|Year : 2022 | Volume
| Issue : 1 | Page : 56-61
Effectiveness of antibacterial-coated suture material to prevent post-operative superficial surgical site infection among patients undergoing abdominal wall closure
JP Sabari, M R. Rakesh Praveen Raj
Department of General Surgery, Azeezia Institute of Medical Science, Kollam, Kerala, India
|Date of Submission||11-May-2022|
|Date of Decision||15-May-2022|
|Date of Acceptance||17-May-2022|
|Date of Web Publication||14-Jul-2022|
Dr. M R. Rakesh Praveen Raj
Department of General Surgery, Azeezia Institute of Medical Science, Kollam, Kerala
Source of Support: None, Conflict of Interest: None
Background: Despite the use of prophylactic antibiotics, surgical site infection (SSI) is still a real risk of surgery. This study focuses on the method of wound closure with regard to the suture material used since the suture material itself has long been known to be a significant cause or cofactor in SSIs. We compared the rates of superficial SSIs in patients in whom the subcutaneous layer of abdominal incisions was closed with antibacterial-coated polyglactin 910 suture materials with those in whom coated polyglactin 910 alone was used. Materials and Methods: Patients were divided into two groups as per the unit system. The patients selected for the study were those undergoing abdominal wall closures. All patients above 18 years of age, who undergoes abdominal surgery for various ailments at our hospital, were included in the study. All the patients were given antibiotics pre-operatively and post-operatively. The patients were followed up for up to the day of discharge, 1-week post-discharge and 30-day post-operative as routinely followed in our institute. Results: There was a statistically significant relationship between plain polyglactin 910 and triclosan-coated polyglactin 910 (P < 0.05). The infection rate associated with the use of plain polyglactin 910 was 22.6% and with triclosan-coated polyglactin 910 was 12.3 (P = 0.025). The most common organism causing skin and skin-structure infection were Klebsiella (26%) and Staphylococcus (26%). Conclusion: Our study confirms a significant benefit to the patient in reducing superficial SSI in abdominal wall closure with the use of triclosan-coated polyglactin 910 when compared to plain polyglactin 910 usage for the same.
Keywords: Abdominal surgery, polyglactin, skin and skin structure infection, triclosan
|How to cite this article:|
Sabari J P, Praveen Raj M R. Effectiveness of antibacterial-coated suture material to prevent post-operative superficial surgical site infection among patients undergoing abdominal wall closure. Kerala Surg J 2022;28:56-61
|How to cite this URL:|
Sabari J P, Praveen Raj M R. Effectiveness of antibacterial-coated suture material to prevent post-operative superficial surgical site infection among patients undergoing abdominal wall closure. Kerala Surg J [serial online] 2022 [cited 2023 Feb 5];28:56-61. Available from: http://www.keralasurgj.com/text.asp?2022/28/1/56/350895
| Introduction|| |
Surgical site infection (SSI) is still a frequent type of nosocomial infection, accounting for about 15% of the total number of nosocomial infections even in the modern era of immaculate sterilisation approaches and highly effective antibiotics. SSI is split into three groups: superficial SSIs, deep SSIs and organ space SSIs. As this study focuses on superficial SSIs, it has been elaborated further. Superficial SSI must meet the following two criteria, the first that occurs within 30 days of procedure and the second that involves only skin and subcutaneous tissue around the incision plus at least one of the following criteria, organisms isolated from an aseptically obtained culture of fluid/tissue from the incision, at least one of the following signs or symptoms of infection pain/tenderness at the incision site, localised swelling, erythema or increased temperature, diagnosis of superficial incisional, SSIs by a surgeon or attending physician. The following are not considered superficial SSI, stitch abscess (minimal inflammation and discharge confined to points of suture penetration), infection of an episiotomy or neonatal circumcision, infected burns and incisional SSI that extends into the facial and muscle layer (deep SSI).
A system of classification for surgical wounds based on the degree of microbial contamination was developed by the US National Research Council group in 1964. Four wound classes with an increased risk of SSI were described: clean, clean-contaminated, contaminated and dirty. In this study, SSIs were researched based on each of the wound classes.
