OBJECTIVES: Silver dressings are used for years for reduction of bacterial load in wounds. Our objective was to assess cost-effectiveness of an alginate-based silver dressing versus calcium alginate for treatment of hard-to-heal wounds, either infected or critically colonized, under the perspective of the private healthcare system in Brazil. METHODS: An analytical decision model was developed for simulating the cost-effectiveness ratio between silver alginate and calcium alginate for: diabetic foot ulcers, leg venous ulcers and pressure ulcers. Cost-effectiveness analysis considered clinical data obtained from a systematic review of literature and total treatment costs estimated throughout values from secondary databases. All epidemiological data and model assumptions were validated by Expert Panel. RESULTS: The systematic review achieved evidence level “B”, according to the Oxford´s grade. Outcomes considered were clinical signs of infection and bacteriological status from lesions. Incremental cost-effectiveness ratios have shown cost-savings of approximately 40 thousand Brazilian Reais per patient, independent on the subgroup. Such results are driven from treatment costs lower in 35 to 40% for the silver group, compared to the control. Additionally, we could observe better results of improvement in bacteriological status and infection signs avoided (incremental effectiveness of 22% and 30% respectively). CONCLUSIONS: Patients treated with silver alginate develop lower trends on worsening infectious status in their lesions and its use can reduce total treatment costs. Thus, silver alginate can offer a feasible alternative for infected or critically colonized hard-to-heal wounds treatment.