrict choice. When developing a formulary, if dressings have similar technical specifications but different agents or prices, decision making should consider cost and the factors listed in recommendation 1.4.

  • Information on the cost of dressings should be available to healthcare professionals so that they can decide, using the factors listed in recommendation 1.4, which of the clinically appropriate options is the least expensive.

Considerations for healthcare professionals

  • These recommendations do not replace clinical reasoning. If more than one type of dressing is clinically appropriate, the choice of dressing should be based on patient preferences and cost, taking into account the factors listed in recommendations 1.3 and 1.4.

  • Healthcare professionals should work with commissioners and procurement specialists who cover their NHS trust to ensure access to an appropriate range of antimicrobial dressings.

Considerations for people with locally infected leg ulcers

  • People with locally infected leg ulcers should be involved when deciding which antimicrobial dressing to use. They should be given information on the antimicrobial dressing that is being prescribed and, where possible, offered options that meet their needs.

  • People with locally infected leg ulcers should be given support if they have any issues and wish to change to another type of antimicrobial dressing.

NICE has produced tools and resources to support the implementation of this guidance.

Why the committee made these recommendations

There are many topical antimicrobial dressings available for locally infected leg ulcers, with a variety of antimicrobial agents that vary in technical specification and cost. This assessment aims to determine whether the differences in clinical, economic and non-clinical outcomes attributed to those antimicrobial agents could justify price variation.

Because of uncertainties in the clinical evidence, it is not possible to say whether any antimicrobial agent works better than the others. These uncertainties include:

  • a lack of direct comparisons of antimicrobial agents

  • differences in:

    • the outcomes measured and

    • when the outcomes were measured.

More evidence is needed on how well different antimicrobial dressings work before it would be possible to say whether price differences are justified.

Evidence shows that people with locally infected leg ulcers are often not involved in selecting their antimicrobial dressing. There are many quality-of-life factors that could be impacted by using an antimicrobial dressing and these should be discussed with the person when choosing a dressing.