You are on page 1of 10

Journal of Gastrointestinal Surgery

https://doi.org/10.1007/s11605-018-3832-8

REVIEW ARTICLE

The Efficacy of Antimicrobial-Coated Sutures for Preventing Incisional


Surgical Site Infections in Digestive Surgery: a Systematic
Review and Meta-analysis
Motoi Uchino 1 & Toru Mizuguchi 2 & Hiroki Ohge 3 & Seiji Haji 4 & Junzo Shimizu 5 & Yasuhiko Mohri 6 &
Chizuru Yamashita 7 & Yuichi Kitagawa 8 & Katsunori Suzuki 9 & Motomu Kobayashi 10 & Masahiro Kobayashi 11 &
Fumie Sakamoto 12 & Masahiro Yoshida 13 & Toshihiko Mayumi 14 & Koichi Hirata 15 & On behalf of the SSI Prevention
Guideline Committee of the Japan Society for Surgical Infection

Received: 5 March 2018 / Accepted: 29 May 2018


# 2018 The Society for Surgery of the Alimentary Tract

Abstract
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 sys-
tematic 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).

Electronic supplementary material The online version of this article


(https://doi.org/10.1007/s11605-018-3832-8) contains supplementary
material, which is available to authorized users.

* Motoi Uchino 8
Department of Infection Control, National Center for Geriatrics and
uchino2s@hyo-med.ac.jp Gerontology, Obu, Japan
9
Division of Infection Control and Prevention, University of
1 Occupational and Environmental Health, Fukuoka, Japan
Department of Inflammatory Bowel Disease, Hyogo College of
Medicine, 1-1, Mukogawacho, Nishinomiya, Japan 10
Department of Anesthesiology and Resuscitology, Okayama
2
Department of Surgery, Surgical Oncology & Science, Sapporo University Hospital, Okayama, Japan
Medical University, Sapporo, Japan 11
3
Kitasato University School of Pharmacy, Tokyo, Japan
Department of Infectious Diseases, Hiroshima University Hospital,
12
Hiroshima, Japan Infection Control Manager, QI Center, St. Luke’s International
4 University, Tokyo, Japan
Department of Surgery, Takatsuki General Hospital, Osaka, Japan
13
5
Department of Surgery, Osaka Rosai Hospital, Osaka, Japan Hemodialysis and Surgery, International University of Health and
Welfare Ichikawa Hospital, Ichikawa, Japan
6
Department of Surgery, Mie Prefectural General Medical Center,
14
Yokkaichi, Japan Department of Emergency Medicine, School of Medicine, University
7
of Occupational and Environmental Health, Fukuoka, Japan
Department of Anesthesiology and Critical Care Medicine, Fujita
15
Health University School of Medicine, Toyoake, Japan Department of Surgery, JR Sapporo Hospital, Sapporo, Japan
J Gastrointest Surg

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.

Keywords Antimicrobial-coated suture . Surgical site infection . Digestive surgery . Colorectal surgery

