Do antibacterial-coated sutures reduce wound infection in head and neck cancer reconstruction?

A Novel Coated Suture Displays Antimicrobial Activity Without Compromising Structural Properties

BACKGROUND

Treated or coated sutures promise to prevent contamination of wounds.

PURPOSE

The purpose of the study was to coat surgical sutures with a new quaternary ammonium silane (QAS) antimicrobial compound at two different application temperatures and then to evaluate the resulting structural, physical, mechanical, and biological properties.

STUDY DESIGN, SETTING, SAMPLE

In vitro and in vivo studies were conducted using male albino Wistar rats approved by the Joint Ethical Committee of IMU and Postgraduate Medical Institute, Lahore. Only suture samples, coated uniformly with verified presence of the compound and of adequate length were used. Samples which were not coated uniformly and with inadequate length or damaged were excluded.

PREDICTOR VARIABLE

Predictor variables were sutures with and without QAS coatings and different temperatures. Sutures were coated with QAS at 0.5 and 1.0% wt/vol using the dip coating technique and sutures with and without QAS coating were tested at 25 and 40 °C temperatures.

MAIN OUTCOME VARIABLE(S)

Outcome variables of structural and physico-mechanical properties of QAS-coated and non-coated sutures were measured using Fourier transform infrared spectroscopy (for structural changes), confocal laser and scanning electron (for diameter changes), and tensile strength/modulus (for mechanical testing). Biologic outcome variables were tested (bacterial viability); macrophage cultures from Wistar rats were tested (M1/M2 polarization detecting IL-6 and IL-10). Macrophage cells were analyzed with CD80+ (M1) and CD163+ (M2). Chemotaxis index was calculated as a ratio of quantitative fluorescence of cells.

COVARIATES

Not applicable.

ANALYSES

Ordinal data among groups were compared using the Wilcoxon Mann-Whitney U test along with the comparison of histological analysis using the Wilcoxon Sign-rank test (P < .05).

RESULTS

Fourier transform infrared spectroscopy peak at 1490 cm-1 confirmed the presence of QAS on suture's surfaces with a significant increase (P < .05) in diameter (0.99 ± 0.5-mm) and weight (0.77 ± 0.02-mg) observed for 1% QAS groups treated at 40 °C. Non-coated samples heated at 25 °C had significantly (P < .05) less diameters (0.22 ± 0.03-mm) and weights (0.26 ± 0.06-mg). Highest tensile strength/modulus was observed for 0.5% QAS-coated samples which also had significantly higher antibacterial characteristics than other sutures (P < .05). QAS-coated sutures significantly increased M1 and M2 markers.

CONCLUSION AND RELEVANCE

QAS coating conferred antibacterial action properties without compromising the physical and mechanical properties of the suture.

Antimicrobial-coated sutures versus non-coated sutures in reducing surgical site infection: an updated systematic review and meta-analysis

BACKGROUND

Antimicrobial-coated sutures are one of the strategies to avoid surgical site infection (SSI) caused by microbial colonization on the surface of surgical sutures.

AIM

To investigate the effectiveness of antimicrobial-coated sutures in reducing SSI and develop the latest systematic evaluation evidence for clinical SSI prevention and the use of antimicrobial-coated sutures.

METHODS

The databases of MEDLINE, Embase, CINAHL, Cochrane, African Index Medicus, and WHO Global Health were searched from October 10th, 1990 to March 3rd, 2023 with language restricted to English, Spanish, and French. Meta-analysis was used to evaluate the impact of antimicrobial-coated sutures on SSI and whether their effectiveness is influenced by the type of sutures or wounds. Subgroup analyses were conducted based on type of sutures and wounds. Finally, quality of the retrieved evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

FINDINGS

Twenty-six randomized control trials (RCTs) and nine observational studies (OBSs) met the inclusion criteria. Antimicrobial sutures significantly reduced SSI risk (RCTs: odds ratio: 0.74; 95% confidence interval: 0.63-0.87; P = 0.0002; OBSs: OR: 0.61; 95% CI: 0.48-0.76; P < 0.0001). Only subgroup analysis of Polydioxanone Suture (PDS) Plus vs PDS, Vicryl Plus vs Vicryl and mixed wounds revealed consistent results in favour of antimicrobial-coated sutures. According to GRADE, the quality of RCT evidence is moderate, while that of OBS evidence is low.

CONCLUSION

Antimicrobial-coated sutures are effective in reducing the risk of postoperative SSI among a large number of surgical patients. However, the available evidence is of moderate/low quality and many studies had conflicts of interest.

Dual-stimuli responsive smart nanoprobe for precise diagnosis and synergistic multi-modalities therapy of superficial squamous cell carcinoma

BACKGROUND

Although the promising advancements of current therapeutic approaches is available for the squamous cell carcinoma (SCC) patients, the clinical treatment of SCC still faces many difficulties. The surgical irreparable disfigurement and the postoperative wound infection largely hamper the recovery, and the chemo/radiotherapy leads to toxic side effects.

