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

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.

Systematic review and meta-analysis comparing surgical site infection in abdominal surgery between triclosan-coated and uncoated sutures

PURPOSE

Surgical site infection (SSI) is a frequent complication after abdominal surgery and impacts morbidity, mortality and medical costs. This systematic review evaluates whether the use of triclosan-coated sutures for closing the fascia during abdominal surgery reduces the rate of SSI compared to uncoated sutures.

METHODS

A systematic review and meta-analysis were conducted using the PRISMA guidelines. On February 17, 2024, a literature search was performed in Medline ALL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Embase. Randomized controlled trials (RCTs) on abdominal fascial closure in human adults, comparing triclosan-coated and uncoated sutures, were included. The risk of bias was assessed using the Cochrane RoB 2 tool. Pooled meta-analysis was performed using RevMan.

RESULTS

Out of 1523 records, eleven RCTs were included, with a total of 10,234 patients: 5159 in the triclosan-coated group and 5075 in the uncoated group. The incidence of SSI was statistically significantly lower in the triclosan-coated group (14.8% vs. 17.3%) with an odds ratio (OR) of 0.84 (95% CI [0.75, 0.93], p = 0.001). When polydioxanone was evaluated separately (coated N = 3999, uncoated N = 3900), triclosan-coating reduced SSI; 17.5% vs. 20.1%, OR 0.86 (95% CI [0.77; 0.96], p = 0.008). When polyglactin 910 was evaluated (coated N = 1160, uncoated N = 1175), triclosan-coating reduced the incidence of SSI; 5.4% vs. 7.8%, OR 0.67 (95% CI [0.48; 0.94], p = 0.02).

CONCLUSION

According to the results of this meta-analysis the use of triclosan-coated sutures for fascial closure statistically significantly reduces the incidence of SSI after abdominal surgery with a risk difference of about 2%.

The effectiveness of fascial closure with antimicrobial-coated sutures in preventing incisional surgical site infections in gastrointestinal surgery: a systematic review and meta-analysis

The aim of this study was to conduct a systematic review and meta-analysis of the efficacy of fascial closure using antimicrobial-sutures specifically for the prevention of surgical site infections (SSIs) in gastrointestinal surgery, as part of the revision of the SSI prevention guidelines of the Japanese Society of Surgical Infectious Diseases (JSSI). We searched CENTRAL, PubMed and ICHUSHI-Web in May 2023, and included randomized controlled trials (RCTs) comparing antimicrobial-coated and non-coated sutures for fascial closure in gastrointestinal surgery (PROSPERO No. CRD42023430377). Three authors independently screened the RCTs. We assessed the risk of bias and the GRADE criteria for the extracted data. The primary outcome was incisional SSI and the secondary outcomes were abdominal wall dehiscence and the length of postoperative hospital stay. This study was supported partially by the JSSI. A total of 10 RCTs and 5396 patients were included. The use of antimicrobial-coated sutures significantly lowered the risk of incisional SSIs compared with non-coated suture (risk ratio: 0.79, 95% confidence intervals: 0.64-0.98). In subgroup analyses, antimicrobial-coated sutures reduced the risk of SSIs for open surgeries, and when monofilament sutures were used. Antimicrobial-coated sutures did not reduce the incidence of abdominal wall dehiscence and the length of hospital stay compared with non-coated sutures. The certainty of the evidence was rated as moderate according to the GRADE criteria, because of risk of bias. In conclusion, the use of antimicrobial-coated sutures for fascial closure in gastrointestinal surgery is associated with a significantly lower risk of SSI than non-coated sutures.

Plus Sutures for preventing surgical site infection: a systematic review of clinical outcomes with economic and environmental models

BACKGROUND

Surgical site infections (SSIs) represent ~ 20% of all hospital-acquired infections in surgical patients and are associated with prolonged hospital stay, admission to intensive care, and mortality. We conducted a systematic review with economic and environmental models to assess whether triclosan-coated sutures (Plus Sutures) provide benefits over non-coated sutures in the reduction of SSI risk.

METHODS

Searches were conducted in fifteen databases. A total of 1,991 records were retrieved. Following deduplication and screening by two independent reviewers, 31 randomized controlled trials in adults and children were included in the review. Similarity of the studies was assessed by narrative review and confirmed by quantitative assessment. A fixed effects meta-analysis of SSI incidence model including all groups of patients estimated a risk ratio of 0.71 (95% confidence interval: 0.64 to 0.79) indicating those in the Plus Sutures group had a 29% reduction in the risk of developing an SSI compared with those in the control group (p < 0.001). Safety outcomes were analysed qualitatively.

RESULTS

The economic model estimated the use of Plus Sutures to result in average cost savings of £13.63 per patient. Plus Sutures remained cost-saving in all subgroup analyses with cost-savings ranging between £11 (clean wounds) and £140 (non-clean wounds). The environmental impact of SSI is substantial, and the model suggests that the introduction of Plus Sutures could result in potential environmental benefits.

CONCLUSIONS

The evidence suggests that Plus Sutures are associated with a reduced incidence of SSI across all surgery types alongside cost savings when compared with standard sutures.

Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update

The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Can Triclosan-Coated Sutures Reduce the Incidence of Surgical Site Infections and Intra-Abdominal Infection: A Double-Blinded Randomized Controlled Trial

Abstract Background: Surgical site infections (SSIs) are the most common nosocomial infections suffered by surgical patients. They increase medical costs and prolong hospital stay. With respect to gastrointestinal surgery, SSIs are reported to have an incidence of up to 30%, and they frequently cause morbidity. The aim of this study was to prospectively investigate whether use of triclosan-coated sutures for abdominal incision closure during colorectal surgery reduces the incidence of SSI. Patients and Methods: This was a double-blinded randomized controlled trial in a single academic surgical hospital. Patients who underwent laparoscopic or open colorectal surgery were included. Patients were pre-operatively randomly assigned to either the Vicryl^® Plus (VP) or Vicryl^® (Ethicon Inc., Somerville, NJ) group. The patients and medical staff were blinded. Results: The primary end point was overall SSI rate and SSI at 30 days. Over a six-year period, 811 patients who underwent colorectal surgery and provided informed consent were randomly assigned (VP group, 396 patients; Vicryl group, 415 patients). No differences in baseline demographics were observed between the groups. The overall incidence of SSI was 4.8% (39/811 patients). There were no statistically significant differences in mean length of post-operative hospital stay between the groups (VP group, 9.3 days; Vicryl group, 9.6 days; p = 0.587). Statistically significant differences in SSI rate after post-operative day 30 were observed between the groups (VP group, 1 patient [7.1%]; Vicryl group, 7 patients [28.0%]; p = 0.039). Conclusions: Although use of triclosan-coated sutures did not reduce incidence of SSI within 30 days post-operatively, it is associated with reduced SSI rate after post-operative day 30.

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.

Triclosan-coated barbed sutures in elective laparoscopic colorectal cancer surgery: a propensity score matched cohort study

BACKGROUND

Most of the studies published to date which assess the role of antibacterial sutures in surgical site infection (SSI) prevention include heterogeneous groups of patients, and it is therefore difficult to draw conclusions. The objective of the present study was to investigate whether the use of Triclosan-coated barbed sutures (TCBS) was associated with a lower incidence of incisional SSI and lower duration of hospital stay compared to standard sutures, in elective laparoscopic colorectal cancer surgery.

METHOD

Observational including patients who underwent elective colorectal cancer laparoscopic surgery between January 2015 and December 2020. The patients were divided into two groups according to the suture used for fascial closure of the extraction incision, TCBS vs conventional non-coated sutures (CNCS), and the rate of SSI was analysed. The TCBS cases were matched to CNCS cases by propensity score matching to obtain comparable groups of patients.

RESULTS

488 patients met the inclusion criteria. After adjusting the patients with the propensity score, two new groups of patients were generated: 143 TCBS cases versus 143 CNCS cases. Overall incisional SSI appeared in 16 (5.6%) of the patients with a significant difference between groups depending on the type of suture used, 9.8% in the group of CNCS and 1.4% in the group of TCBS (OR 0.239 (CI 95%: 0.065-0.880)). Hospital stay was significantly shorter in TCBS group than in CNCS, 5 vs 6 days (p < 0.001).