Introduction patients, diseases and surgical procedures, several wound clas-


ses, different suture materials, and heterogeneity in method
Surgical site infection (SSI) is the most common complication quality. Although the effectiveness of antimicrobial-coated su-
after digestive tract surgery. SSIs not only reduce the patient’s tures remains unclear, Henriksen18 recently reported the effi-
quality of life (QOL) but also increase medical costs.1–4 Risk cacy of antimicrobial-coated sutures for preventing SSIs after
factors for SSI include diabetes, obesity, smoking, malnutri- abdominal surgery. However, that meta-analysis included
tion, and immunosuppression, which are well-known patient clean wounds even for gastrointestinal surgery. Moreover, sev-
comorbidities that are difficult to eradicate before surgery.5–7 eral wound classes were included in the analyses. Although
Therefore, to decrease the risk of SSI, several interventions are Sandini19 also reported the efficacy of antimicrobial-coated
being considered and established, such as the use of prophy- sutures in colorectal surgery, two additional RCTs were pub-
lactic antibiotics, hair removal with clippers, mechanical and lished after that study.
chemical bowel preparation, skin antisepsis, the use of sterile Herein, to establish recommendations for the Japan
gowns, instruments, and gloves, maintenance of constant Society for Surgical Infection (JSSI) SSI prevention guide-
body temperature during surgery, and irrigation before wound lines, we conducted a systematic review and meta-analysis
closure.8 to analyze the efficacy of antimicrobial-coated sutures com-
Moreover, antimicrobial-coated suture material has recent- pared to non-coated sutures for the prevention of SSIs fol-
ly been shown to prevent SSIs, and many surgeons are using it lowing digestive surgery restricted to clean-contaminated
to close abdominal wounds because the bacterial colonization wounds and mixed wounds greater than class 2 (specifical-
of and biofilm formation on suture material could affect ly colorectal surgery).
SSIs.9,10 Triclosan has known antimicrobial properties against
bacteria. In addition, coating suture materials provide a long-
standing protective effect against bacteria for 1 month after Methods
surgery.11
However, the evidence and recommendations from some To conduct this study, the study protocol was published on
organizations remain controversial. The World Health PROSPERO, which is the international prospective register of
Organization (WHO)12 suggests the use of antimicrobial- systematic reviews (reference: No. CRD42017076780; http://
coated sutures to reduce the risk of SSI, independent of the www.crd.york.ac.uk/PROSPERO). We followed Preferred
type of surgery, with a conditional recommendation and with Reporting Items for Systematic Reviews and Meta-analyses
moderate quality of evidence in the 2016 global guidelines for (PRISMA) guidelines. Ethical approval was not necessary
the prevention of SSI. The Centers for Disease Control (CDC) because this study is a meta-analysis.
and the Wisconsin Department of Health Services (DHS) also
set forth weak recommendations with moderate-quality evi- Literature Search Strategy
dence in their 2017 guidelines.13,14 The American College of
Surgeons and Surgical Infection Society has recommended the We performed a comprehensive search in PubMed, the
use of antimicrobial-coated sutures, but use should be limited Cochrane Central Register of Controlled Trials (CENTRAL),
to clean or clean-contaminated surgery.15 The Society for and ICHUSHI web (Japanese search engine of the Japan
Healthcare Epidemiology of America (SHEA)/Infectious Medical Abstracts Society (JAMAS)) from January 2000 to
Diseases Society of America (IDSA)16 practical recommenda- September 2017. Supplemental File 1 shows the search strat-
tion in 2014 stated, BDo not routinely use antiseptic- egy used for PubMed. In addition, these strategies were trans-
impregnated sutures as a strategy to prevent SSI,^ and the lated for different database syntaxes. The evaluable studies
National Institute for Health and Care Excellence (NICE)17 and other hand-selected papers were added manually.
updated guideline in 2013 stated, BAntimicrobial-coated su-
tures may reduce the SSI risk compared to uncoated sutures, Study Eligibility
although this effect may be specific to particular types of
surgery.^ These differing recommendations could be induced Studies meeting the following criteria were included in the
by several differences during analysis, including different meta-analysis: (1) Participants: Patients who received
J Gastrointest Surg

digestive surgery with wound classifications greater than 2 Sub-analyses distinct from the suture materials, including
which include clean-contaminated, contaminated, or dirty/ mono-filament and poly-filament suture materials, were per-
infected wounds, including upper and lower gastrointestinal formed, and the surgeries were limited to colorectal surgery or
surgery and pancreatico-hepatobiliary surgery.20 Patients un- surgery with a class 2 wound (clean-contaminated). The sub-
dergoing abdominal surgeries with a clean wound, such as analyses were performed in restricted studies with extracted num-
hernia surgery without intestinal tract opening, were not in- bers that clearly stated the incidence of SSIs from all the RCTs.
cluded. Patients of any age who underwent any digestive sur-
gical procedures were eligible for inclusion. (2) Intervention: Statistical Analysis
Abdominal wound closure with antimicrobial-coated suture
material. (3) Comparison: Abdominal wound closure with We performed a random-effects meta-analysis for each out-
antimicrobial-coated suture material compared with non- come of interest. Outcomes were calculated using Windows
coated suture material. (4) Outcomes: incidence of SSI and Review Manager Software 5.3 (The Nordic Cochrane Centre,
hospital stay length. (5) Study design: RCTs and OBSs were The Collaboration, 2014, Copenhagen, Denmark). The risk
included. ratio (RR) with 95% confidence intervals (CI) for the inci-
The language of publication was restricted to English and dence of SSI in RCTs and the odds ratio (OR) with 95% CI
Japanese with an English abstract that included the incidence for the incidence of SSI in OBSs were used to weight the
of SSIs. Articles with in vitro studies or animal studies and interval. Weighted mean differences (MD) with 95% CI were
those without the proper number of events were not included. used to analyze the hospital stay length. P value < 0.05 was
The article selection was performed and confirmed indepen- considered statistically significant. Heterogeneity was quanti-
dently by two authors (M Uchino and T Mizuguchi). fied using I-squared and tau-squared indexes, testing the null
hypothesis that all studies share a common effect size.
Data Extraction and Quality Assessment

