A retrospective non-randomized study on the impact of INTEGUSEAL, a preoperative microbial skin sealant, on the rate of surgical site infections after cardiac surgery

Prevention of surgical site sternal infections in cardiac surgery: a two-centre prospective randomized controlled study

OBJECTIVES

Surgical site infection (SSI) of the sternum is a devastating complication in cardiac surgery. The aim of this prospective randomized controlled two-centre clinical study was to compare the use of a gentamicin-collagen sponge (Genta-Coll® resorb) and of a cyanoacrylate-based microbial skin sealant (InteguSeal®) on the SSI rate of the sternum.

METHODS

We analysed data from 996 consecutive patients following isolated coronary artery bypass grafting between 2012 and 2014. The patients were randomized into three groups: standard group (S-group), Genta-Coll group (G-group) and InteguSeal group (I-group). The primary study end-point was to analyse the incidence of superficial and deep sternal SSI. The secondary study end-point was to determine independent risk factors for an increased SSI rate.

RESULTS

Of the 996 patients investigated, 332 patients were in S-group, 336 patients in G-group and 328 patients in I-group. The mean age was 67.7 ± 9.4 years, 18.6% were women and the overall SSI rate was 6.2% with 2.2% deep sternal wound infections. SSI rates were 8.3% (S-group), 5.4% (G-group) and 4.9% (I-group) (P 0.16). Multiple regression analysis demonstrated a preoperative body mass index (BMI) of >30 kg/m² (P 0.047), re-thoracotomy for postoperative bleeding (P < 0.001) and sternum instability (P < 0.001) as independent predictors for an increased SSI rate.

CONCLUSIONS

The application of InteguSeal® or Genta-Coll® resorb had no significant influence on the incidence of the sternal SSI rate in 996 consecutive cardiac surgery patients but demonstrated a trend towards a benefit from using these prophylactic approaches. Multiple regression analysis demonstrated a preoperative BMI of >30 kg/m², re-thoracotomy for bleeding and sternum instability as independent predictors for an increased sternal SSI rate.

Cyanoacrylate microbial sealants for skin preparation prior to surgery

BACKGROUND

Surgical site infections (i.e. incisions that become infected) are a continuing concern in health care. Microbial sealant is a liquid that can be applied to the skin immediately before surgery and is thought to help reduce the incidence of surgical site infections (SSIs) by sealing in the skin flora, thus preventing contamination and infection of the surgical site.

OBJECTIVES

To assess the effects of the preoperative application of microbial sealants (compared with no microbial sealant) on rates of SSI in people undergoing clean surgery.

SEARCH METHODS

For this second update we searched the following electronic databases in May 2015: the Cochrane Wounds 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. There were no restrictions based on language or date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) were eligible for inclusion if they involved people undergoing clean surgery (i.e. surgery that does not involve the breathing system, gut, genital or urinary tract, or any part of the body with an existing infection) in an operating theatre and compared the use of preoperative microbial sealants with no microbial sealant.

DATA COLLECTION AND ANALYSIS

All review authors independently extracted data on the characteristics, risk of bias and outcomes of the eligible trials.

MAIN RESULTS

Seven trials (859 participants undergoing clean surgery) met the inclusion criteria. The trials all compared cyanoacrylate microbial sealant with no sealant. We found there were fewer SSIs with the use of microbial sealant (23/443 participants) than with the control comparison (46/416 participants). There was no evidence of a difference between the two groups in surgical site infection rates following the use of microbial sealants when the results were pooled (risk ratio (RR) 0.53, 95% CI 0.24 to 1.18). There were adverse events in three studies, but these were not judged to be a result of the use of microbial sealant.

AUTHORS' CONCLUSIONS

In this second update there is still insufficient evidence available to determine whether the use of microbial sealants reduces the risk of surgical site infection or not. Further rigorous, adequately-powered RCTs are required to investigate this properly.