CONCLUSION

TCBS was associated with a lower incidence of incisional SSI compared to standard sutures in a cohort of patients undergoing elective laparoscopic colorectal cancer surgery.

Evaluation of Triclosan coated suture in obstetrical surgery: A prospective randomized controlled study (NCT05330650)

OBJECTIVES

To assess the effectiveness of Triclosan coated suture in reducing surgical site infections (SSIs) rate after caesarian delivery (CD).

STUDY DESIGN

Three hundred eighty patients were randomly assigned to closure with polyglactin non coated suture VICRYL, or with polyglactin coated suture VICRYL Plus after caesarian section. The primary outcome was the rate of SSIs within 30 days after surgery and secondary outcomes were the rate of wound healing complications.

RESULTS

SSI rate was 2.5% in Triclosan group compared to 8.1% with non-coated suture. Use of Triclosan coated suture (TCS) was associated with 69% reduction in SSI rate (p = 0.037; ORa:0.294; 95% CI:0.094-0.921). The use of Triclosan coated suture was associated with statistically lower risk of wound oedema (2.5% vs 10%), (p = 0.019; OR:0.595), dehiscence (3.8% vs 10.6%), (p = 0.023; OR:0.316) and hematoma (p = 0.035; OR:0.423).

CONCLUSION

Our results confirm the effectiveness of Triclosan coated suture in reducing SSI rate and wound healing disturbances.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov / ID (NCT05330650).

Effectiveness of Triclosan-Coated Sutures Compared with Uncoated Sutures in Preventing Surgical Site Infection after Abdominal Wall Closure in Open/Laparoscopic Colorectal Surgery

BACKGROUND

Previous randomized trials have assessed the effectiveness of triclosan-coated sutures in fascia closure after midline laparotomy in preventing surgical site infections (SSIs); however, available evidence remain inconclusive. We aimed to evaluate the effectiveness of triclosan-coated sutures in abdominal fascia closure to prevent postoperative SSIs.

STUDY DESIGN

This study was a multicenter prospective trial conducted within 24 Japanese secondary and tertiary care centers and a propensity score (PS)-matched analysis. Patients 20 years of age or older who underwent elective surgery for colorectal cancer (CRC) were included. Between July 2016 and July 2019, 2,207 patients were prospectively enrolled into the triclosan-coated sutures or uncoated sutures groups. The per-protocol population comprised 2,195 patients. The PS matching was performed for 1,579 patients: 926 patients in the coated group and 653 patients in the uncoated group. The abdominal fascia after midline laparotomy was closed with triclosan-coated or uncoated sutures depending on group. The primary endpoint was the incidence of an SSI. Secondary endpoints were length of hospital stay and surgical complication rates.

RESULTS

The recorded SSI rates were 4.2% in the triclosan-coated group and 6.74% in the uncoated suture group (p = 0.028). There were no serious adverse events in the groups. The final logistic regression model showed that several variables affected the occurrence of SSI. Our meta-analysis included six phase-III trials, and our study evaluated 4,797 patients. The results show a significant superiority of triclosan-coated sutures over uncoated suture material.

CONCLUSION

Triclosan-coated sutures reduce the incidence of SSI after elective CRC surgery.

Do Triclosan Sutures Modify the Microbial Diversity of Surgical Site Infections? A Systematic Review and Meta-Analysis

Randomised controlled clinical trials (RCTs) report a lower incidence rate of surgical site infections (SSIs) with triclosan sutures (TSs) compared with non-triclosan sutures (NTSs). Do triclosan sutures modify the microbial diversity of culture-confirmed SSIs (ccSSIs)? If so, this would support the association between TS antimicrobial activity and the SSI incidence rate. This prospective systematic literature review (PROSPERO CRD42019125099) was conducted according to PRISMA. RCTs that compared the incidence of SSIs with TSs and NTSs and reported microbial counts from SSI cultures per suture group were eligible. The microbial species were grouped by genus, and the association between genera and sutures was tested. The pooled relative risk (RR) of ccSSIs was also calculated. Twelve RCTs were eligible. No publication bias was identified. The microorganism count was 180 in 124 SSIs with TSs versus 246 in 199 SSIs with NTSs. No significant difference in microbial diversity was found, but statistical power was low for test results to support or challenge the association between the antimicrobial activity of TSs and the reduced rate of SSIs. The RR of the ccSSIs was significant and consistent with comprehensive meta-analyses. The certainty of the pooled RR was moderate.

Association of serum and fat tissue antibiotic concentrations with surgical site infections in lower gastrointestinal surgery

BACKGROUND

During surgery, the effectiveness of perioperative prophylactic antibiotic administration against surgical site infections is inferred from serum concentrations and not from tissues where local infections occur. This study aimed to measure the serum and tissue concentrations of cefmetazole in colorectal surgery cases to clarify whether there is an association between the incidence of surgical site infections and antibiotic concentrations.

METHODS

This prospective cohort study was performed at a single tertiary care center. The data of 105 patients who underwent colorectal surgery between October 2017 and September 2019 were evaluated. The primary outcome was the incidence of surgical site infections. Univariate analysis was performed to investigate the association between surgical site infections, perioperative factors, and the serum and tissue concentrations of cefmetazole.

RESULTS

The incidence of surgical site infections was 13/105 (12.4%). Cefmetazole concentrations were measured at initial incision (serum; 101 vs 93.1 mg/L, P = .75, subcutaneous fat tissue; 2.8 vs 3.7 mg/g, P = .15), intestinal resection (serum; 35.1 vs 36.7 mg/L, P = .63, mesenteric adipose tissue; 1.3 vs 1.7 mg/g, P = .55), and at skin closure (serum; 34.5 vs 44.8 mg/L, P = .18, subcutaneous fat tissue; 1.0 vs 2.2 mg/g, P = .09). In univariate analysis with P ≤ .10, cefmetazole concentration in subcutaneous fat tissue at skin closure was found to be a significant risk factor for surgical site infections. Age, additional intraoperative administration of cefmetazole, and creatinine clearance were also significant risk factors for the occurrence of surgical site infections.

CONCLUSION

Low subcutaneous fat cefmetazole concentrations at skin closure during gastrointestinal operations may also be involved in the occurrence of surgical site infections.

Effect of triclosan-coated sutures for abdominal wound closure on the incidence of abdominal wound dehiscence: a protocol for an individual participant data meta-analysis

INTRODUCTION

Acute abdominal wound dehiscence (AWD) or burst abdomen is a severe complication after abdominal surgery with an incidence up to 3.8%. Surgical site infection (SSI) is the biggest risk factor for the development of AWD. It is strongly suggested that the use of triclosan-coated sutures (TCS) for wound closure reduces the risk of SSI. We hypothesise that the use of TCS for abdominal wound closure may reduce the risk of AWD. Current randomised controlled trials (RCTs) lack power to investigate this. Therefore, the purpose of this individual participant data meta-analysis is to evaluate the effect of TCS for abdominal wound closure on the incidence of AWD.

METHODS AND ANALYSIS

We will conduct a systematic review of Medline, Embase and Cochrane Central Register of Controlled Trials for RCTs investigating the effect of TCS compared with non-coated sutures for abdominal wound closure in adult participants scheduled for open abdominal surgery. Two independent reviewers will assess eligible studies for inclusion and methodological quality. Authors of eligible studies will be invited to collaborate and share individual participant data. The primary outcome will be AWD within 30 days after surgery requiring reoperation. Secondary outcomes include SSI, all-cause reoperations, length of hospital stay and all-cause mortality within 30 days after surgery. Data will be analysed with a one-step approach, followed by a two-step approach. In the one-step approach, treatment effects will be estimated as a risk ratio with corresponding 95% CI in a generalised linear mixed model framework with a log link and binomial distribution assumption. The quality of evidence will be judged using the Grading of Recommendations Assessment Development and Evaluation approach.