RESULTS

Herein, a novel pH/Hyaluronidase (HAase) dual-stimuli triggered smart nanoprobe Fe^IIITA@HA has been designed through the biomineralization of Fe³⁺ and polyphenol tannic acid (TA) under the control of hyaluronic acid (HA) matrix. With the HA residues on the outer surface, Fe^IIITA@HA nanoprobes can specifically target the SCC cells through the over-expressed CD44, and accumulate in the carcinoma region after intravenously administration. The abundant HAase in carcinoma microenvironment will trigger the degradation of HA molecules, thereby exposing the Fe^IIITA complex. After ingesting by tumor cells via CD44 mediated endocytosis, the acidic lysosomal condition will further trigger the protonation of TA molecules, finally leading to the Fe³⁺ release of nanoprobe, and inducing a hybrid ferroptosis/apoptosis of tumor cells through peroxidase activity and glutathione depletion. In addition, Owing to the outstanding T₁ magnetic resonance imaging (MRI) performance and phototermal conversion efficiency of nanoprobes, the MRI-guided photothermal therapy (PTT) can be also combined to complement the Fe³⁺-induced cancer therapy. Meanwhile, it was also found that the nanoprobes can promote the recruitment of CD4⁺ and CD8⁺ T cells to inhibit the tumor growth through the cytokines secretion. In addition, the Fe^IIITA@HA nanoprobes can be eliminated from the body and no obvious adverse side effect can be found in histological analysis, which confirmed the biosafety of them.

CONCLUSION

The current Fe^IIITA@HA nanoprobe has huge potential in clinical translation in the field of precise diagnosis and intelligent synergistic therapy of superficial SCC. This strategy will promisingly avoid the surgical defects, and reduce the systemic side effect of traditional chemotherapy, paving a new way for the future SCC treatment.

Decreasing Surgical Site Infections in Plastic Surgery: A Systematic Review and Meta-analysis of Level 1 Evidence

BACKGROUND

Although many interventions are implemented to prevent surgical site infections (SSIs) in plastic surgery, their supporting evidence is inconsistent.

OBJECTIVES

The goal of this study was to assess the efficacy of methods for decreasing SSIs in plastic surgery.

METHODS

A systematic review and meta-analysis were performed to compare the effects of SSI prevention methods. All the studies were assessed for quality of evidence according to the GRADE assessment.

RESULTS

Fifty Level 1 randomized controlled trials were included. The most common interventions for preventing SSIs were antibiotic prophylaxis, showering, prepping, draping, and the use of dressings. Current evidence suggests that antibiotic prophylaxis is largely unnecessary and overused in many plastic surgical procedures, with the exception of head and neck oncologic, oral craniofacial, and traumatic hand surgeries.

CONCLUSIONS

Efficacy of antibiotic prophylaxis in plastic surgery is dependent on surgery type. There is a lack evidence that showering and prepping with chlorohexidine and povidone reduces SSIs.

LEVEL OF EVIDENCE: 1

Scar quality examination comparing titanium-coated suture material and non-coated suture material on flap donor sites in reconstructive surgery

Background

Wound healing and scar quality after trauma are subject to impairment through excessive wound healing, chronic wound or even surgical site infections. Optimizing the process of scar formation and skin healing is crucial in virtually all fields of medicine. In this regard, we tested the possible usage and advantages of titanium coated suture material.

Methods

We performed a prospective observational cohort study including 30 patients who underwent soft tissue reconstruction. One half of the donor flap site was sutured with titanium coated suture material, while the other half was closed with non-coated sutures. Scar quality of the donor flap site was assessed by photographs and POSAS scores on days 2–5, 14, 42, 72 and 180 postoperatively.

Results

No difference between the titanium coated sutures and non-coated sutures was seen in the POSAS assessment, neither for the patient scale at 14, 42, 72 and 180 days, nor for the observer scale on the same dates. Comorbidities like diabetes, chronic renal failure and smoking as well as the BMI of each patient affected the wound healing process to an equal degree on both sides of the suture.

Conclusions

No difference between the titanium coated and non-titanium-coated suture material was seen in the POSAS assessment in regard to scar quality and wound healing. The titanium-coated suture material can be considered to be equally as effective and safe in all qualities as the non-titanium-coated suture material, even in patients with comorbidities.

Clinical trial register This study is registered at the German Clinical Trials Register (DRKS) under the registration number DRKS00021767. (https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00021767)

The use of triclosan-coated sutures to prevent surgical site infections: a systematic review and meta-analysis of the literature

INTRODUCTION AND OBJECTIVES

Surgical site infections (SSIs) represent a common and serious complication of all surgical interventions. Microorganisms are able to colonise sutures that are implanted in the skin, which is a causative factor of SSIs. Triclosan-coated sutures are antibacterial sutures aimed at reducing SSIs. Our objective is to update the existing literature by systematically reviewing available evidence to assess the effectiveness of triclosan-coated sutures in the prevention of SSIs.

METHODS

A systematic review of EMBASE, MEDLINE, AMED (Allied and complementary medicine database) and CENTRAL was performed to identify full text randomised controlled trials (RCTs) on 31 May 2019.

INTERVENTION

Triclosan-coated sutures versus non-triclosan-coated sutures.

PRIMARY OUTCOME

Our primary outcome was the development of SSIs at 30 days postoperatively. A meta-analysis was performed using a fixed-effects model.

RESULTS

Twenty-five RCTs were included involving 11 957 participants. Triclosan-coated sutures were used in 6008 participants and non triclosan-coated sutures were used in 5949. Triclosan-coated sutures significantly reduced the risk of SSIs at 30 days (relative risk 0.73, 95% CI 0.65 to 0.82). Further sensitivity analysis demonstrated that triclosan-coated sutures significantly reduced the risk of SSIs in both clean and contaminated surgery.