[Serious adverse events after microbial sealant application in paediatric patients]

BACKGROUND

Integuseal(®) is a cyanoacrylate-based medical device (IIa class), used in surgery after skin preparation to reduce bacterial contamination. It is not officially contraindicated for children.

OBJECTIVES

To describe a case series of skin lesions in pediatric patients after using Integuseal(®) in cardiac surgery.

METHODS

Case series.

RESULTS

Between September 2012 and February 2013, 153 pediatric patients were treated by Integuseal(®) to prepare for a cardiac surgery in our center: 5 patients (2%) had serious cutaneous reactions. The average age of patients having had lesions is 16months (the youngest patient being 1month old and the oldest being 5years and 8months old).

ISSUES

The risk factor in the development of skin lesion seems to be particularly related to the patient's age and sternal location. Other medical literature reports instances of cyanoacrylate intolerance in a variety of other situations.

CONCLUSION

Using Integuseal(®) on children does not appear to be safe.

New strategies for preoperative skin antisepsis

During the past decades, encouraging progress has been made in the prevention of surgical site infections (SSI). However, as SSI still occur today, strategic prevention measures such as standardized skin antisepsis must be implemented and rigorously promoted. Recent discoveries in skin physiology necessitate the development of novel antiseptic agents and procedures in order to ameliorate their efficacy. In particular, alternate target structures in the skin need to be taken into consideration for the development of the next generation of antiseptics. Recent investigations have shown that a high number of microorganisms are located within and in the close vicinity of the hair follicles. This suggests that these structures are an important reservoir of bacterial growth and activity in human skin. To date, it has not been fully elucidated to what extent conventional liquid antiseptics sufficiently target the hair follicle-related microbial population. Modern technologies such as tissue-tolerable plasma (TTP) have been tested for their potential antiseptic efficiency by reducing the bacterial load in the skin and in the hair follicles. First experiments using liposomes to deliver antiseptics into the hair follicles have been evaluated for their potential clinical application. The present review evaluates these two innovative methods for their efficacy and applicability in preoperative skin antiseptics.

Effectiveness of N-butyl cyanoacrylate-based microbial skin sealant on the prevention of surgical site infections

BACKGROUND

Surgical site infections (SSIs) are a serious concern in health care, and wound contamination by endogenous skin flora is a major factor in the development of SSIs. Despite preventive tactics in pre-operative skin care, antibiotic prophylaxis, surgical technique, and post-operative incision care, complete sterilization of the skin is not possible. Recently developed microbial skin sealant forms a continuous but breathable barrier that prevents migration of endogenous skin flora into the incision. The skin sealant closes dermal microabrasions, preventing re-colonization of potential pathogens at the incision. The purpose of this study was to determine the effect of an N-butyl cyanoacrylate-based microbial skin sealant in reducing the occurrence of SSIs in an experimental rodent model.

METHODS

This was a randomized, controlled animal trial. Forty-eight Wistar albino rats were divided into six groups of eight rats each. Three groups received application of sealant against specific bacteria, and three matched control groups received only the bacteria without the sealant. Group one underwent pre-operative hair removal, followed by application of skin sealant, then abdominal incision and closure. Group two (control) simply underwent hair removal, followed by incision and closure, with no skin sealant applied. Group three received an application of cage swabs (containing a mixture of urine, stool and sawdust from the animals' cages) before application of skin sealant, and group four (control) received cage swabs without subsequent skin sealant. Group five received methicillin-resistant Staphylococcus aureus (MRSA) followed by skin sealant, and group six (control) received MRSA without skin sealant. Seven days after surgery, the animals were sacrificed. Samples were taken from the abdomen of each rat and placed in culture medium. Proliferation of the following bacteria were observed: Coagulase-negative staphylococci (CoNS), gram-positive bacilli (GPB), Pseudomonas aeruginosa, and MRSA.

RESULTS

There was a statistically significant difference between the median number of GPB in the group that received cage swabs+sealant and the group that received cage swabs without sealant (median, GPB count 29,430 colony-forming units [CFU]/g vs 359,100  colony-forming units [CFU]/g; p<0.05). The study results showed that microbial skin sealant was not as effective in preventing CoNS or MRSA contamination as it was in preventing GPB contamination.