ETHICS AND DISSEMINATION

The medical ethics committee of the Amsterdam UMC, location AMC in the Netherlands waived the necessity for a formal approval of this study, as this research does not fall under the Medical Research involving Human Subjects Act. Collaborating investigators will deidentify data before sharing. The results will be submitted to a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019121173.

Comparison of Antimicrobial Activity Between Bacitracin-Soaked Sutures and Triclosan Coated Suture

BACKGROUND

With the easily available option for surgeons to soak their suture in antibiotic irrigation solution intraoperatively in mind, this study was designed to evaluate the ability of suture soaked in bacitracin irrigation solution to inhibit the growth of Staphylococcus aureus and Methicillin-resistant Staphylococcus aureus.

MATERIALS AND METHODS

Using standard experimental procedure, sterile suture was soaked in Bacitracin, and dried for 10 min or 6 h, incubated for 24 h on inoculated plates, and examined for zone of inhibition around the suture. This was compared to control unsoaked suture and antimicrobial suture (AMS) currently on the market to determine if the minor intraoperative procedural change of placing suture in antibiotic irrigation solution instead of on the sterile table could confer comparable antimicrobial activity.

RESULTS

The study found the Bacitracin-soaked suture (BSS) consistently inhibited the growth of the test organisms. For both organisms, the BSS exhibited a significantly larger zone of inhibition compared to the unsoaked control suture (P < 0.0001). However, both the AMS currently on the market, and a bacitracin aliquot, exhibited significantly larger zones of inhibition compared to both drying times of the BSS (P < 0.0001).

CONCLUSIONS

Placing sutures in a bacitracin irrigation solution intraoperatively instead of directly on the sterile table can achieve some of the in vitro antimicrobial effect seen from AMS currently on the market. This may result in reduced rates of surgical site infections and associated costs without major procedural change and at reduced overhead.

Synergistic Effects of Silver Carboxylate and Chlorhexidine Gluconate for Wound Care and Prevention of Surgical Site Inflections by Cutibacterium acnes and Methicillin-Resistant Staphylococcus aureus

Background: This study presents the effectiveness of a combined silver carboxylate (AgCar) and chlorohexidine gluconate (AgCar:CHG) chemistry assessed against two commonly encountered nosocomial pathogens, Methicillin-resistant Staphylococcus aureus (MRSA) and Cutibacterium acnes, within the context of surgical antisepsis and wound care. Methods: Through an Institutional Review Board- and Institutional Animal Care and Use Committee (IACUC)-approved protocol, AgCar:CHG was applied to live Yucatan porcine skin and visualized by fast red and green staining to assess level of skin penetration. Dose response curves for Cutibacterium acnes and MRSA were generated to determine the optimal therapeutic ratio of AgCar to CHG. Coatings were applied to two different clinically available sutures and antimicrobial efficacy was evaluated at 24-hour intervals using Kirby-Bauer (KB) assays. Graphite furnace atomic absorption spectroscopy was used to measure AgCar elution from sutures over time. Results: Synergistic application of AgCar:CHG demonstrated deep pilosebaceous gland penetration on Yucatan pig skin. The therapeutic concentration range of AgCar was determined to be between 120 × -150 × and 30 × -60 × dopage for MRSA and Cutibacterium acnes, respectively. A 1:1 therapeutic ratio of AgCar to CHG was found to have 100% bactericidal activity against both pathogens. Sutures coated with AgCar:CHG showed sustained antimicrobial activity against MRSA and Cutibacterium acnes, and were significantly more efficacious than antimicrobial sutures over the three- to four-day period (p < 0.01). Conclusions: This AgCar:CHG chemistry demonstrates deep skin penetration, extended elution, and broad-spectrum antimicrobial activity compared with commercially available options. This chemistry shows promise as an additional tool for the prophylaxis of surgical site infections.

Incidence of surgical site infections with triclosan-coated monofilament versus multifilament sutures in elective colorectal surgery

PURPOSE

Surgical site infections (SSIs) are the most frequent complication of abdominal surgery. Using triclosan-coated sutures for abdominal wall closure reportedly reduces the incidence of SSIs. However, the SSI incidence has not been compared between the use of triclosan-coated multifilament and triclosan-coated monofilament sutures. We, therefore, compared the incidence of incisional SSIs between the use of triclosan-coated polyglactin 910 sutures (Vicryl Plus) and triclosan-coated polydioxanone sutures (PDS Plus).

METHODS

This observational cohort study was conducted on 318 consecutive patients who underwent elective colorectal cancer surgery at the Shiga University of Medical Science Hospital from January 2015 to December 2018. Based on the suture type for abdominal wall closure, 151 patients were enrolled in the PDS Plus group, and 167 were enrolled in the Vicryl Plus group.

RESULTS

The two suture groups were not significantly different in terms of risk factors for SSIs. Other postoperative complications also did not differ markedly between the two groups. In the multivariate logistic regression analysis, the presence of stoma was the only independent risk factor for incisional SSIs.

CONCLUSION

The incidence of incisional SSIs was unaffected by the type of triclosan-coated sutures. The presence of stoma was an independent risk factor for incisional SSIs.

Evaluation of the effect of triclosan coated sutures in the prevention of surgical site infections in a Spanish hospital setting: A prospective, observational study

Background

Surgical site infections (SSIs) are one of the most frequently reported types of hospital-acquired infection and are associated with substantial clinical and economic burden.

Aim

To assess the incidence of SSIs and analyze contributing risk factors in a real-world Spanish hospital setting before and after the implementation of triclosan-coated sutures (TCS).

Methods

A prospective, observational study was conducted at Hospital Clínico Universitario de Santiago de Compostela, Spain. Enrolled patients underwent surgery in the following specialties: general surgery, urology, neurosurgery, gynaecology, and traumatology. The primary outcome of the study was SSI incidence, assessed at a 30-day follow-up. Secondary outcomes were length of hospital stay, and readmission, reintervention, and mortality rates, also at 30 days.

Findings

5,081 patients were included in the study, of which 2,591 were treated using non-coated sutures (NCS) and 2,490 using TCS. After adjusting for potential confounders, TCS significantly reduced SSI rate by 36%, compared with NCS (odds ratio [OR]: 0.64; 95% confidence interval [CI]: 0.48-0.85; P<0.003). When stratified by wound classification, a statistically significant reduction in SSI incidence, in favour of TCS use, was observed for Class IV (dirty) wounds (35.6% versus 22.7% for NCS and TCS, respectively; OR: 0.53; 95% CI: 0.31-0.90).

Conclusion

The use of TCS reduced SSI risk when compared with NCS. This reduction was significant for Class IV wounds, providing evidence that supports the use of TCS for this type of wound.

Biomedical Applications of Quaternized Chitosan

The natural polymer chitosan is the second most abundant biopolymer on earth after chitin and has been extensively explored for preparation of versatile drug delivery systems. The presence of two distinct reactive functional groups (an amino group at C2, and a primary and secondary hydroxyl group at C3 and C6) of chitosan are involved in the transformation of expedient derivatives such as acylated, alkylated, carboxylated, quaternized and esterified chitosan. Amongst these, quaternized chitosan is preferred in pharmaceutical industries owing to its prominent features including superior water solubility, augmented antimicrobial actions, modified wound healing, pH-sensitive targeting, biocompatibility, and biodegradability. It has been explored in a large realm of pharmaceuticals, cosmeceuticals, and the biomedical arena. Immense classy drug delivery systems containing quaternized chitosan have been intended for tissue engineering, wound healing, gene, and vaccine delivery. This review article outlines synthetic techniques, basic characteristics, inherent properties, biomedical applications, and ubiquitous challenges associated to quaternized chitosan.