CONCLUSION

Triclosan-coated sutures have been shown to significantly reduced the risk of SSIs when compared with standard sutures. This is in agreement with previous work in this area. This study represented the largest review to date in this area. This moderate quality evidence recommends the use of triclosan-coated sutures in order to reduce the risk of SSIs particularly in clean and contaminated surgical procedures.

PROSPERO REGISTRATION NUMBER

CRD42014014856.

Biomaterial suture Vicryl Plus reduces wound-related complications

Objective

To compare the wound-related complications following craniotomy in patients with brain gliomas undergoing wound closure using either absorbable antibacterial Vicryl Plus suture or traditional braided silk suture.

Materials and methods

Two hundred and forty-five patients undergoing craniotomy for supratentorial gliomas from January 1, 2011 to December 31, 2013 were retrospectively analyzed. We divided the patients into two groups: the Vicryl Plus group (using absorbable antibacterial Vicryl Plus suture) and the control group (using traditional braided silk suture). The clinical data and wound-related complications after surgery between two groups have been summarized.

Results

Patients in the Vicryl Plus suture group had lower incidence of wound-related complications compared with traditional braided silk suture group (P<0.05). No statistically significant difference was found between the two groups in terms of total medical expense.

Conclusion

Incision closure using absorbable antibacterial Vicryl Plus suture had less wound-related complications than using traditional braided silk suture, without increasing medical expense. Vicryl Plus suture could be a better choice for scalp closure in patients undergoing craniotomy surgery.

Temporal Change of Interleukin-6, C-Reactive Protein, and Skin Temperature after Total Knee Arthroplasty Using Triclosan-Coated Sutures

The risk of surgical site infections (SSIs) after total knee arthroplasty (TKA) can never be eliminated. Antimicrobial sutures containing triclosan have been used to decrease SSIs, but whether triclosan-coated sutures are effective with TKA is unclear. Between 2011 and 2012, 102 patients randomly assigned to a triclosan or a control group were prospectively assessed. The incidence of SSI within 3 months of surgery, length of hospital stay, pain scale, functional scores, wound condition, and serum inflammatory markers during hospitalization and within 3 months postoperatively were compared. At the final follow-up, there were 2 patients with superficial infections (3.9%) in the control group but none in the triclosan group. Lower serum IL-6 was detected in the triclosan group at 4 weeks and 3 months. The local skin temperature of the knees—recorded at 3 months using infrared thermography—was lower in the triclosan group than in the control group. More precise analytical measurements are needed to investigate local and systemic complications, especially in the early subclinical stage. This prospective, randomized, open-label clinical trial is in the public registry: ClinicalTrials.gov (NCT02533492).

Cold Atmospheric Plasma in the Treatment of Osteosarcoma

Human osteosarcoma (OS) is the most common primary malignant bone tumor occurring most commonly in adolescents and young adults. Major improvements in disease-free survival have been achieved by implementing a combination therapy consisting of radical surgical resection of the tumor and systemic multi-agent chemotherapy. However, long-term survival remains poor, so novel targeted therapies to improve outcomes for patients with osteosarcoma remains an area of active research. This includes immunotherapy, photodynamic therapy, or treatment with nanoparticles. Cold atmospheric plasma (CAP), a highly reactive (partially) ionized physical state, has been shown to inherit a significant anticancer capacity, leading to a new field in medicine called “plasma oncology.” The current article summarizes the potential of CAP in the treatment of human OS and reviews the underlying molecular mode of action.

Triclosan-coated sutures for the prevention of surgical-site infections: a meta-analysis

BACKGROUND

The scope of this article is to perform a meta-analysis of the studies that compare the use of triclosan-coated sutures (TCS) to uncoated sutures in prevention of surgical-site infections (SSIs).

METHODS

A systematic search of randomized and non-randomized studies was carried out on Pubmed and Scopus databases until July 2016.

RESULTS

The meta-analysis of 30 studies (19 randomized, 11 non-randomized; 15,385 procedures) gave evidence that TCS were associated with a lower risk of SSIs (risk ratio [RR] = 0.68; 95% confidence interval [CI] 0.57-0.81). Triclosan-coated sutures were associated with lower risk for SSIs in high-quality randomized studies (Jadad score 4 or 5). A lower risk for the development of SSIs based on wound classification was observed in clean, clean-contaminated, and contaminated but not for dirty procedures. No benefit was observed in specific types of surgery: colorectal, cardiac, lower limb vascular or breast surgery. Only a trend was found for lower risk for wound dehiscence, whereas no difference was observed for all-cause mortality.

CONCLUSIONS

Further randomized studies are needed to confirm the role of TCS in specific surgical procedures and whether or not they are related with lower risk for mortality.

Meta-analysis and trial sequential analysis of triclosan-coated sutures for the prevention of surgical-site infection

BACKGROUND

Triclosan-coated sutures (TCS) were developed to reduce the risk of surgical-site infection (SSI). Level 1A evidence of effectiveness has been presented in various recent meta-analyses, yet well designed RCTs have not been able to reproduce these favourable results. The aim of this study was to evaluate all available evidence critically with comprehensive analysis to seek a more reliable answer regarding the effectiveness of TCS in the prevention of SSI.