A standard data entry form was designed for the data extrac- Results
tion. Two reviewers independently extracted the available
study data. The extracted data included author, publication Study Selection
year, study design, conflicts of interest, patient characteristics
(type of disease, type of surgery, and wound class), and types A total of 1147 records were identified using the electronic
of suture material. The primary outcomes were incidences of search strategy, and 10 hand search records were found. After
SSI. The secondary outcome was the length of the hospital the removal of duplicates and screening of the titles and ab-
stay. Any disagreement between the two reviewers was re- stracts, the full texts of 58 studies were assessed for eligibility.
solved by all reviewers at a consensus meeting. A total of 15 studies met the inclusion criteria, including 10
The risk of bias of RCTs was assessed by the method of RCTs and 5 OBSs4,23–26 (Fig. 1).
randomization, allocation concealment, blinding, outcomes,
and follow-up using the Cochrane Collaboration’s tool for Characteristics of Included Studies
assessing the risk of bias.21 Each piece of evidence could be
downgraded according to its risk of bias.21 The quality of the The characteristics of the included studies are stated in Table
evidence from the RCTs and OBSs was further assessed ac- 1. A total of 5188 patients in 15 studies were included, with 10
cording to the Grading of Recommendations Assessment, RCTs and 5 OBSs. All studies reported the incidence of SSI.
Development, and Evaluation (GRADE) approach.22 Some No adverse events were reported. Five studies reported the
discrepancies were also resolved through discussion among duration of hospital stay.4,24,26–28 One study enrolled pediatric
all reviewers at the consensus meeting. patients.31 One RCT30 and one OBS32 were published in
Japanese with English abstracts. The sutured surgical sites in
Endpoints and Sub-analysis the included studies were the abdominal fascia in 12 studies,
the subcutaneous alone in 1 study, and unknown in 2 studies.
The primary endpoint of this systematic review and meta- Regarding the types of surgeries represented, there were 9
analysis was to analyze the effect of antimicrobial-coated su- colorectal surgeries, 4 mixed digestive surgeries, 1 gastric sur-
tures on the prevention of incisional SSI after digestive sur- gery, and 1 pancreaticoduodenectomy.
gery with wound classes greater than 2 in the available RCTs The RCTs included 6 studies that performed surgeries lim-
and OBSs. ited to class 2 wounds or described the incidence distinct from
The secondary endpoint was to analyze the length of the the wound class. Only one study was performed during emer-
hospital stay according to the use of antimicrobial-coated gent surgeries and was limited to the dirty/infected wound
sutures. classes.29 The remaining 3 studies were analyses conducted
J Gastrointest Surg

Records identified Additional records


through database searching identified through other sources
PubMed (N=1,030) (N=10)
Cochrane Library (N=28)
Ichushi web (N=89)

Record screened (1st screening) Records excluded based on title


N=1,157 or abstract after removing
duplicates
N=1,099

Full-text articles assessed for eligibility Full-text articles excluded with reasons
(2nd screening) N=43
N=58 Mixed surgery (n=23)
Include wound class 1 (n=4)
Review (n=15)
Studies included in qualitative synthesis Language (n=1)
N=15

Studies included in quantitative synthesis


Meta-analysis for 10 RCTs
Meta-analysis for 5 OBSs
Fig. 1 Flowchart of the literature search according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)

together with mixed wound classes. Supplemental File 2 antimicrobial coating were 147/1511 (9.7%) with coated
shows the assessment of the RCTs using Cochrane collabora- sutures and 186/1462 (12.7%) with non-coated sutures.
tion’s risk of bias tool. The overall risk of bias was low to Overall, antimicrobial-coated sutures were superior for re-
moderate, except in 1 RCT which did not state the ducing the incidence of incisional SSIs (RR 0.67, 95% CI:
methodology.30 The surgeons were not blinded to the inter- 0.48 to 0.94, p = 0.02) in the RCTs (Fig. 2a). In OBSs, the
vention in 2 studies.4,24 In 3 studies, blinding of the partici- incidences of incisional SSI were 77/1091 (7.1%) with
pants or personnel to intervention was not stated.4,27,29 Six coated sutures and 184/1124 (16.4%) with non-coated su-
studies were large RCTs.4,23,25–27,31 However, the remaining tures. The superior effect of antimicrobial-coated sutures
4 studies were small RCTs with fewer than 100 participants in was also found in OBSs (OR 0.4, 95% CI 0.3 to 0.54, p <
each treatment.23,24,29,30 0.001) (Fig. 2b). In Supplemental File 4, the funnel plot for
Regarding the suture materials in the RCTs, mono- studies reporting the RRs of SSIs was used to detect pub-
filament sutures were used in 4 RCTs, and poly-filament lication bias. All the points representing the studies fall
sutures were used in 4 RCTs. