Topical antimicrobial prophylaxis in colorectal surgery for the prevention of surgical wound infection: a systematic review and meta-analysis

Effect of local prolonged-release incisional doxycycline on surgical site infection prophylaxis in abdominal colorectal surgery: the SHIELD 1 randomized clinical trial

INTRODUCTION

Despite advanced infection control practices including preoperative antibiotic prophylaxis, surgical site infection (SSI) remains a challenge. This study aimed to test whether local administration of a novel prolonged-release doxycycline-polymer-lipid encapsulation matrix (D-PLEX) before wound closure, concomitantly with standard of care (SOC), reduces the incidence of incisional SSI after elective abdominal colorectal surgery.

MATERIALS AND METHODS

This was a phase 3 randomized, controlled, double-blind, multinational study (SHIELD 1) between June 2020 to June 2022. Patients with at least one abdominal incision length greater than 10 cm were randomized 1:1 to the investigational arm (D-PLEX+SOC) or control (SOC) arm. The primary outcome was a composite of incisional SSI, incisional reintervention, and all-cause mortality.

RESULTS

A total of 974 patients were analyzed, of whom 579 (59.4%) were male. The mean age (±SD) was 64.2±13.0 years. The primary outcome occurred in 9.3% of D-PLEX patients versus 12.1% (SOC) [risk difference estimate (RDE), -2.8%; 95% CI (-6.7%, 1.0%), P =0.1520]. In a pre-specified analysis by incision length, a reduction in the primary outcome was observed in the greater than 20 cm subpopulation: 8% (D-PLEX) versus 17.5% (SOC) [RDE, -9.4%; 95% CI (-15.5%, -3.2%), P =0.0032]. In the greater than 10 to less than or equal to 20 cm subgroup, no reduction was observed: 9.9% versus 7.9% [RDE, 2.0%; 95% CI (-2.8%, 6.7%), P =0.4133]. Exploratory post hoc analyses of patients with increased SSI risk (≥1 patient-specific comorbidity) indicated a reduction in the incidence of the primary outcome: 9.0% (D-PLEX) versus 13.7% (SOC) [RDE, -4.8%; 95% CI (-9.5%, -0.1%), P =0.0472]. The D-PLEX safety profile was good (no difference in treatment-emergent adverse events between the groups).

CONCLUSIONS

The SHIELD 1 study did not meet its primary outcome of reduced incisional SSI, incisional reinterventions, or all-cause mortality. Pre-specified and post hoc analyses suggested that D-PLEX may reduce the incidence of the primary outcome event in patients with increased SSI risk, including lengthy incisions.

Prevention and Risk Assessment of Cardiac Device Infections in Clinical Practice

The implantation of cardiac electronic devices (CIEDs), including pacemakers and defibrillators, has become increasingly prevalent in recent years and has been accompanied by a significant rise in cardiac device infections (CDIs), which pose a substantial clinical and economic burden. CDIs are associated with hospitalizations and prolonged antibiotic therapy and often necessitate device removal, leading to increased morbidity, mortality, and healthcare costs worldwide. Approximately 1-2% of CIED implants are associated with infections, making this a critical issue to address. In this contemporary review, we discuss the burden of CDIs with their risk factors, healthcare costs, prevention strategies, and clinical management.

Reduction in surgical site infections by localized administration with D-PLEX100 in patients with multiple risk factors undergoing colorectal surgery

BACKGROUND

D-PLEX₁₀₀ is a novel drug-eluting lipid polymer matrix that supplies a high, local concentration of doxycycline for approximately 30 days. The objective of this post-hoc analysis was to assess the efficacy of D-PLEX₁₀₀ in preventing superficial and deep SSIs in patients with ≥2 risk factors.

PATIENTS AND METHODS

A post-hoc analysis of a previously reported prospective randomized trial assessing D-PLEX₁₀₀ plus Standard of Care (SOC) versus SOC alone in colorectal surgery was performed to assess SSI rate in patients with ≥2 risk factors.

RESULTS

The overall incidence of SSI was significantly lower for the D-PLEX₁₀₀ arm (9.9%) versus SOC (21%), p = 0.033. Patients with ≥2 risk factors, SSI incidence was 37.5% for SOC and 15.8% in D-PLEX₁₀₀ treated patients.

CONCLUSIONS

D-PLEX₁₀₀ reduces the incidence of SSIs beyond benefits associated with SOC treatment alone and including patients with ≥2 risk factors. D-PLEX₁₀₀ may be a promising addition to established SSI prophylaxis bundles.

