Topical Treatment

Initiate topical antifungal therapy on patients with at least three of the above risk factors above in Evaluation and Treatment.20,22 There is no clear evidence that any topical treatment improves outcomes; however, Dakin’s Solution is commonly used. Dakin’s used an irrigation solution, which is how it was originally described for use, is likely beneficial for severe infections, including fungal infections. Use Dakin’s solution in lieu of saline irrigations for patients meeting criteria.23,24

In terms of wound dressings in patients with concern for IFI, nothing has been definitively proven to improve outcomes, but using a topical antifungal is still conditionally recommended. Options include Dakin’s-soaked Kerlix dressings, Silver Nitrate Solution, or honey.20,22-28 VAC (negative pressure wound dressings) are not recommended early in the treatment of IFI, or suspected IFI, because daily trips to the operating room are needed for debridement/washout, diagnostics, and source control.

Use of Dakin’s solution in the prevention or treatment of IFI, though widespread and probably superior to saline or dry gauze, is unproven. At the US Army Burn Center, a 0.5% aqueous solution of silver nitrate, rather than Dakin’s solution, is the preferred treatment for open wounds at risk of IFI. Established IFIs may be treated with topical Nystatin powder. Topical Silver Nitrate is not always available in the deployed environment.29

A standardized operative note for wound description is available and should be used throughout the continuum of care for patients at increased risk for IFI. Utilization of this operative note may facilitate the early detection of sequential wound necrosis , which is the crucial first sign of IFI – Appendix B. Description of Bastion Classification of lower limb injuries is presented in Appendix C. Document on the first page of the Operative Note.