METHODS

PubMed, MEDLINE, Embase and Cochrane Library databases were searched from 1990 to November 2015 for RCTs that compared TCS with sutures that were exactly the same, but uncoated, in the prevention of SSI. Pooled relative risks (RRs) with corresponding 95 per cent confidence intervals were estimated using a random-effects model. Metaregression was used to substantiate subgroup effects, trial sequential analysis was employed to assess the risk of random error, and quality of evidence was determined using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

Twenty-one RCTs including 6462 patients were included. Risk of bias was serious. Pooled effects showed a RR of 0·72 (95 per cent c.i. 0·60 to 0·86; P < 0·001) for all publications. At a risk of 138 SSIs per 1000 procedures, the use of TCS reduced this by 39 (95 per cent c.i. 19, 55). Trial sequential analysis confirmed a RR reduction of 15 per cent for the use of TCS.

CONCLUSION

GRADE assessment shows moderate-quality evidence that TCS are effective in reducing SSI. Trial sequential analysis indicates that the effect was robust, and additional data are unlikely to alter the summary effect.

Meta-analysis of the potential economic impact following introduction of absorbable antimicrobial sutures

BACKGROUND

Despite several randomized trials, systematic reviews and meta-analyses that have demonstrated the effectiveness of antimicrobial (triclosan-coated or -impregnated) sutures (TCS), the clinical and economic impact of using these sutures compared with conventional non-antimicrobial-coated absorbable sutures (NCS) remains poorly documented.

METHODS

An independent systematic review and meta-analysis of all published evidence from January 2005 to September 2016 comparing TCS with NCS was conducted. Surgical-site infection (SSI) was the primary outcome. The results of the meta-analysis were used in a decision-tree deterministic and stochastic cost model, using the National Health Service (NHS England)-based cost of inpatient admissions for infections and differential costs of TCS versus NCS.

RESULTS

Thirty-four studies were included in the final assessment from an initial 163 identified citations; 20 of 34 studies were randomized, and 17 of 34 reported blinding of physicians and assessors. Using a random-effects model, the odds ratio for SSI in the TCS compared with NCS control groups was statistically significant (odds ratio 0·61, 95 per cent c.i. 0·52 to 0·73; P < 0·001). There was significant heterogeneity (I² = 49 per cent). Using random-effects event estimates of SSI for TCS and NCS for each individual wound type, the mean savings per surgical procedure from using antimicrobial sutures were significant: £91·25 (90 per cent c.i. 49·62 to 142·76) (€105·09 (57·15 to 164·41); exchange rate 15 November 2016) across all wound types.

CONCLUSION

The reviewed literature suggested that antimicrobial sutures may result in significant savings across various surgical wound types.

New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective

Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.

An Economic Model: Value of Antimicrobial-Coated Sutures to Society, Hospitals, and Third-Party Payers in Preventing Abdominal Surgical Site Infections

Background

While the persistence of high surgical site infection (SSI) rates has prompted the advent of more expensive sutures that are coated with antimicrobial agents to prevent SSIs, the economic value of such sutures has yet to be determined.

Methods

Using TreeAge Pro, we developed a decision analytic model to determine the cost-effectiveness of using antimicrobial sutures in abdominal incisions from the hospital, third-party payer, and societal perspectives. Sensitivity analyses systematically varied the risk of developing an SSI (range, 5%–20%), the cost of triclosan-coated sutures (range, $5–$25/inch), and triclosan-coated suture efficacy in preventing infection (range, 5%–50%) to highlight the range of costs associated with using such sutures.

Results

Triclosan-coated sutures saved $4,109–$13,975 (hospital perspective), $4,133–$14,297 (third-party payer perspective), and $40,127–$53,244 (societal perspective) per SSI prevented, when a surgery had a 15% SSI risk, depending on their efficacy. If the SSI risk was no more than 5% and the efficacy in preventing SSIs was no more than 10%, triclosan-coated sutures resulted in extra expenditure for hospitals and third-party payers (resulting in extra costs of $1,626 and $1,071 per SSI prevented for hospitals and third-party payers, respectively; SSI risk, 5%; efficacy, 10%).

Conclusions

Our results suggest that switching to triclosan-coated sutures from the uncoated sutures can both prevent SSIs and save substantial costs for hospitals, third-party payers, and society, as long as efficacy in preventing SSIs is at least 10% and SSI risk is at least 10%.

Efficacy of triclosan-coated sutures for reducing risk of surgical site infection in adults: a meta-analysis of randomized clinical trials

BACKGROUND

Surgical site infection (SSI) is the third most frequent type of nosocomial infections. Triclosan-coated sutures are often used to reduce the risk of SSI, but studies examining this have given conflicting results. Therefore, this meta-analysis was performed to assess the efficacy of triclosan-coated sutures for reducing risk of SSI in adults.

METHODS

PubMed, EMBASE, Google Scholar, and ClinicalTrials.gov were searched to identify randomized clinical trials evaluating triclosan-coated sutures for preventing SSI on patients 18 y or older.

RESULTS

Thirteen randomized clinical trials involving 5256 participants were included. Triclosan-coated sutures were associated with lower risk of SSI than uncoated sutures across all surgeries (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.65-0.88, P < 0.001). Similar proportions of patients experienced wound dehiscence with either type of suture (RR 0.97, 95% CI 0.49-1.89, P = 0.92). Subgroup analysis showed lower risk of SSI with triclosan-coated sutures in abdominal surgeries (RR 0.70, 95% CI 0.50-0.99, P = 0.04) and group with prophylactic antibiotic (RR 0.79, 95% CI 0.63-0.99, P = 0.04). However, such risk reduction was not observed in cardiac surgeries, breast surgeries, or group without prophylactic antibiotic.