A meta-analysis examined the effect of topical nursing application of antimicrobial as a prophylaxis for the stoppage of surgical wound infection in colorectal surgery

To assess the impact of topical antimicrobial (TA) as a prophylaxis for the stoppage of surgical wound infection (SWI) in colorectal surgery (CS), we lead a meta-analysis. 9160 participants with CS were enrolled in the chosen studies; 4719 of them used TA, while 4441 served as controls. To assess the effectiveness of TA application in lowering SWIs following CS, odds ratios (OR) with 95% confidence intervals (CIs) were computed with a dichotomous technique with a fixed- or random-effect model. Significantly lower SWIs post CS for TA as whole (OR, 0.50; 95% CI, 0.38-0.64; P < .001), gentamicin collagen sponge and beads (OR, 0.52; 95% CI, 0.32-0.86; P = .01), triclosan impregnated fascial suture (OR, 0.57; 95% CI, 0.38-0.84; P = .005), antibiotic powder, ointment, lavage, or injection for the abdominal wound (OR, 0.35; 95% CI, 0.21-0.59; P < .001), and ionised silver dressing on the closed abdominal wound (OR, 0.45; 95% CI, 0.27-0.77; P = .003) compared to control. Significantly lower SWIs post CS for TA as a whole, gentamicin collagen sponge and beads, triclosan impregnated fascial sutures, antibiotic powder, ointment, lavage, or injection for the abdominal wound, and ionised silver dressing on the closed abdominal wound compared with control. The low sample size of 8 out of the 39 included studies in this meta-analysis calls for precaution when analysing the outcomes.

A prospective, randomized assessment of a novel, local antibiotic releasing platform for the prevention of superficial and deep surgical site infections

BACKGROUND

Despite significant advances in infection control guidelines and practices, surgical site infections (SSIs) remain a substantial cause of morbidity, prolonged hospitalization, and mortality among patients having both elective and emergent surgeries. D-PLEX₁₀₀ is a novel, antibiotic-eluting polymer-lipid matrix that supplies a high, local concentration of doxycycline for the prevention of superficial and deep SSIs. The aim of our study was to evaluate the safety and efficacy of D-PLEX in addition to standard of care (SOC) in preventing superficial and deep surgical site infections for patients undergoing elective colorectal surgery.

METHODS

From October 10, 2018 to October 6, 2019, as part of a Phase 2 clinical trial, we randomly assigned 202 patients who had scheduled elective colorectal surgery to receive either standard of care SSI prophylaxis or D-PLEX₁₀₀ in addition to standard of care. The primary objective was to assess the efficacy of D-PLEX₁₀₀ in superficial and deep SSI reduction, as measured by the incidence of SSIs within 30 days, as adjudicated by both an individual assessor and a three-person endpoint adjudication committee, all of whom were blinded to study-group assignments. Safety was assessed by the stratification and incidence of treatment-emergent adverse events.

RESULTS

One hundred and seventy-nine patients were evaluated in the per protocol population, 88 in the intervention arm [51 males, 37 females, median age (64.0 range: 19-92) years] and 91 in the control arm [57 males, 34 females, median age 64.5 (range: 21-88) years]. The SSI rate within 30 day post-index surgery revealed a 64% relative risk reduction in SSI rate in the D-PLEX₁₀₀ plus standard of care (SOC) group [n = 7/88 (8%)] vs SOC alone [n = 20/91 (22%)]; p = 0.0115. There was no significant difference in treatment-emergent adverse events.

CONCLUSIONS

D-PLEX₁₀₀ application leads to a statistically significant reduction in superficial and deep surgical site infections in this colorectal clinical model without any associated increase in adverse events.

Effect of wound irrigation on the prevention of surgical site infections: A meta-analysis

We performed a meta-analysis to evaluate the effect of wound irrigation on the prevention of surgical site infections. A systematic literature search up to January 2022 was done and 24 studies included 4967 subjects under surgery at the start of the study; antibiotic irrigation was used with 1372 of them, 1261 were aqueous povidone-iodine irrigation, and 2334 were saline irrigation or no irrigation for surgical site infections prevention in all surgical populations. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to evaluate the effect of different wound irrigation on the prevention of surgical site infections by the dichotomous method with a random or fixed-influence model. Antibiotic irrigation had significantly lower surgical site infections in all surgical populations (OR, 0.48; 95% CI, 0.36-0.62, P < .001) compared with saline irrigation or no irrigation for the subject under surgery. Aqueous povidone-iodine irrigation had significantly lower surgical site infections in all surgical populations (OR, 0.40; 95% CI, 0.20-0.81, P = .01) compared with saline irrigation or no irrigation for the subject under surgery. Antibiotic irrigation and aqueous povidone-iodine irrigation significantly lowered surgical site infections in all surgical populations compared with saline irrigation or no irrigation for the subject under surgery. Further studies are required.