Skin wounds are at risk of SSI and therefore lead to increased morbidity, delayed recovery and prolonged hospital stay. The prevalence of SSI in the developed world is estimated at around 5%. The development of SSI is a multifactorial phenomenon, which requires a multimodal approach to prevent and treat it in a timely manner to avoid financial, psychological and health-related quality of life consequences. Several predisposing aetiopathological factors for SSI include immunosuppression, nutritional deficiencies, diabetes mellitus, hypoproteinemias, congestive cardiac failure, hepatic failure, renal failure and the use of steroids and chemotherapy agents. In addition, wound contamination, contaminated instruments, surgical technique and sutures used to close skin plays an important role in the incidence of SSI. The prevention of SSI by various invasive and non-invasive interventions is the most common measure, surgeons and other healthcare professionals advocate to tackle the problem of SSI. This includes the use of prophylactic antibiotics and various other multimodal approaches already reported in the medical literature.
Triclosan (5-chloro-2- [2,4-dichlorophenoxy]phenol) is an antibacterial and an antifungal agent in use since 1972 incorporated into soaps, toothpastes, deodorants and mouthwashes. It acts as a biocide targeting multiple cytoplasmic and membrane sites. At lower concentrations, triclosan is bacteriostatic. It targets bacteria by inhibiting fatty acid synthesis. Triclosan binds to bacterial enoyl-acid carrier protein reductase (ENR) enzyme increasing the enzyme's affinity for NAD+ resulting in the formation of a stable ternary complex of ENR-NAD-triclosan which is unable to participate in fatty acid synthesis. Hence, the bacterial cell membranes cannot be produced effectively. Since humans do not have the ENR enzyme, the human cell membranes are not affected.
The aims of the study were to determine the incidence of superficial SSIs in abdominal wall incisions closed with triclosan-coated polyglactin 910 sutures and to compare the incidence of superficial SSI in abdominal wall incisions closed with triclosan-coated polyglactin 910 suture with those closed with plain polyglactin 910 suture.
| Materials and Methods|| |
It was a longitudinal observational study conducted in the Department of General Surgery of a tertiary hospital during December 2017–June 2019. All the patients in the age group above 18 years undergoing abdominal surgery with superficial SSI (skin and subcutaneous layer only) developing within a 30-day post-surgery were included. Known immunocompromised patients with diabetes or acquired immunodeficiency syndrome were excluded. The sample size was calculated using the formula
m = 2
χ = 0.8
1 − β = 90%
A = 5%
The sample size was 53.29 in each group so the total sample size was 106:
Patients were divided into two groups; each group comprising 53 patients. In one group, triclosan-coated polyglactin 910 suture was used, whereas in the second group, plain polyglactin 910 suture was used in wound closure. The patients selected for the study were those undergoing abdominal wall closures. All the patients were given antibiotics pre-operatively and post-operatively. Antibiotic selection was according to the standard antibiotic protocol. These patients were followed up for up to the day of discharge, 1-week post-discharge and 30-day post-operative. In the event of the development of signs of infection in between these visits, the patients were educated to visit us in the outpatient department despite the date of review already given.
It was an observational study and hence no interventions were done to influence the outcomes of these patients specifically for the purpose of the study. At our institute, all instruments are sterilised as per NABH guidelines by ethylene oxide sterilisation technique. In the event of such an infection, wound/pus culture swab was taken and culture studies were done to assess the infectious agents involved.
All the patients included in the study were evaluated as per the following protocol, clinical history and physical examination, investigations including haematological (haemoglobin, total leucocyte count, differential leucocyte count, HIV spot and random blood sugar), biochemistry (serum creatinine), urine analysis (routine and microscopic examination) and ultrasonography abdomen and pelvis. Non-contrast computed tomography scan of the abdomen and pelvis was asked for when indicated.
The above data were then recorded in a study pro forma and analysed using statistical software, namely the SPSS 16.0 (IBM-SPSS, India) and MedCalc 9.0.1. Microsoft Word and Excel were used to generate graphs, tables, etc. Percentages were calculated, Chi-square test was applied to find the association between the risk factors and superficial SSIs. The superficial SSI rates were reported as percentages within each group and compared between the groups using a t-test for proportions. The time frame between surgery and the development of a superficial SSI was summarised as mean and standard deviation. This was compared between the two groups using an independent sample t-test if the data are normally distributed. The commonly observed bacteria in the two groups were listed as numbers and percentages. All statistical tests were considered statistically significant at P < 0.05 level of significance.
| Results|| |
The study subjects were classified according to their age and gender, type of diagnosis and surgical procedure performed.