CONCLUSIONS

Triclosan-coated sutures can decrease the incidence of SSI in abdominal surgeries and might not interfere with wound healing process. Nevertheless, further studies are needed to examine whether triclosan-coated sutures are effective at preventing SSI in non-abdominal surgeries and to further study the interaction of antibiotic prophylaxis with triclosan-coated sutures.

Antibacterial suture vs silk for the surgical removal of impacted lower third molars. A randomized clinical study

Background

The aim of this study was to evaluate the clinical and microbiological impact of an antibacterial suture (Monocryl® Plus) in the surgical removal of I3M.

Material and Methods

A “split-mouth”, prospective pilot clinical study was designed involving 20 patients programmed for the surgical removal of I3M. Each side was randomly sutured with Monocryl® Plus or silk suture and removed for microbiological study 72 hours and 7 days after surgery. Presence of SSI, wound bleeding and the degree of discomfort associated with each type of suture material (scored by means of a visual analog scale) were evaluated. The level of contamination of each material was observed under the scanning electron microscope.

Results

Wound bleeding upon suture removing was slightly greater after 72 hours and 7 days with black silk suture, though the differences were not statistically significant (p=0.752 and p=0.113, respectively). Patient discomfort was very similar with both types of suture material (p=0.861). Only one case of SSI was recorded with black silk suture after 72 hours. Microbiologically, the antibacterial suture showed a lesser presence of microorganisms (p<0.001, at 72h and p=0.033 at 7th day, respectively). The most common bacterial species included grampositive cocci (Streptococcus viridans group, Neisseria spp., Coagulasenegative Staphylococcus and Peptostreptococcus), gramnegative cocci (Veillonella), grampositive Bacilli (Lactobacillus), and gramnegative Bacilli (Prevotella).

Conclusions

The greatest antibacterial effect of Monocryl Plus suture was observed after 72 hours. According to most authors, there is no doubt that this antibacterial suture can provide little safety in the control of SSI.

Key words:Antibacterial suture, monocryl® plus, vicryl® plus, third molar surgery, postoperative infection, surgical site infection (SSI).

Triclosan-coated sutures reduce the risk of surgical site infections: a systematic review and meta-analysis

OBJECTIVE To analyze available evidence on the effectiveness of triclosan-coated sutures (TCSs) in reducing the risk of surgical site infection (SSI). DESIGN Systematic review and meta-analysis. METHODS A systematic search of both randomized (RCTs) and nonrandomized (non-RCT) studies was performed on PubMed Medline, OVID, EMBASE, and SCOPUS, without restrictions in language and publication type. Random-effects models were utilized and pooled estimates were reported as the relative risk (RR) ratio with 95% confidence interval (CI). Tests for heterogeneity as well as meta-regression, subgroup, and sensitivity analyses were performed. RESULTS A total of 29 studies (22 RCTs, 7 non-RCTs) were included in the meta-analysis. The overall RR of acquiring an SSI was 0.65 (95% CI: 0.55-0.77; I2=42.4%, P=.01) in favor of TCS use. The pooled RR was particularly lower for the abdominal surgery group (RR: 0.56; 95% CI: 0.41-0.77) and was robust to sensitivity analysis. Meta-regression analysis revealed that study design, in part, may explain heterogeneity (P=.03). The pooled RR subgroup meta-analyses for randomized controlled trials (RCTs) and non-RCTs were 0.74 (95% CI: 0.61-0.89) and 0.53 (95% CI: 0.42-0.66), respectively, both of which favored the use of TCSs. CONCLUSION The random-effects meta-analysis based on RCTs suggests that TCSs reduced the risk of SSI by 26% among patients undergoing surgery. This effect was particularly evident among those who underwent abdominal surgery.

Triclosan-coated sutures reduce wound infections after spinal surgery: a retrospective, nonrandomized, clinical study

BACKGROUND CONTEXT

Surgical site infection (SSI) is a serious postoperative complication. The incidence of SSIs is lower in clean orthopedic surgery than in other fields, but it is higher after spinal surgery, reaching 4.15% in high-risk patients. Several studies reported that triclosan-coated polyglactin 910 sutures (Vicryl Plus; Ethicon, Inc., Somerville, NJ, USA) significantly reduced the infection rate in the general surgical, neurosurgical, and thoracic surgical fields. However, there have been no studies on the effects of such coated sutures on the incidence of SSIs in orthopedics.

PURPOSE

To compare the incidence of wound infections after spinal surgery using triclosan-coated suture materials with that of noncoated ones.

STUDY DESIGN/SETTING

A retrospective, nonrandomized, and clinical study.

PATIENT SAMPLE

From May 2010 to April 2012, 405 patients underwent a spinal surgical procedure in the Department of Orthopedic Surgery of two university hospitals.

OUTCOME MEASURES

The primary outcome was the number of wound infections and dehiscences.

METHODS

Two hundred five patients had a conventional wound closure with polyglactin 910 suture (Vicryl) between May 2010 and April 2011 (Time Period 1 [TP1]), and 200 patients underwent wound closure with triclosan-coated polyglactin 910 suture (Vicryl Plus) between May 2011 and April 2012 (TP2). Statistical comparisons of wound infections, dehiscence, and risk factors for poor wound healing or infection were performed. None of the authors has any conflict of interest associated with this study.

RESULTS

There were two cases of wound dehiscence in TP1 and one in TP2 (p=.509). Using noncoated sutures in TP1, eight patients (3.90%) had wound infections, whereas one patient (0.50%) had wound infections in TP2 (using triclosan-coated sutures); the difference was significant (p=.020).