Use of gentamicin-collagen sponge (Collatamp® G) in minimally invasive colorectal cancer surgery: A propensity score-matched study

Background

Minimally invasive surgery is commonly used to treat patients with colorectal cancer, although it can cause surgical site infections (SSIs) that can affect the oncologic outcome. Use of a gentamicin-collagen sponge may help reduce the occurrence of SSIs. We aimed to determine the effectiveness of a gentamicin-collagen sponge in reducing SSIs in minimally invasive surgery for colorectal cancer.

Methods

We retrospectively reviewed the records of 310 patients who were diagnosed with colorectal cancer at our hospital and underwent minimally invasive surgery between December 1, 2018, and February 28, 2021. Propensity score matching was conducted with a 1:1 ratio using logistic regression. The primary outcome was the incidence of SSIs in the mini-laparotomy wound. The secondary endpoints were factors affecting the incidence of SSIs.

Results

After propensity score matching, 130 patients were assigned to each group. There were no differences in clinical characteristics between the two groups. SSIs occurred in 2 (1.5%) and 3 (2.3%) patients in the gentamicin-collagen sponge and control groups, respectively (p<0.999). The following factors showed a statistically significant association with SSIs: body mass index >25 kg/m² (odds ratio, 39.0; 95% confidence interval, 1.90–802.21; p = 0.018), liver disease (odds ratio, 254.8; 95% confidence interval, 10.43–6222.61; p = 0.001), and right hemicolectomy (odds ratio, 36.22; 95% confidence interval, 2.37–554.63; p = 0.010).

Conclusion

Applying a gentamicin-collagen sponge to the mini-laparotomy wound did not reduce the frequency of SSIs. Further studies should be conducted on whether the selective use of gentamicin-collagen sponges may help reduce SSIs in high-risk patients.

Delphi Consensus on Intraoperative Technical/Surgical Aspects to Prevent Surgical Site Infection after Colorectal Surgery

BACKGROUND

Previous studies have focused on the development and evaluation of care bundles to reduce the risk of surgical site infection (SSI) throughout the perioperative period. A focused examination of the technical/surgical aspects of SSI reduction during CRS has not been conducted. This study aimed to develop an expert consensus on intraoperative technical/surgical aspects of SSI prevention by the surgical team during colorectal surgery (CRS).

STUDY DESIGN

In a modified Delphi process, a panel of 15 colorectal surgeons developed a consensus on intraoperative technical/surgical aspects of SSI prevention undertaken by surgical personnel during CRS using information from a targeted literature review and expert opinion. Consensus was developed with up to three rounds per topic, with a prespecified threshold of ≥70% agreement.

RESULTS

In 3 Delphi rounds, the 15 panelists achieved consensus on 16 evidence-based statements. The consensus panel supported the use of wound protectors/retractors, sterile incision closure tray, preclosure glove change, and antimicrobial sutures in reducing SSI along with wound irrigation with aqueous iodine and closed-incision negative pressure wound therapy in high-risk, contaminated wounds.

CONCLUSIONS

Using a modified Delphi method, consensus has been achieved on a tailored set of recommendations on technical/surgical aspects that should be considered by surgical personnel during CRS to reduce the risk of SSI, particularly in areas where the evidence base is controversial or lacking. This document forms the basis for ongoing evidence for the topics discussed in this article or new topics based on newly emerging technologies in CRS.

Reducing surgical site infections in low-income and middle-income countries (FALCON): a pragmatic, multicentre, stratified, randomised controlled trial

BACKGROUND

Surgical site infection (SSI) is the most common postoperative complication worldwide. WHO guidelines to prevent SSI recommend alcoholic chlorhexidine skin preparation and fascial closure using triclosan-coated sutures, but called for assessment of both interventions in low-resource settings. This study aimed to test both interventions in low-income and middle-income countries.

METHODS

FALCON was a 2 × 2 factorial, randomised controlled trial stratified by whether surgery was clean-contaminated, or contaminated or dirty, including patients undergoing abdominal surgery with a skin incision of 5 cm or greater. This trial was undertaken in 54 hospitals in seven countries (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa). Patients were computer randomised 1:1:1:1 to: (1) 2% alcoholic chlorhexidine and non-coated suture, (2) 2% alcoholic chlorhexidine and triclosan-coated suture, (3) 10% aqueous povidone-iodine and non-coated suture, or (4) 10% aqueous povidone-iodine and triclosan-coated suture. Patients and outcome assessors were masked to intervention allocation. The primary outcome was SSI, reported by trained outcome assessors, and presented using adjusted relative risks and 95% CIs. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03700749.