CONCLUSIONS

Use of a microbial skin sealant before surgery can lower the rate of SSIs by reducing the migration of some specific bacterial agents. Additional data are needed to validate its use in clinical practice.

Cyanoacrylate microbial sealant may reduce the prevalence of positive cultures in revision shoulder arthroplasty

BACKGROUND

Cyanoacrylate-based, microbial sealant is an adhesive skin barrier designed to prevent bacterial contamination in surgical wounds. This type of adhesive barrier could have use in decreasing the incidence of positive cultures and subsequent infection in shoulder arthroplasty.

QUESTIONS/PURPOSES

We therefore evaluated whether cyanoacrylate microbial sealant reduced the positive intraoperative culture rates in revision shoulder arthroplasty.

METHODS

We retrospectively reviewed 55 patients who underwent revision shoulder arthroplasties. Intraoperative aerobic and anaerobic deep tissue culture results taken during the revisions were compared. Cultures were taken of the deep synovial tissue lining the prosthesis. Patients were divided into two groups: those who underwent standard preparations with adhesive, iodine-barrier drapes (Group SP) and those who had placement of cyanoacrylate microbial sealant in addition to the standard prep (Group MS).

RESULTS

The prevalence of cases with positive cultures was 18% (seven of 40) in Group SP compared with 7% (one of 15) in Group MS. The prevalence of positive, anaerobic Propionibacterium acnes cultures was 13% in Group SP compared with 7% in Group MS. The prevalence of infections confirmed at revision surgery was 8% in Group SP versus 0% in Group MS.

CONCLUSIONS

Our observations suggest application of a cyanoacrylate microbial sealant may reduce the prevalence of positive cultures and thereby subsequent infections in revision shoulder arthroplasties.

LEVEL OF EVIDENCE

Level III, retrospective cohort study. See Guidelines for Authors for a complete description of levels of evidence.

Cyanoacrylate microbial sealants for skin preparation prior to surgery

BACKGROUND

Surgical site infections (i.e. incisions that become infected) are a continuing concern in health care. Microbial sealant is a liquid that can be applied to the skin immediately before surgery and is thought to help reduce the incidence of surgical site infections (SSIs) by sealing in the skin flora, thus preventing contamination and infection of the surgical site.

OBJECTIVES

To assess the effects of the preoperative application of microbial sealants (compared with no microbial sealant) on rates of SSI in people undergoing clean surgery.

SEARCH METHODS

For this first update we searched the following electronic databases in July 2013: the Cochrane Wounds Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid MEDLINE - In-Process & Other Non-Indexed Citations, Ovid EMBASE and EBSCO CINAHL.

SELECTION CRITERIA

Randomised controlled trials (RCTs) were eligible for inclusion if they involved people undergoing clean surgery (i.e. surgery that does not involve the breathing system, gut, genital or urinary tract or any part of the body with an existing infection) in an operating theatre and compared the use of preoperative microbial sealants with no microbial sealant.

DATA COLLECTION AND ANALYSIS

All review authors independently extracted data on the characteristics, risk of bias and outcomes of the eligible trials.

MAIN RESULTS

Three trials (524 participants undergoing clean surgery) met the inclusion criteria. The trials all compared cyanoacrylate microbial sealant with no sealant, and, when pooled, we found there were fewer SSIs with the use of microbial sealant (10/261 participants) than with the control comparison (29/274 participants). The difference between the two groups was statistically significant (risk ratio (RR) 0.36, 95% CI 0.18 to 0.72) but given the number of participants and quality of the studies, they should be treated with caution. There were some adverse events in one study, but these were not judged to be a result of the use of microbial sealant.

AUTHORS' CONCLUSIONS

In this first update there is still insufficient evidence available to determine whether the use of microbial sealants reduces the risk of surgical site infection or not. Further rigorous, adequately-powered RCTs are required to investigate this properly.