Superiority trial comparing intraoperative wound irrigation with aqueous 10% povidone-iodine to saline for the purpose of reducing surgical site infection after elective gastrointestinal surgery: study protocol for a randomised controlled trial

INTRODUCTION

Surgical site infection (SSI) is one of the most common complications after gastrointestinal surgery, with a reported incidence of approximately 10%-25%, which is higher than the rates after other types of surgery. Intraoperative wound irrigation (IOWI) is a simple intervention for SSI prevention, and recent studies have reported that IOWI with aqueous povidone-iodine (PVP-I) is significantly more effective at reducing the incidence of SSI than saline. However, the evidence level of previous trials evaluating the efficacy of aqueous PVP-I solution for preventing SSI has been low.

METHODS AND ANALYSES

We propose a single-institute, prospective, randomised, blinded-endpoint trial to assess the superiority of IOWI with aqueous 10% PVP-I solution compared with normal saline for reducing SSI in clean-contaminated wounds after elective gastrointestinal surgery. In the study group, IOWI with 40 mL of aqueous 10% PVP-I solution is performed for 1 min before skin suture, and in the control group, IOWI with 100 mL of saline is performed for 1 min before skin suture. We hypothesise that IOWI with aqueous 10% PVP-I solution will achieve a 50% reduction in the incidence of SSIs. The target number of cases is set at 950. The primary outcome is the incidence of incisional SSI up to postoperative day 30 and will be analysed in the modified intention-to-treat set.

ETHICS AND DISSEMINATION

This trial was designed and is being conducted by Saitama Medical Center, Jichi Medical University, with approval from the Bioethics Committee for Clinical Research, Saitama Medical Center, Jichi Medical University. Participant recruitment began in June 2019. The final results will be reported in international peer-reviewed journals immediately after trial completion.

TRIAL REGISTRATION NUMBER

UMIN000036889.

β-Cyclodextrin/Triclosan Complex-Grafted Methacrylated Glycol Chitosan Hydorgel by Photocrosslinking via Visible Light Irradiation for a Tissue Bio-Adhesive

Accelerating wound healing with minimized bacterial infection has become a topic of interest in the development of the new generation of tissue bio-adhesives. In this study, we fabricated a hydrogel system (MGC-g-CD-ic-TCS) consisting of triclosan (TCS)-complexed beta-cyclodextrin (β-CD)-conjugated methacrylated glycol chitosan (MGC) as an antibacterial tissue adhesive. Proton nuclear magnetic resonance (1H NMR) and differential scanning calorimetry (DSC) results showed the inclusion complex formation between MGC-g-CD and TCS. The increase of storage modulus (G') of MGC-g-CD-ic-TCS after visible light irradiation for 200 s indicated its hydrogelation. The swollen hydrogel in aqueous solution resulted in two release behaviors of an initial burst and sustained release. Importantly, in vitro and in vivo results indicated that MGC-g-CD-ic-TCS inhibited bacterial infection and improved wound healing, suggesting its high potential application as an antibacterial tissue bio-adhesive.

The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018

BACKGROUND

The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide.

METHODS

We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies.

RESULTS

There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese.

CONCLUSIONS

The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients.

Assessment of the Risk and Economic Burden of Surgical Site Infection Following Colorectal Surgery Using a US Longitudinal Database: Is There a Role for Innovative Antimicrobial Wound Closure Technology to Reduce the Risk of Infection?

BACKGROUND

Colorectal surgical procedures place substantial burden on health care systems because of the high complication risk, of surgical site infections in particular. The risk of surgical site infection after colorectal surgery is one of the highest of any surgical specialty.

OBJECTIVE

The purpose of this study was to determine the incidence, cost of infections after colorectal surgery, and potential economic benefit of using antimicrobial wound closure to improve patient outcomes.

DESIGN

Retrospective observational cohort analysis and probabilistic cost analysis were performed.

SETTINGS

The analysis utilized a database for colorectal patients in the United States between 2014 and 2018.

PATIENTS

A total of 107,665 patients who underwent colorectal surgery were included in the analysis.

MAIN OUTCOME MEASURES

Rate of infection was together with identified between 3 and 180 days postoperatively, infection risk factors, infection costs over 24 months postoperatively by payer type (commercial payers and Medicare), and potential costs avoided per patient by using an evidence-based innovative wound closure technology.

RESULTS

Surgical site infections were diagnosed postoperatively in 23.9% of patients (4.0% superficial incisional and 19.9% deep incisional/organ space). Risk factors significantly increased risk of deep incisional/organ-space infection and included several patient comorbidities, age, payer type, and admission type. After 12 months, adjusted increased costs associated with infections ranged from $36,429 to $144,809 for commercial payers and $17,551 to $102,280 for Medicare, depending on surgical site infection type. Adjusted incremental costs continued to increase over a 24-month study period for both payers. Use of antimicrobial wound closure for colorectal surgery is projected to significantly reduce median payer costs by $809 to $1170 per patient compared with traditional wound closure.

LIMITATIONS

The inherent biases associated with retrospective databases limited this study.

CONCLUSIONS

Surgical site infection cost burden was found to be higher than previously reported, with payer costs escalating over a 24-month postoperative period. Cost analysis results for adopting antimicrobial wound closure aligns with previous evidence-based studies, suggesting a fiscal benefit for its use as a component of a comprehensive evidence-based surgical care bundle for reducing the risk of infection. See Video Abstract at http://links.lww.com/DCR/B358. EVALUACIÓN DEL RIESGO Y LA CARGA ECONÓMICA DE LA INFECCIÓN DEL SITIO QUIRÚRGICO DESPUÉS DE UNA CIRUGÍA COLORRECTAL UTILIZANDO UNA BASE DE DATOS LONGITUDINAL DE EE.UU.: ¿EXISTE UN PAPEL PARA LA TECNOLOGÍA INNOVADORA DE CIERRE DE HERIDAS ANTIMICROBIANAS PARA REDUCIR EL RIESGO DE INFECCIÓN?: Los procedimientos quirúrgicos colorrectales suponen una carga considerable para los sistemas de salud debido al alto riesgo de complicaciones, particularmente las infecciones del sitio quirúrgico. El riesgo de infección posoperatoria del sitio quirúrgico colorrectal es uno de los más altos de cualquier especialidad quirúrgica.El propósito de este estudio fue determinar la incidencia, el costo de las infecciones después de la cirugía colorrectal y el beneficio económico potencial del uso del cierre de la herida con antimicrobianos para mejorar los resultados de los pacientes.Análisis retrospectivo de cohorte observacional y análisis de costo probabilístico.El análisis utilizó la base de datos para pacientes colorrectales en los Estados Unidos entre 2014 y 2018.Un total de 107,665 pacientes sometidos a cirugía colorrectal.Se identificó una tasa de infección entre 3 y 180 días después de la operación, los factores de riesgo de infección, los costos de infección durante 24 meses posteriores a la operación por tipo de pagador (pagadores comerciales y Medicare), y los costos potenciales evitados por paciente utilizando una tecnología innovadora de cierre de heridas basada en evidencias.Infecciones del sitio quirúrgico, diagnosticadas postoperatoriamente en el 23,9% de los pacientes (4,0% incisional superficial y 19,9% incisional profunda / espacio orgánico). Los factores de riesgo aumentaron significativamente el riesgo de infección profunda por incisión / espacio orgánico e incluyeron comorbilidades selectivas del paciente, edad, tipo de pagador y tipo de admisión. Después de 12 meses, el aumento de los costos asociados con las infecciones varió de $ 36,429 a $ 144,809 para los pagadores comerciales y de $ 17,551 a $ 102,280 para Medicare, según el tipo de infección del sitio quirúrgico. Los costos incrementales ajustados continuaron aumentando durante un período de estudio de 24 meses para ambos pagadores. Se prevé que el uso del cierre antimicrobiano de la herida para la cirugía colorrectal reducirá significativamente los costos medios del pagador en $ 809- $ 1,170 por paciente en comparación con el cierre tradicional de la herida.Los sesgos inherentes asociados a las bases de datos retrospectivas limitaron este estudio.Se encontró que la carga del costo de la infección del sitio quirúrgico es mayor que la reportada previamente, y los costos del pagador aumentaron durante un período postoperatorio de 24 meses. Los resultados del análisis de costos para la adopción del cierre de heridas antimicrobianas se alinean con estudios previos basados en evidencia, lo que sugiere un beneficio fiscal para su uso como componente de un paquete integral de atención quirúrgica basada en evidencia para reducir el riesgo de infección. Consulte Video Resumen en http://links.lww.com/DCR/B358.

