We thank everyone who read our S3 guideline on local treatment and all those who contributed to the technical-critical discourse with their reader’s letters. Professor Dr. Dissemond very aptly describes how wound care products are often credited with far too much importance and that wound healing is ultimately centrally dependent on treating the underlying cause and not on the dressings.
It would not be expedient to have a discussion around the expendability of wound care products. Because of lacking robust study results, the guideline group therefore approved “good clinical practice” recommendations that define clear requirements in terms of wound treatment (among others, see recommendations E28 and E29) and has created a basis for the care of persons with chronic wounds on the basis of systematically consented expert opinion.
Similarly, criteria to be heeded for the use of wound care products were agreed via consensus with the participating specialty societies within the AWMF. Adhering to these criteria should lead to a sensible use of wound care products in the context of patient-oriented treatment.
Lacking evidence should not incite fears but prompt insistence on an assessment of the benefit of wound care products, with end points that are of relevance to patients.
The negative recommendation for medical honey indeed resulted from a study of chronic leg ulcer, and comparable data for diabetic foot syndrome are lacking. On the basis of the existing evidence, and balancing possible strain imposed on the patient with costs, the guideline group decided on a negative recommendation.
As Dr. Zerm correctly states, a positive effect of honey on wound healing has not been documented by high-quality studies so far. This is the case for all wounds that are the subject of our guideline.
We share Dr. Zerm’s desire for good evidence, not only for honey treatment.
The recommendation of the guideline, that hyperbaric oxygenation should be used as an additional therapeutic option “for patients with diabetic foot syndrome in whom all possible revascularization measures have been tried without success and the danger remains that the limb may have to be amputated,” was approved on the basis of the existing evidence at the time the consensus on the recommendation was reached. When the guideline is updated the recommendation will be adapted to the new, relevant evidence.
We thank Dr. Reiß for his critical comments and share his view that expedient wound treatment requires taking into consideration aspects of hygiene, adherence to the recommendations from the Robert Koch-Institute and individual bodily hygiene as well as, for example, active periodic wound cleaning.
Nowadays, the systematic review of the evidence is seen as the gold standard for guidelines (1, 2). Because of the method used in its compilation, the guideline was recognized by the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) as an S3 guideline according to the association’s regulations (3), such as described correctly by Professor Dr. Kröger. The difference between S3 guidelines and S1 guidelines is explained on the association’s website and easily accessible for everyone (3).
An S3 guideline is based on systematic review, selection, and evaluation, of the literature, according to the criteria of evidence based medicine and on a structured consensus reached in a representative body.
If no robust evidence is found, substantial uncertainty remains, which has to be articulated and dealt with.
Transparency and decision aids are needed, which are based on an explanation of the evidence and recommendations that are clearly signposted as expert opinion.
The availability of evidence also has to be considered in providing information to patients and in medical practice. In order to satisfy the transparency criterion, the steps in the process are described in detail in the methods section on the guideline development.
Dr. med. Mike Rüttermann
Consultant Plastic Surgeon
University Medical Center Groningen
9700 RB Groningen/NL
Conflict of interest statement
The author declares that no conflict of interest exists.
|1.||Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, et al.: AGREE II: advancing guideline development, reporting, and evaluation in health care. Prev Med 2010, 51: 421–4 CrossRef MEDLINE|
|2.||Deutsches Instrument zur methodischen Leitlinien-Bewertung (DELBI). Fassung 2005/2006 + Domäne 8 (2008). www.leitlinien.de/leitlinienmethodik/leitlinienbewertung/delbi.|
|3.||Das AWMF-Regelwerk Leitlinien. Ständige Kommission „Leitlinien“ der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF).1th edition 2012. www.awmf.org/leitlinien/awmf-regelwerk/ll-entwicklung/awmf-regelwerk-01-planung-und-organisation.html.|
|4.||Rüttermann M, Maier-Hasselmann A, Nink-Grebe B, Burckhardt M: Local treatment of chronic wounds in patients with peripheral vascular disease, chronic venous insufficiency and diabetes. Dtsch Arztebl Int 2013; 110(3): 25–31. VOLLTEXT|