FINDINGS

Between Dec 10, 2018, and Sept 7, 2020, 5788 patients (3091 in clean-contaminated stratum, 2697 in contaminated or dirty stratum) were randomised (1446 to alcoholic chlorhexidine and non-coated suture, 1446 to alcoholic chlorhexidine and triclosan-coated suture, 1447 to aqueous povidone-iodine and non-coated suture, and 1449 to aqueous povidone-iodine and triclosan-coated suture). 14·0% (810/5788) of patients were children and 66·9% (3873/5788) had emergency surgery. The overall SSI rate was 22·0% (1163/5284; clean-contaminated stratum 15·5% [454/2923], contaminated or dirty stratum 30·0% [709/2361]). For both strata, there was no evidence of a difference in the risk of SSI with alcoholic chlorhexidine versus povidone-iodine (clean-contaminated stratum 15·3% [223/1455] vs 15·7% [231/1468], relative risk 0·97 [95% CI 0·82-1·14]; contaminated or dirty stratum 28·3% [338/1194] vs 31·8% [371/1167], relative risk 0·91 [95% CI 0·81-1·02]), or with triclosan-coated sutures versus non-coated sutures (clean-contaminated stratum 14·7% [215/1459] vs 16·3% [239/1464], relative risk 0·90 [95% CI 0·77-1·06]; contaminated or dirty stratum 29·4% [347/1181] vs 30·7% [362/1180], relative risk 0·98 [95% CI 0·87-1·10]). With both strata combined, there were no differences using alcoholic chlorhexidine or triclosan-coated sutures.

INTERPRETATION

This trial did not show benefit from 2% alcoholic chlorhexidine skin preparation compared with povidone-iodine, or with triclosan-coated sutures compared with non-coated sutures, in preventing SSI in clean-contaminated or contaminated or dirty surgical wounds. Both interventions are more expensive than alternatives, and these findings do not support recommendations for routine use.

FUNDING

National Institute for Health Research (NIHR) Global Health Research Unit Grant, BD.

Editor's Choice - Systematic Review and Meta-Analysis of Wound Adjuncts for the Prevention of Groin Wound Surgical Site Infection in Arterial Surgery

OBJECTIVE

Groin incision surgical site infections (SSIs) following arterial surgery are common and are a source of considerable morbidity. This review evaluates interventions and adjuncts delivered immediately before, during, or after skin closure, to prevent SSIs in patients undergoing arterial interventions involving a groin incision.

DATA SOURCES

MEDLINE, EMBASE, and CENTRAL databases were searched.

REVIEW METHODS

This review was undertaken according to established international reporting guidelines and was registered prospectively with the International prospective register of systematic reviews (CRD42020185170). The MEDLINE, EMBASE, and CENTRAL databases were searched using pre-defined search terms without date restriction. Randomised controlled trials (RCTs) and observational studies recruiting patients with non-infected groin incisions for arterial exposure were included; SSI rates and other outcomes were captured. Interventions reported in two or more studies were subjected to meta-analysis.

RESULTS

The search identified 1 532 articles. Seventeen RCTs and seven observational studies, reporting on 3 747 patients undergoing 4 130 groin incisions were included. A total of seven interventions and nine outcomes were reported upon. Prophylactic closed incision negative pressure wound therapy (ciNPWT) reduced groin SSIs compared with standard dressings (odds ratio [OR] 0.34, 95% CI 0.23 - 0.51; p < .001, GRADE strength of evidence: moderate). Local antibiotics did not reduce groin SSIs (OR 0.60 95% CI 0.30 - 1.21 p = .15, GRADE strength: low). Subcuticular sutures (vs. transdermal sutures or clips) reduced groin SSI rates (OR 0.33, 95% CI 0.17 - 0.65, p = .001, GRADE strength: low). Wound drains, platelet rich plasma, fibrin glue, and silver alginate dressings did not show any significant effect on SSI rates.

CONCLUSION

There is evidence that ciNPWT and subcuticular sutures reduce groin SSI in patients undergoing arterial vascular interventions involving a groin incision. Local antibiotics did not reduce groin wound SSI, although the strength of this evidence is lower. No other interventions demonstrated a significant effect.

Surgical complications in colorectal cancer patients

BACKGROUND

Advancements in diagnostic and therapeutic sciences have allowed early diagnosis and treatment of cancer. Colorectal cancer is one of the most commonly reported cancers, particularly in elderly patients.

METHODS

Open and laparoscopic surgeries are used for the removal of the tumor, along with chemotherapy, depending on the stage of cancer. However, colorectal cancer surgery is associated with a great number of complications, that affect the efficacy of the surgery and overall health and survival of the patient.

RESULTS

Prevalence of these complications have shown discrepancies depending on the condition of the patient and disease and surgical skills of the surgeon. Preoperative evaluation, intraoperative care and postoperative measures can reduce the incidence of these complications.

CONCLUSION

This review highlights some frequently reported complications associated with colorectal cancer surgery, their risk factors and subsequent therapeutic measures to treat them.