CONCLUSIONS

The use of triclosan-coated polyglactin 910 sutures instead of polyglactin 910 sutures may reduce the number of wound infections after spinal surgery.

Novel Coating of Surgical Suture Confers Antimicrobial Activity Against Porphyromonas gingivalis and Enterococcus faecalis

BACKGROUND

The oral cavity is colonized by >10(9) bacteria, many of which can increase heart disease risk when seeded into the bloodstream. Most dentoalveolar surgeries require the use of surgical sutures. Suture placement and removal can increase the risk of postoperative infection and bacteremia. The aim of this study is to evaluate the antimicrobial activity of a novel quaternary ammonium compound, K21, when coated on different suture materials.

METHODS

The periodontal pathogen Porphyromonas gingivalis and the endodontic species Enterococcus faecalis were grown to early log phase and inoculated on enriched Brucella blood agar, on which were placed identical lengths of surgical suture (chromic gut, polyester suture, silk, and nylon suture) and control unwaxed dental floss impregnated with K21 at 5%, 10%, 20%, and 25% volume/volume in ethanol vehicle. Controls included the following: 1) sutures treated with vehicle; 2) untreated sutures; and 3) unwaxed floss. Zones of inhibition in millimeters were measured at five randomized sites per suture/floss for each concentration and material used. Mean ± SD of zones of inhibition were calculated, and analysis of variance (P <0.05) was used to determine whether differences were statistically significant.

RESULTS

The results indicate that K21-coated suture at concentrations ranging from 5% to 25%, depending on the type of suture, have antimicrobial activity for P. gingivalis and E. faecalis. Nylon suture coated with K21 at 5%, 10%, 20%, and 25% resulted in zones ranging from 3 to 11 mm. Polyester suture was more effective at lower K21 concentrations with 5% (P = 0.0031), 10% (P = 0.0011), and 20% (P = 0.0002), yielding 7.5, 8.3, and 10.5 mm zones of inhibition. K21-coated silk suture yielded significant zones of inhibition at 25% (P <0.0001), whereas chromic gut was effective at K21 concentrations of 5% (P = 0.0081) and 25% (P <0.0001).

CONCLUSION

It is concluded that K21-coated surgical sutures have antimicrobial activity for bacterial species of direct relevance to postoperative infection and bacteremia.

Silicone surface with drug nanodepots for medical devices

An ideal surface of poly(dimethylsiloxane) (PDMS) medical devices requires sustained drug release to combat various tissue responses and infection. At present, a noncovalent surface coating with drug molecules using binders possesses a detachment problem, while covalently linking drug molecules to the surface provides no releasable drug. Here, a platform that allows the deposition of diverse drugs onto the PDMS surface in an adequate quantity with reliable attachment and a sustained-release character is demonstrated. First, a PDMS surface with carboxyl functionality (PDMS-COOH) is generated by subjecting a PDMS piece to an oxygen plasma treatment to obtain silanol moieties on its surface, then condensing the silanols with (3-aminopropyl)triethoxysilane molecules to generate amino groups, and finally reacting the amino groups with succinic anhydride. The drug-loaded carriers with hydroxyl groups on their surface can then be esterified to PDMS-COOH, resulting in a PDMS surface covalently grafted with drug-filled nanocarriers so that the drugs inside the securely grafted carriers can be released. Demonstrated here is the covalent linking of the surface of a PDMS endotracheal tube with budesonide-loaded ethylcellulose nanoparticles. A secure and high drug accumulation at the surface of the tubes (0.025 mg/cm2) can be achieved without changes in its bulk property such as hardness (Shore-A), and sustained release of budesonide with a high release flux during the first week followed by a reduced release flux over the subsequent 3 weeks can be obtained. In addition, the grafted tube possesses more hydrophilic surface and thus is more tissue-compatible. The grafted PDMS pieces show a reduced in vitro inflammation in cell culture and a lower level of in vivo tissue responses, including a reduced level of inflammation, compared to the unmodified PDMS pieces, when implanted in rats. Although demonstrated with budesonide and a PDMS endotracheal tube, this platform of grafting a PDMS surface with drug-loaded particles can be applied to other drugs and other devices.

Bacterial biofilms on implanted suture material are a cause of surgical site infection

BACKGROUND

Surgical site infection (SSI) has been estimated to occur in up to 5% of all procedures, accounting for up to 0.5% of all hospital costs. Bacterial biofilms residing on implanted foreign bodies have been implicated as contributing or causative factors in a wide variety of infectious scenarios, but little consideration has been given to the potential for implanted, submerged suture material to act as a host for biofilm and thus serve as a nidus of infection.

METHODS

We report a series of 15 patients who underwent open Roux-en-Y gastric bypass (with musculofascial closure with permanent, multifilament sutures) who developed longstanding and refractory SSIs in the abdominal wall. Explanted suture material at subsequent exploration was examined for biofilm with confocal laser-scanning microscopy (CLSM) and fluorescence in situ hybridization (FISH).

RESULTS

All 15 patients at re-exploration were found to have gross evidence of a "slimy" matrix or dense reactive granulation tissue localized to the implanted sutures. Confocal laser-scanning microscopy revealed abundant biofilm present on all sutures examined; FISH was able to identify the presence of specific pathogens in the biofilm. Complete removal of the foreign bodies (and attendant biofilms) resulted in all cases in cure of the SSI.

CONCLUSION

Bacterial biofilms on implanted suture material can manifest as persistent surgical site infections that require complete removal of the underlying foreign body substrata for resolution.