The economic benefits of surgical site infection prevention in adults: a systematic review

BACKGROUND

Surgical site infections (SSIs) present a significant burden to healthcare and patients in terms of excess length of stay, distress, disability and death. SSI risk and the associated economic burden may be reduced through adherence to prevention guidelines although the irreducible minimum is unclear.

AIM

To evaluate the methods used to estimate the cost-effectiveness of prevention strategies for all SSIs.

METHODS

PubMed, Medline, CINAHL, and UK National Health Service Economic Evaluation Database were searched from inception to January 2020 to identify English language economic evaluation studies, embedded economic evaluations, and studies with some analysis in relation to cost and benefit in adult patients receiving surgical care in any setting. Risk of bias was assessed using two published checklists.

FINDINGS

Thirty-two studies involving 24,043 participants were included. Most studies evaluated SSI prevention in orthopaedic surgeries. Antibiotic prophylaxis, screening, treating, or decolonization of meticillin-resistant Staphylococcus aureus and surgical wound closure were the main methods evaluated. Methods ranged from cost-analyses to cost-effectiveness and cost-utility analyses. Synthesis of results was not possible due to heterogeneity. All studies reported some economic benefit associated with preventing SSI; however, measures of benefit were not reported consistently and the quality of studies was low to moderate. Limited evidence in relation to SSI impact on quality of life was identified.

CONCLUSION

Current evidence in relation to the economic benefits of SSI prevention is limited. Further robust studies that utilize sound economic and epidemiological methods are required to inform future investment decisions in SSI prevention.

Neurosurgical Post-Operative Wound Infections: A retrospective study on surgical site infections for quality improvement

Despite efforts to maintain a meticulous aseptic environment, wound infection is one of the most common complications following surgery and may be related to dehiscence, haemorrhage, infection, and/or poor surgical technique. With the appearance of new wound closure techniques and suture materials, we felt compelled to perform a retrospective study on our institution's neurosurgical population to determine how our institution compared to others in terms of incidence of surgical site infection (SSI). A retrospective analysis was performed at our single institution for all patients that had cranial or spine surgery by a neurosurgeon for the past 15 years. The data were extracted via Crimson Continuum of Care software program and analysed using χ² and relative risk. The data retrieval software program collected a total of 1184 cranial and spinal surgeries. Of these 1184 cases, 12 resulted in post-operative wound infections. Using these collected values, we compared the results with published values in the literature. Prior studies have shown that up to 33% of surgical cases have post-operative infections. Using this reported value in comparison with our data, χ² testing equals 547.893 with 1 df, P = .0001 (confidence interval = 0.05), which demonstrated statistical significance when compared with surgical literature. The results from this retrospective analysis demonstrated that the rate of neurosurgical post-operative SSI falls within the range consistent with the literature, which has shown rates of infection from <1% up to 15% depending on the type of surgery, surgical technique, and patient characteristics. SSIs can be an unfortunate and costly post-operative complication. Risks factors in the past have been studied, but introspection by each institution is an important metric to ensure accountability and provide optimal patient care in comparison with established data and guidelines. No deviation from current techniques is deemed necessary at our institution based on the results.

Introduction of a care bundle effectively and sustainably reduces patient-reported surgical site infection in patients undergoing colorectal surgery

BACKGROUND

Surgical site infection (SSI) is one of the most common healthcare-associated infections and is particularly prevalent following colorectal surgery. It is associated with an increase in patient morbidity and healthcare costs. SSI is difficult to monitor as it frequently presents after discharge from hospital, especially if enhanced recovery programmes are in place.

AIM

To develop an effective method for measuring patient-reported 30-day SSI in patients undergoing colorectal resection. To implement a new care bundle capable of delivering a sustainable reduction in SSI.

METHODS

The Public Health England SSI surveillance questionnaire was used. Several data collection methods were tested including postal and telephone-based systems. A new SSI bundle was introduced in our centre incorporating four evidence-based interventions: 2% chlorhexidine skin preparation; repeat-dose antibiotics after 4 h; dual-ring wound protectors; and triclosan-coated sutures for wound closure. System changes were introduced to ensure that the change was sustainable.

FINDINGS

The most reliable method of measuring patient-reported SSI was found to be postal questionnaire with telephone calls made to non-responders. Response rates to the SSI surveillance questionnaire were consistently >75%. Introduction of the new care bundle produced a significant reduction in SSI from 20% to 10% (P ≤ 0.0001) which has been sustained for six years.

CONCLUSION

This is a reliable method for measuring 30-day patient-reported SSI rates. The introduction of this new care bundle has halved the rate of SSI from 20% to 10%.

Risk Factors for Wound Infection After Laparoscopic Surgery for Colon Cancer

Objective:

To clarify risk factors for wound infection after laparoscopic surgery for colon cancer.

Subjects and Methods:

The study group comprised 1144 patients. Univariate and multivariate analyses were performed to assess the following 14 postoperative risk factors for wound infection.

Results:

Univariate analysis showed that the following 4 risk factors were related to wound infection: tumor location right-sided colon cancer, a preoperative serum albumin level of ≤2.5 g/dL, anastomotic technique [functional end-to-end anastomosis (FEEA)], and sutures used at the time of wound closure non–polydioxanone sutures (PDS)-Plus. Multivariate analysis indicated that 3 factors were independent risk factors for wound infection: a preoperative serum albumin level of ≤2.5 g/dL, FEEA, and the use of non-PDS-Plus sutures wound closure.

Conclusions:

Risk factors for wound infection after laparoscopic surgery for colon cancer were a preoperative serum albumin level of ≤2.5 g/dL, FEEA, and the use of non-PDS-Plus sutures.

Surgical site infection prevention measures in General Surgery: Position statement by the Surgical Infections Division of the Spanish Association of Surgery

Surgical site infection is associated with prolonged hospital stay and increased morbidity, mortality and healthcare costs, as well as a poorer patient quality of life. Many hospitals have adopted scientifically-validated guidelines for the prevention of surgical site infection. Most of these protocols have resulted in improved postoperative results. The Surgical Infection Division of the Spanish Association of Surgery conducted a critical review of the scientific evidence and the most recent international guidelines in order to select measures with the highest degree of evidence to be applied in Spanish surgical services. The best measures are: no removal or clipping of hair from the surgical field, skin decontamination with alcohol solutions, adequate systemic antibiotic prophylaxis (administration within 30-60minutes before the incision in a single preoperative dose; intraoperative re-dosing when indicated), maintenance of normothermia and perioperative maintenance of glucose levels.

Triclosan: antimicrobial mechanisms, antibiotics interactions, clinical applications, and human health

The large-scale applications of Triclosan in industrial and household products have created many health and environmental concerns. Despite the fears of its drug-resistance and other issues, Triclosan is still an effective drug against many infectious organisms. Knowing the cross-interactions of Triclosan with different antibiotics, bacteria, and humans can provide much-needed information for the risk assessment of this drug. We review the current understanding of the antimicrobial mechanisms of Triclosan, how microbes become resistant to Triclosan, and the synergistic and antagonistic effects of Triclosan with different antibiotics. Current literature on the clinical applications of Triclosan and its effect on fetus/child development are also summarized.

Biocompatible Polymers and their Potential Biomedical Applications: A Review

Background:

Biocompatible polymers are gaining great interest in the field of biomedical applications. The term biocompatibility refers to the suitability of a polymer to body and body fluids exposure. Biocompatible polymers are both synthetic (man-made) and natural and aid in the close vicinity of a living system or work in intimacy with living cells. These are used to gauge, treat, boost, or substitute any tissue, organ or function of the body. A biocompatible polymer improves body functions without altering its normal functioning and triggering allergies or other side effects. It encompasses advances in tissue culture, tissue scaffolds, implantation, artificial grafts, wound fabrication, controlled drug delivery, bone filler material, etc.