The total subjects' mean age was 45.9 ± 17.0 years with a range of 18–86 years. [Table 1] shows the age distribution according to the gender of the study subjects. Males were 78.1% and females were 21.9%. The mean age of the males was 44.8 ± 17.6 and females 50.1 ± 14.2 years. The difference between the mean ages was not statistically significant (P > 0.05).
The diagnosis of study subjects [Table 2] shows that intestinal obstruction was the major (35.84%) diagnosis. Duodenal perforation was the second most common diagnosis (32.9%), followed by others. Appendicular abscess (1.8%) and retroperitoneal hematoma (1.8%) were the least diagnosed.
[Table 3] details the procedures adopted among the study subjects. The omental patch (33.01%) was the leading procedure on the subjects. About 24.52% of subjects underwent resection anastomosis as the second most common procedure. Gastrojejunostomy and obstruction release were the least performed procedure with a 0.94% incidence of each. The differences between them were statistically very highly significant (P < 0.001).
The association of type of suture materials used with the outcome of post operative skin and skin structure infection (SSSI) on 3rd postoperative day are shown in [Table 4]. There was no statistically significant association between the suture materials with the outcome of infections on the 3rd day of surgery (P > 0.05).
|Table 4: Association between the suture materials used and infections on the 3rd day of surgery|
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[Table 5] shows the relationship between the suture materials with the outcome of post-operative SSSI was stated on the 7th day of operations. The results revealed that there was a statistically significant relationship between them (P < 0.05). The positive outcome of infection (11%) of Polyglactin (PGL)−was significantly differed with the positive outcome of infection (1.8%) of PGL+. Similarly, the negative outcome of infections (39.7%) was associated with PG − and negative outcome of infections (48.1%) was associated with PGL+.
|Table 5: Association between the suture materials used and infections on the 7th day of surgery|
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[Table 6] shows the relationship between the suture materials and the total outcome of infections. There was a statistically significant relationship between them (P < 0.05). The positive outcome of infection (22.6%) of PGL− was significantly differed with the positive outcome of infection (12.3%) of PGL+. Similarly, the negative outcome of infections (27.4%) was associated with PGL− and negative outcome of infections (37.7%) was associated with PGL+ materials.
|Table 6: Association between the suture materials used and total infections of surgery|
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[Table 7] shows the culture types of total SSI. The most common pathogen was Klebsiella spp. (26%) and Staphylococcus aureus (26%), followed by Escherichia More Details coli (13%), other 14% and no growth 20%. [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] show the SSI, Bacterial colonies and antibiotic coated suture materials, with details of the antibiotic material.
|Figure 1: The 7th post-operative day showing SSSI. SSSI: Skin and skin structure infection|
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|Figure 2: The 30th post-operative day showing SSSI. SSSI: Skin and skin structure infection|
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|Figure 3: Bacterial colonies (dark red) are visible in all areas of a Petri dish More Details except for the 'zone of inhibition around a antibacterial suture|
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| Discussion|| |
SSI remains a major burden in healthcare and so it is imperative that more research is done to find new innovative ways of reducing its incidence. The purpose of this study was to evaluate the effectiveness of antimicrobial-coated suture and triclosan-coated polyglactin 910 suture in reducing superficial SSI in abdominal wall closure. The incidence of post-operative wound infections is high among contaminated and dirty wounds. It is for this reason that we decided to study wound infection rates in the emergency setup, to assess the quality of surgical care we give to our patients.
The age of the patient was not found to be a contributing risk factor in the development of SSI. There was no age group associated with an increased risk of developing SSI (P = 0.761). Our study population had a median age for males of 44.8 and females of 50.1.
From this study, we demonstrated a reduction of superficial SSI when triclosan-coated polyglactin 910 was used as compared to plain polyglactin 910. There was a statistically significant difference (P < 0.05) demonstrated between the two sutures. This is in line with some previous studies that also demonstrated a statistically significant difference between the two sutures. In a randomised control trial (RCT) done in the UK (2019), 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. The study concluded that triclosan-coated sutures significantly reduced the risk of SSIs when compared with standard sutures.
A prospective study by Jung et al. enrolled 916 patients who underwent curative radical gastrectomy at the Samsung Medical Centre from December 2009 to September 2011. They examined the occurrence of SSI (primary end point), assessments of wound healing (secondary end point) and evaluated post-operatively on days 3, 7 and 30. Of the 916 patients, 122 were excluded post-operatively by screening (out of the study protocol, adverse events, etc.). The remaining 794 patients were enrolled and monitored post-operatively. The cumulative SSI incidence was 11 cases (1.39%) on day 30. Seromas were most frequently detected in wound healing assessments, with a cumulative incidence of 147 cases (18.51%) on day 30. They concluded the use of triclosan-coated sutures (Vicryl Plus) for abdominal wall closure can reduce the number of SSIs in gastric cancer surgery.