Continuous versus interrupted skin sutures for non-obstetric surgery

BACKGROUND

Most surgical procedures involve a cut in the skin, allowing the surgeon to gain access to the surgical site. Most surgical wounds are closed fully at the end of the procedure; this review focuses on these closed wounds. There are many ways to close the surgical incision, for example, using sutures (stitches), staples, tissue adhesives or tapes. Skin sutures can be continuous or interrupted. In general, continuous sutures are usually subcuticular and can be absorbable or non-absorbable, while interrupted sutures are usually non-absorbable and involve the full thickness of the skin - although some surgeons do use absorbable interrupted sutures.

OBJECTIVES

To compare the benefits and harms of continuous compared with interrupted skin closure techniques in participants undergoing non-obstetric surgery.

SEARCH METHODS

In August 2013 we searched the following databases: Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) that compared skin closure using continuous sutures with skin closure using interrupted sutures, irrespective of whether there were differences in the nature of the suture materials used in the two groups. We included all relevant RCTs in the analysis, irrespective of language of publication, publication status, publication year or sample size.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials and extracted data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for comparing binary outcomes between the groups, and calculated the mean difference (MD) with 95% CI for comparing continuous outcomes. We performed meta-analysis using a fixed-effect model and a random-effects model. We performed intention-to-treat analysis whenever possible.

MAIN RESULTS

We included five RCTs with a total of 827 participants. Outcomes were available for 730 participants (384 participants randomised to continuous sutures and 346 participants to interrupted sutures). All the trials were of unclear or high risk of bias. The participants underwent abdominal or groin operations. The only outcomes reported in the trials were superficial surgical site infection, superficial wound dehiscence (breakdown) and length of hospital stay. Other important outcomes such as quality of life, long-term patient outcomes and use of healthcare resources were not reported in these trials.Overall, 6.5% (39/602 participants, four trials) developed superficial surgical site infections. There was no significant difference between the groups in the proportion of participants who developed superficial surgical site infections (RR 0.73; 95% CI 0.40 to 1.33). A total of 23 participants (23/625 (3.7%), four trials) developed superficial wound dehiscence. Twenty-two of the 23 participants belonged to the interrupted suture group.The proportion of participants who developed superficial wound dehiscence was statistically significantly lower in the continuous suture group compared to the interrupted suture group (RR 0.08; 95% CI 0.02 to 0.35). Most of these wound dehiscences were reported in two recent trials in which the continuous skin suture groups received absorbable subcuticular sutures while the interrupted skin suture groups received non-absorbable transcutaneous sutures. The non-absorbable sutures were removed seven to nine days after surgery in the interrupted sutures groups whilst sutures in the comparator groups were not removed, being absorbable. The continuous suture technique with absorbable suture does not require suture removal and provides support for the wound for a longer period of time. This may have contributed to the difference between the two groups in the proportion of participants who developed superficial wound dehiscence. There was no significant difference in the length of the hospital stay between the two groups (MD -1.40 days; 95% CI -7.14 to 4.34).

AUTHORS' CONCLUSIONS

Superficial wound dehiscence may be reduced by using continuous subcuticular sutures. However, there is uncertainty about this because of the quality of the evidence. Besides, the nature of the suture material used may have led to this observation, as the continuous suturing technique used suture material that did not need to be removed, whereas the comparator used interrupted (non-absorbable) sutures that did need to be removed. Differences in the methods of skin closure have the potential to affect patient outcomes and use of healthcare resources. Further well-designed trials at low risk of bias are necessary to determine which type of suturing is better.

In vitro efficacy of a novel active-release antimicrobial coating to eradicate biofilms of Pseudomonas aeruginosa

Implant-related infections are becoming increasingly difficult to treat due to the formation of biofilms on implant surfaces. This study analyzed the in vitro efficacy of a novel antimicrobial coating against biofilms of Pseudomonas aeruginosa, using a flow cell system. Results indicated that P. aeruginosa biofilms were reduced by greater than 8 log10 units in less than 24 h. Data indicated that this active-release coating may be promising for preventing biofilm implant-related infections.

Effect of triclosan-coated sutures on the incidence of surgical wound infection after lower limb revascularization surgery: a randomized controlled trial

BACKGROUND

Surgical wound infection (SWI) is a common complication after peripheral vascular surgery. In a prospective study, triclosan-coated sutures were reported to decrease the incidence of surgical site infection after various surgical procedures. The aim of our study was to test the hypothesis that use of triclosan-coated sutures decreases the incidence of SWI after lower limb vascular surgery.

METHODS

This prospective, randomized, multicenter, double-blinded trial was conducted between July 2010 and January 2011 in five hospitals in Finland. We randomly allocated 276 patients undergoing lower limb revascularization surgery to a study (n = 139) or a control (n = 137) group. Surgical wounds in the study group were closed with triclosan-coated suture material, and wounds in the control group were closed with noncoated sutures. The main outcome measure was SWI. A surgical wound complication was considered to be an infection if there were bacteria isolated from the wound or if there were areas of localized redness, heat, swelling, and pain around the wound appearing within 30 days after the operative procedure. Logistic regression analysis was used to assess the independent effect of triclosan-coated sutures on the incidence of SWI.

RESULTS

Altogether, 61 (22.1 %) patients developed SWI. SWI occurred in 31 (22.3 %) patients in the study group and in 30 (21.9 %) patients in the control group (odds ratio 1.10, 95% confidence interval 0.61-2.01, p = 0.75.)