Objectives:

This review provides an insight into the remarkable contribution made by some well-known biopolymers such as polylactic-co-glycolic acid, poly(ε-caprolactone) (PCL), polyLactic Acid, poly(3- hydroxybutyrate-co-3-hydroxyvalerate) (PHBV), Chitosan and Cellulose in the therapeutic measure for many biomedical applications.

Methods: :

Various techniques and methods have made biopolymers more significant in the biomedical fields such as augmentation (replaced petroleum based polymers), film processing, injection modeling, blow molding techniques, controlled / implantable drug delivery devices, biological grafting, nano technology, tissue engineering etc.

Results:

The fore mentioned techniques and other advanced techniques have resulted in improved biocompatibility, nontoxicity, renewability, mild processing conditions, health condition, reduced immunological reactions and minimized side effects that would occur if synthetic polymers are used in a host cell.

Conclusion:

Biopolymers have brought effective and attainable targets in pharmaceutics and therapeutics. There are huge numbers of biopolymers reported in the literature that has been used effectively and extensively.

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.

Randomised controlled trial of triclosan coated vs uncoated sutures in primary hip and knee arthroplasty

BACKGROUND

Triclosan-coated vicryl plus suture (Ethicon, Inc.) was developed to reduce microbial colonisation during surgical procedures. However, its effect on wound healing and surgical site infections remain unclear after hip and knee arthro-plasty surgery.

AIM

To determine the effect of triclosan-coated sutures (TCS) vs non-coated sutures on wound healing, following primary hip and knee arthroplasties.

METHODS

A single-centred, double-blind randomised controlled trial (RCT) was undertaken. We randomly allocated patients to receive either the triclosan-coated sutures (TCS vicryl plus) or non-coated sutures (NCS vicryl) during the closure of unilateral primary hip and knee arthroplasties. We utilised the ASEPSIS wound scoring system to evaluate wound healing for the first 6 weeks post-operatively.

RESULTS

One hundred and fifty patients undergoing primary total hip or knee arthroplasty over a one-year period were included. Eighty-one were randomised to the TCS group and 69 to the NCS group. Despite no statistically significant difference in the ASEPSIS scores among the study groups (P = 0.75), sensitivity analysis using the Mann Whitney test (P = 0.036) as well as assessment of the wound complications at 6 weeks follow up, demonstrated significantly higher wound complication rates in the TCS group (8 vs 1, P = 0.03).

CONCLUSION

No clear advantage was demonstrated for using the TCS. However, larger multi-centred RCTs are required to validate their use in hip and knee arthroplasty surgery.

Effect of Triclosan-Coated Suture on Surgical Site Infection of Abdominal Fascial Closures

Background: Surgical site infections (SSIs) are a serious problem after abdominal surgery. This study aimed to compare closure of fascia with triclosan-coated monofilament polydioxanone (PDS) or standard PDS in decreasing the incidence of SSIs in patients who underwent abdominal surgery. Methods: In this randomized study, a total of 890 consecutive patients undergoing laparotomy for any gastrointestinal pathology were allocated to closure of the fascia with triclosan-coated PDS (treatment group; TG) or standard PDS (control group; CG). Patients were assessed every day during the hospital stay for SSIs and at the first, second, and fourth week after discharge. The surgical site was assessed in terms of superficial, deep incisional, or organ/site SSI. Results: The main important finding was that SSIs were reduced as much as 24% by using triclosan-coated PDS. Surgical site infections occurred in 200 patients (22.4%), with 105 being early (in the first week) and 95 occurring late. Eighty five of the SSIs (19.1%) were noted in patients in the TG, whereas 115 of them (25.8%) were in the CG (p = 0.016). The infections were superficial in 126 patients, deep incisional in 48 patients, and organ/site in 26 patients. Most of patients (n = 651) had clean-contaminated sites. In subgroup analysis, SSI rates with triclosan-coated PDS were lower in clean, clean-contaminated, and contaminated incisions (0 in the TG versus 24.2% in the CG; p = 0.009; 13.6% in the TG versus 24.3% in the CG, p = 0.001; and 16.6% in the TG versus 27.8% in the CG; p < 0.0001, respectively). Conclusions: Closure of the fascia with triclosan-coated PDS decreased SSI rates as much as 24%. Also, SSIs were decreased significantly at clean, clean-contaminated, and contaminated sites. Therefore, triclosan-coated PDS might be recommended for fascial closure as a means of decreasing SSIs.

Quaternized chitosan promotes the antiproliferative effect of vemurafenib in melanoma cells by increasing cell permeability

Background

As one of the most invasive cutaneous carcinomas among all types of skin cancer, malignant melanoma remains a severe challenge in oncology and plastic surgery. Selective small-molecule inhibitors of V600E-mutant B-Raf (vemurafenib, for instance) have demonstrated satisfactory therapeutic efficacy in melanoma patients. However, acquired resistance during the period of drug administration has limited their clinical application.

Materials and methods

In the present study, human melanoma cells with the B-Raf^V600E mutation were treated with the indicated concentrations of vemurafenib, quaternized chitosan, or a combination of vemurafenib and quaternized chitosan. Cell proliferation and viability were evaluated using cell counting kit-8 assay and DAPI staining, and the IC₅₀ values for vemurafenib in melanoma cells were also determined. Cell apoptosis was evaluated by Live/Dead cell staining using confocal laser scanning microscopy and Annexin V-FITC Apoptosis detection using flow cytometry, respectively. The leakage of ATP and K⁺ into the cell supernatants was measured to evaluate cell permeability. Furthermore, the surface charge variation of melanoma cells after drug treatment was determined by measuring the zeta potential of the cell membrane to clarify the electrostatic interaction between quaternized chitosan and the cells.

Results

Our results indicated that the addition of quaternized chitosan could promote the antiproliferative effect of vemurafenib in melanoma cells and could also promote the cell apoptosis of melanoma cells treated with vemurafenib. In addition, quaternized chitosan could increase cell permeability at early stages of co-culture, thus contributing to the improvement in intracellular drug uptake. Meanwhile, the majority of the negative surface charge of the cells was counteracted by the quaternized chitosan, indicating that the surface charge of melanoma cells was disturbed after the addition of quaternized chitosan.

Conclusion

This study indicated that disturbance of the surface charge of the cell membrane by quaternized chitosan is an important mechanism involved in changes in cell permeability, which promote the antiproliferative effect of vemurafenib in melanoma cells. Our preliminarily investigation provides new insights into the improvement of clinical melanoma therapy in the future.

Suture choice to reduce occurrence of surgical site infection, hernia, wound dehiscence and sinus/fistula: a network meta-analysis

BACKGROUND

There are many options and little guiding evidence when choosing suture types with which to close the abdominal wall fascia. This network meta-analysis investigated the effect of suture materials on surgical site infection, hernia, wound dehiscence and sinus/fistula occurrence after abdominal surgery. The aim was to provide clarity on whether previous recommendations on suture choice could be followed with confidence.

METHODS AND METHODS

In February 2017, the Cochrane Central Register of Controlled Trials, Medline, EMBASE and Science Citation Index Expanded were searched for randomised controlled trials investigating the effect of suture choice on these four complications in closing the abdomen. A reference search of identified trials was performed. Prisma guidelines and the Cochrane risk of bias tool were followed in the data extraction and synthesis. Two review authors screened titles and abstracts of trials identified. A random effect model was used for the surgical site infection network based on the deviance information criterion statistics.

RESULTS

Thirty-one trials were included (11,533 participants). No suture material reached the predetermined 90% probability threshold for determination of 'best treatment' for any outcome. Pairwise comparisons largely showed no differences between suture types for all outcomes measured. However, nylon demonstrated a reduction in the occurrence of incisional hernias with respect to two commonly used absorbable sutures: polyglycolic acid (odds ratio, OR 1.91; 95% confidence interval, CI, 1.01-3.63) and polyglyconate (OR 2.18; 95% CI 1.17-4.07).