A RCT was done in Italy in 2018 on 15 patients comparing antimicrobial-coated sutures with conventional sutures and assessing the clinical effectiveness of antimicrobial sutures to decrease the risk for SSIs. On the basis of these selected trial results and the heterogeneous findings concluded Triclosan coated sutures (TCSs) could reduce the occurrence of SSI and the antimicrobial suture was effective in decreasing the risk for post-operative SSIs in a broad population of patients undergoing surgery.
A systematic review and meta-analysis were performed with a random-effects model. Meta-regression analysis assessed whether the effect of antimicrobial coating changed according to the type of suture and surgery. Thirteen RCTs and five observational studies (OBSs) met the inclusion criteria. Antimicrobial sutures significantly reduced SSI risk (for RCTs: odds ratios [OR] 0.72, 95% confidence interval [CI] 0.59–0.88, P = 0.001, I2 = 14%; for OBSs: OR 0.58, 95% CI 0.40–0.83, P = 0.003, I2 = 22%). The effect of antimicrobial coating was similar between different sutures, wounds and procedure types. The quality of RCT evidence was moderate, and OBS evidence was very low quality. They concluded that triclosan-coated sutures may reduce SSI risk.
It is important to note that the mechanisms leading to SSIs are not fully understood; however, the presence of foreign material like a suture is known to lower the size of bacterial inoculum necessary to cause infection, hence, creating an antibacterial environment within the wound is supposed to reduce the risk of SSI. This was the thinking behind the creation of antimicrobial-coated suture.
Although triclosan-coated polyglactin 910 has been demonstrated to reduce SSI in some areas such as abdominal surgery, it has not been found to be effective in others. One possibility is that like all good innovations it may be overused and misused. The widespread use of triclosan for many years in topically personal hygiene products such as toothpaste, soap, etc., may lead to diminished antimicrobial activity. This inevitable can lead to the development of drug resistance, this has been demonstrated in some studies.
| Conclusion|| |
There was a statistically significant relationship between plain polyglactin 910 and triclosan-coated polyglactin 910 (P < 0.05). The positive outcome of infection (22.6%) of plain polyglactin 910 significantly differed from the positive outcome of infection (12.3%) of triclosan-coated polyglactin 910. Similarly, the negative outcome of infections associated with plain polyglactin 910 was (27.4%) and negative outcome of infections (associated with triclosan-coated polyglactin 910 materials was (37.7%). There was a definite advantage inferred to the patients using triclosan-coated polyglactin 910 in reducing superficial SSI. In conclusion, it is the opinion of the researcher that triclosan-coated sutures have a role to play in reducing SSI. More studies should be done to clearly define the role of triclosan and its indications in surgery. Microbiological culture and sensitivity should be done routinely for all the patients who developed SSI to know the pattern of local causative agents and the most appropriate antibiotics to reduce the development of drug resistance. Microbiological testing for local patterns of resistance to triclosan should also be done.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: A modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606-8.
Heath RJ, Rubin JR, Holland DR, Zhang E, Snow ME, Rock CO. Mechanism of triclosan inhibition of bacterial fatty acid synthesis. J Biol Chem 1999;274:11110-4.
Ahmed I, Boulton AJ, Rizvi S, Carlos W, Dickenson E, Smith NA, et al.
The use of triclosan-coated sutures to prevent surgical site infections. A systematic review and meta-analysis of the literature. BMJ Open 2019;9:e029727.
Jung KH, Oh SJ, Choi KK, Kim SM, Choi MG, Lee JH, et al.
Effect of triclosan-coated sutures on surgical site infection after gastric cancer surgery via midline laparotomy. Ann Surg Treat Res 2014;87:311-8.
Onesti MG, Carella S, Scuderi N. Effectiveness of antimicrobial-coated sutures for the prevention of surgical site infection: A review of the literature. Eur Rev Med Pharmacol Sci 2018;22:5729-39.
Wu X, Kubilay NZ, Ren J, Allegranzi B, Bischoff P, Zayed B, et al.
Antimicrobial-coated sutures to decrease surgical site infections: A systematic review and meta-analysis. Eur J Clin Microbiol Infect Dis 2017;36:19-32.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]