CONCLUSIONS

The use of triclosan-coated sutures does not reduce the incidence of SWI after lower limb vascular surgery.

Triclosan-coated sutures reduce the incidence of wound infections and the costs after colorectal surgery: a randomized controlled trial

BACKGROUND

In colorectal surgeries, surgical site infections (SSIs) frequently cause morbidity; an incidence of up to 20% has been shown in previous studies. Recently, to prevent microbial colonization of suture material in operative wounds, triclosan-coated polyglactin suture materials with antimicrobial activity have been developed; however, their significance in colorectal surgery remains unclear. This randomized controlled trial was conducted to assess the value of triclosan-coated polyglactin sutures in colorectal surgery.

METHODS

A total of 410 consecutive patients who had undergone elective colorectal operations were enrolled in this trial. Of those patients, the 206 in the study group underwent wound closure with triclosan-coated polyglactin 910 antimicrobial sutures, and the 204 patients in the control group received conventional wound closures with polyglactin 910 sutures.

RESULTS

The study group and the control group were comparable regarding risk factors for SSIs. The incidence of wound infection in the study group was 9 of 206 patients (4.3%), and that in the control group was 19 of 204 patients (9.3%). The difference is statistically significant in the 2 groups (P = .047). The median additional cost of wound infection management was $2,310. The actual entire additional cost, therefore, of 9 patients in the study group was $18,370, and that of 19 patients in the control group was $60,814.

CONCLUSION

Triclosan-coated sutures can reduce the incidence of wound infections and the costs in colorectal surgery.

Antibacterial-coated suture in reducing surgical site infection in breast surgery: a prospective study

Background. To reduce the incidence of microbial colonization of suture material, Triclosan- (TC-)coated suture materials have been developed. The aim of this study was to assess the incidence of suture-related complications (SRC) in breast surgery with and without the use of TC-coated sutures. Methods. We performed a study on two consecutive periods: 92 patients underwent breast surgery with conventional sutures (Group 1) and 98 with TC-coated sutures (Group 2). We performed subgroups analyses and developed a model to predict SRC in Group 1 and tested its clinical efficacy in Group 2 using a nomogram-based approach. Results. The SRC rates were 13% in Group 1 and 8% in Group 2. We found that some subgroups may benefit from TC-coated sutures. The discrimination obtained from a logistic regression model developed in Group 1 and based on multifocality, age and axillary lymphadenectomy was 0.88 (95% CI 0.77-0.95) (P < 10(-4)). There was a significant difference in Group 2 between predicted probabilities and observed percentages (P < 10(-5)). The predicted and observed proportions of complications in the high-risk group were 38% and 13%, respectively. Conclusion. This study used individual predictions of SRC and showed that using TC-coated suture may prevent SRC. This was particularly significant in high-risk patients.

In vivo efficacy of a silicone‒cationic steroid antimicrobial coating to prevent implant-related infection

Active release antimicrobial coatings for medical devices have been developed to prevent and treat biofilm implant-related infections. To date, only a handful of coatings have been put into clinical use, with limited success. In this study, a novel antimicrobial compound was incorporated into a silicone (polydimethylsiloxane or PDMS) polymer to develop a novel active release coating that addressed several limitations of current device coatings. The efficacy of this coating was optimized using an in vitro flow cells system, then translated to an animal model of a simulated Type IIIB open fracture wherein well-established biofilms were used as initial inocula. Results indicated that the novel coating was able to prevent infection in 100% (9/9) of animals that were treated with biofilms and the novel coating (treatment group). In contrast, 100% (9/9) of animals that were inoculated with biofilms and not treated with the coating (positive control), did develop infection. Nine animals were used as negative controls, i.e., those that were not treated with biofilms, and showed a rate of infection of 11% (1/9). Eight animals were treated with the novel coating only to determine its effect on host tissue. Results indicated that the novel active release coating may have significant promise for future application to prevent biofilm implant-related infections in patients.

Triclosan-coated sutures do not reduce leg wound infections after coronary artery bypass grafting

OBJECTIVES

Leg wound infection is a common complication after coronary artery bypass grafting (CABG). Suture contamination has been suggested as a mechanism of surgical site infections. Vicryl Plus(®) is a polyglacitin suture coated with the antiseptic chemical substance Triclosan, which has been shown to inhibit the growth of Staphylococcus aureus in vitro. The first aim of the present study was to compare Vicryl Plus with conventional Vicryl(®) sutures with regard to leg wound infections following CABG. The second aim was to examine patient- and operative characteristics, which are assumed to predict leg wound infections.

METHODS

After statistical calculations a priori, 328 CABG patients were prospectively randomized to leg wound closure with Vicryl Plus (164 patients) or conventional Vicryl sutures (164 patients). Incidences of leg wound infection and predictors of infection related to patient- and operative characteristics were examined.

RESULTS

The incidence of leg wound infections was 10.4% (17/163) in the Vicryl group, and 10.0% (16/160) in the Vicryl Plus group (P = 1.00). Patients with leg wound infections had increased body mass index and prolonged extracorporeal circulation and aortic clamping time compared with patients without infections.

CONCLUSIONS

In the present study, we report for the first time that Vicryl Plus did not reduce the incidence of leg wound infections in patients undergoing CABG. Obesity and prolonged time of extracorporeal circulation were both associated with the increased risk of infections. Currently, the clinical role and indication for the use of Vicryl Plus have yet to be defined.