CONCLUSIONS

No suture type can be considered the 'best treatment' for the prevention of surgical site infection, hernia, wound dehiscence and sinus/fistula occurrence.

The Efficacy of Antimicrobial-Coated Sutures for Preventing Incisional Surgical Site Infections in Digestive Surgery: a Systematic Review and Meta-analysis

BACKGROUND

Antimicrobial-coated sutures have recently become well known for preventing surgical site infections (SSIs). However, the evidence and recommendations from some organizations remain controversial. Therefore, we conducted a systematic review and meta-analysis to analyze the efficacy of antimicrobial-coated sutures for preventing SSIs in digestive surgery.

METHODS

We performed a systematic review of literature published from 2000 to 2017 (registered on PROSPERO, No. CRD42017076780). We included studies defined as randomized controlled trials (RCTs) and observational studies (OBSs) for the prevention of SSIs and the reduction in hospital stay length associated with digestive surgery.

RESULTS

In the 10 RCTs, the incidence rates of incisional SSIs were 160/1798 (8.9%) with coated sutures and 205/1690 (12.1%) with non-coated sutures. Overall, antimicrobial-coated sutures were superior for reducing the incidence of incisional SSI (risk ratio (RR) 0.67, 95% confidence intervals (CI) 0.48-0.94, p = 0.02) in RCTs for digestive surgery with the mixed wound class and surgeries limited to a clean-contaminated wound (RR 0.66, 95% CI 0.44-0.98, p = 0.04). A superior effect of antimicrobial-coated sutures was found in 9 RCTs that involved only colorectal surgeries (RR 0.69, 95% CI 0.49-0.98, p = 0.04). The mean hospital stay length was similar with coated or uncoated sutures in 5 RCTs involving colorectal surgery (mean difference (MD) - 5.00, 95% CI 16.68-6.69, p = 0.4).

CONCLUSION

Antimicrobial-coated sutures are significantly more efficacious for preventing SSIs during digestive and colorectal surgery, even when restricted to clean-contaminated wounds. However, the hospital stay length was not affected.

[Triclosan-coated sutures in colorectal surgery : Assessment and meta-analysis of the recommendations of the WHO guideline]

BACKGROUND

In the global guidelines for the prevention of surgical site infections (SSI), the World Health Organization (WHO) recommends the general use of triclosan-coated sutures irrespective of the type of surgical intervention.

OBJECTIVE

Can this recommendation on the use of triclosan-coated sutures be confirmed by a meta-analysis specifically for colorectal surgery?

METHODS

Randomized and non-randomized clinical trials comparing triclosan-coated and uncoated sutures for the efficacy in reducing the SSI rate in colorectal surgery were identified by a systematic literature review. In addition, various quality criteria were set for the studies to be included: SSI definition according to the Centers for Disease Control and Prevention (CDC), a priori sample size calculation and a maximum SSI rate of 20%. The odds ratios were pooled using a fixed and random effects model, the 95% confidence intervals (CI) were calculated and subgroup analyses were carried out.

RESULTS

Included in the meta-analysis were 3 prospective randomized trials (RCT) and 3 non-randomized trials involving a total of 2957 subjects. The average SSI rate was 6.90% (76/1101) in the triclosan group and 9.11% (169/1856) in the control group, resulting in an odds ratio of 0.62 (95% CI: 0.29-1.31). Subgroup analysis showed a decreased risk for SSI in monocentric trials (OR = 0.39, 95% CI: 0.25-0.60) but an increased SSI risk in multicenter trials (OR = 1.75, 95% CI: 1.11-2.77).

CONCLUSION

Against the background of a moderate to high risk of bias and the partially contradictory findings of the studies, the general recommendation of the WHO on the use of triclosan-coated sutures for colorectal surgery could not be confirmed.

Comparison of intraoperative handling and wound healing between (NEOSORB® plus) and coated polyglactin 910 suture (NEOSORB®): a prospective, single-blind, randomized controlled trial

Background

Coated polyglactin 910 suture with chlorhexidine (NEOSORB® Plus) has recently been developed to imbue the parent suture with antibacterial activity against organisms that commonly cause surgical site infections (SSI). This prospective, single-blinded, randomized trial, was performed to compare the intraoperative handling and wound healing characteristics of NEOSORB® Plus with those of the traditional polyglactin 910 suture (NEOSORB®) in urologic surgery patients.

Methods

Patients (aged 19 to 80 years, n = 100) were randomized in a 1:1 ratio for treatment with either NEOSORB® Plus or NEOSORB®, and stratified into an open surgery or a minimally invasive surgery group. The primary endpoint was the assessment of overall intraoperative handling of the sutures. Secondary endpoints included specific intraoperative handling measures and wound healing characteristics. Wound healing was assessed at one and 11 days after surgery. Cumulative skin infection, seroma, and suture sinus events within 30 days after surgery were also evaluated.

Results

A total of 96 patients were included, with 47 patients in the NEOSORB® Plus group and 49 patients in the NEOSORB® group. Scores for intraoperative handling were favorable and were not significantly different between the two suture groups. Wound healing characteristics were also comparable. The incidence of adverse events was 13.6%, although none were deemed attributable to the suture, and no difference was observed between the two groups.

Conclusions

NEOSORB® Plus is not inferior to traditional sutures in terms of intraoperative handling and wound healing, potentially making NEOSORB® Plus a beneficial alternative for patients at increased risk of SSI.

Trial registration

ClinicalTrials.gov: NCT02431039. Trial registration date 14 August 2015.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0377-4) contains supplementary material, which is available to authorized users.

Mechanical properties of Triclosan sutures

To avoid infections and wound healing disorders, Triclosan coated sutures have been invented. Little is known of these sutures regarding their tensile properties. Three different Triclosan coated sutures (Vicryl 1 plus, PDS 0 plus, Monocryl 3-0 plus) were tested at several time points over 42 days regarding load to failure, strain, and stiffness compared to their non-coated versions (Vicryl 1, PDS 0, Monocryl 3-0). Four different measurement points were made. Suture loops were fixed in a material testing machine over two metal bars which were moved apart creating a stress to the fiber. Unpaired, two-tailed t-test were performed for each group (untreated and treated) while level of significance was defined at a level of p < 0.05. Vicryl 1 was significantly stronger on day 14 than Vicryl 1 plus (p = 0.033). On day 28, significant changes were found in PDS 0 which was weaker compared to PDS 0 plus (p = 0.039) and Vicryl 1 which was stronger than Vicryl 1 plus (p = 0.032). We have seen that Vicryl 1 plus sutures are significantly weaker according to loading to failure after 14 and 28 days, which might cause incisional hernias. PDS 0 sutures are used to reconstruct tendons, therefore a longer durableness might be of interest as re-ruptures of tendons are problematic. Our in vitro findings support, the use of Triclosan coated PDS plus sutures and Vicryl sutures as they show a longer resistance. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1777-1782, 2018.

In Vivo and In Vitro Anti-Bacterial Efficacy of Absorbable Barbed Polydioxanone Monofilament Tissue Control Device with Triclosan. Surg Infect (Larchmt) 2018;19:430-437. [PMID: 29624479 DOI: 10.1089/sur.2017.275]

BACKGROUND

This study evaluated the in vitro and in vivo anti-bacterial efficacy of STRATAFIX™ Symmetric PDS™ Plus Knotless Tissue Control Devices in comparison with standard absorbable polydioxanone devices lacking triclosan, utilizing challenges by gram-positive and gram-negative bacteria.

METHODS

The STRATAFIX^™ Symmetric PDS^™ Plus Knotless Tissue Control Device was tested for in vitro efficacy against Staphylococcus aureus, methicillin-resistant S. aureus (MRSA), S. epidermidis, methicillin-resistant S. epidermidis (MRSE), Klebsiella pneumoniae, and Escherichia coli using a zone of inhibition (ZOI) assay. The ZOI was used to determine: immediate anti-bacterial efficacy at 24 hours, sustained efficacy for as long as 23 days, and stability for as long as 36 months. Bacterial colonization of the device in vitro was evaluated by scanning electron microscopy and enumerating viable adherent bacteria, expressed as colony-forming units (CFU) per centimeter on the device. In vivo evaluations were conducted in guinea pigs and mice where 3 to 4 cm of the test device and the control suture (commercial Quill™ PDO without triclosan) were implanted subcutaneously through separate catheters into opposite sides of the dorsolateral region. Each implantation site was challenged directly through the indwelling catheter with 10⁶ CFU of S. aureus (guinea pigs) or 10⁷ CFU of E. coli (mice). At 48 hours post-implantation, the test device and control suture were explanted for bacterial enumeration.

RESULTS

The STRATAFIX^™ Symmetric PDS^™ Plus Knotless Tissue Control Device demonstrated in vitro anti-bacterial activity against all test organisms. This activity was maintained for 11 and 23 days when tested against E. coli and S. aureus, respectively. The device was not colonized by test bacteria in vitro. The anti-bacterial activity remained stable for as long as 36 months of storage at 30°C and 75% relative humidity. In vivo evaluation in animal models demonstrated a 1.16-log reduction in S. aureus and a 1.83-log reduction in E. coli relative to the control device. (p < 0.05) Conclusion: The STRATAFIX^™ Symmetric PDS^™ Plus Knotless Tissue Control Device exhibited anti-bacterial efficacy in vitro against a wide range of clinically significant bacterial species with long-lasting inhibition of colonization by S. aureus, and E. coli. It inhibited colonization by S. aureus and E. coli in vitro and in vivo. Thus, the STRATAFIX^™ Symmetric PDS^™ Plus Knotless Tissue Control Device represents a powerful technology to help mitigate one of the risk factors for surgical site infections.

Effect of triclosan-coated sutures on the incidence of surgical site infection after abdominal wall closure in gastroenterological surgery: a double-blind, randomized controlled trial in a single center

BACKGROUND

Surgical site infection is one of the most common postoperative complications after gastroenterologic surgery. This study investigated the effect of triclosan-coated sutures in decreasing the incidence of surgical site infections after abdominal wall closure in gastroenterologic surgery.

METHODS

A prospective, double-blind, randomized, controlled parallel adaptive group-sequential superiority trial was conducted from March 2014 to March 2017 in a single center. Eligible patients were those who underwent gastroenterologic surgery. Patients were allocated randomly to receive either abdominal wall closure with triclosan-coated sutures (the study group) or sutures without triclosan (the control group). The primary end point was the incidence of superficial or deep surgical site infections within 30 days after operation. This study was registered with the University Hospital Medical Information Network-Clinical Trials Registry (http://www.umin.ac.jp/ctr/), identification number UMIN000013054.

RESULTS

A total of 1,013 patients (study group, 508 patients; control group, 505 patients) were analyzed by a modified intention-to-treat approach. The wounds in 990 (97.7%) of the 1,013 patients were classified as clean-contaminated. The primary end point (incidence of superficial or deep surgical site infections) was 35 (6.9%) of 508 patients in the study group and 30 (5.9%) of 505 in the control group. The incidence of surgical site infections did not differ markedly between the 2 groups (95% confidence interval: 0.686-2.010, P = .609). Of the 65 infections, 42 (64.6%) were superficial surgical site infections, with similar frequencies in the 2 groups, and 23 (35.4%) were deep surgical site infections, again with similar frequencies in the 2 groups.

CONCLUSION

Triclosan-coated sutures did not decrease the incidence of surgical site infections after abdominal wall closure in gastroenterologic surgery.

Triclosan-coated sutures and surgical site infection in abdominal surgery: the TRISTAN review, meta-analysis and trial sequential analysis

INTRODUCTION

Surgical site infection (SSI) is a frequent complication of abdominal surgery causing increased morbidity. Triclosan-coated sutures are recommended to reduce SSI. The aim of this systematic review and meta-analysis was to evaluate the evidence from randomized controlled trials (RCT) comparing the rate of SSI in abdominal surgery when using triclosan-coated or uncoated sutures for fascial closure.

METHODS

A systematic literature search was conducted using Medline, EMBASE, the Cochrane library, CINAHL, Scopus and Web of Science including publications until August 2017. The quality of the RCTs was evaluated using critical appraisal checklists from SIGN. Meta-analyses and trial sequential analysis were performed with Review Manager v5.3 and TSA software, respectively.

RESULTS

Eight RCTs on abdominal wall closure were included in the meta-analysis. In an overall comparison including both triclosan-coated Vicryl and PDS sutures for fascial closure, triclosan-coated sutures were superior in reducing the rate of SSI (OR 0.67; 0.46-0.98). When evaluating PDS sutures separately, there was no effect of triclosan-coating on the rate of SSI (OR 0.85; 0.61-1.17). Trial sequential analysis showed that the required information size (RIS) of 797 patients for triclosan-coated Vicryl sutures was almost reached with an accrued information size (AIS) of 795 patients. For triclosan-coated PDS sutures an AIS of 2707 patients was obtained, but the RIS was estimated to be 18,693 patients.

CONCLUSION

Triclosan-coated Vicryl sutures for abdominal fascial closure decrease the risk of SSI significantly and based on the trial sequential analysis further RCTs will not change that outcome. There was no effect on SSI rate with the use of triclosan-coated PDS sutures for abdominal fascial closure, and it is unknown whether additional RCTs will change that.

Plastic wound protectors decreased surgical site infections following laparoscopic-assisted colectomy for colorectal cancer: A retrospective cohort study

Laparoscopic surgery is widespread and safe for the management of patients with colorectal cancer (CRC). Although the use of standard surgical techniques can prevent perioperative wound infections, surgical site infections (SSIs) remain an unresolved complication in laparoscopic-assisted colectomy. The present study investigated the ability of plastic wound protectors applied to the extraction incision during the externalized portion of the procedure to reduce the rate of infection in laparoscopic-assisted colectomy. We completed a retrospective review of the medical records of patients who underwent nonemergent laparoscopic-assisted between January 2015 and June 2016. Outcomes for patients with and without the use of a wound protector were compared. A total of 109 patients were included in this study. There was 1 patient in the wound protector group (n = 57) and 7 in the nonwound protector group (n = 52) who developed a wound infection at the colon extraction site (P = .02). Furthermore, the average postoperative hospital stay in the wound protector group was shorter compared to the nonwound protector group (7.47 ± 0.24 vs 8.73 ± 0.54 days, P = .03). In conclusion, this study indicates that the use of a plastic wound protector during laparoscope-assisted colectomy does reduce postoperative wound infection rates, and the wound protectors are beneficial for specimen extraction and digestive tract reconstruction.

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.

The Effect of Antibiotic-Coated Sutures on the Incidence of Surgical Site Infections in Abdominal Closures: a Meta-Analysis

OBJECTIVE

This meta-analysis aims to determine if antibiotic-impregnated sutures for abdominal fascial closure prevent postoperative surgical site infections (SSIs), hernias, and/or dehiscence.

METHODS

MEDLINE and EMBASE databases (1946-2016) were searched. Randomized controlled trials comparing antibiotic-impregnated sutures to standard sutures for abdominal closure were eligible. Risk of bias was evaluated using the Cochrane Handbooks definitions.

RESULTS

Four-hundred fifty articles were reviewed; five eligible studies (N = 3117) were identified. All studies routinely used prophylactic antibiotics. Overall risk of SSI in the antibiotic-impregnated suture group was 10.4 vs. 13.0% in the control group. Pooled data showed no difference in SSI between suture types (odds ratio 0.79, 95% CI 0.57-1.09, P = 0.15, I ² = 44%). There was no evidence of subgroup effect by suture material (polydioxanone vs. polyglactin 910; P = 0.19) or by comparing colorectal surgery studies to others (P = 0.67). There was a high risk of bias in two studies, one for high loss to follow-up and one for not using an intent-to-treat analysis.

CONCLUSION

Our meta-analysis is the most comprehensive review on the utility of antibiotic-impregnated sutures in abdominal surgery to prevent SSI. We found no evidence to support routine use of these sutures.

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.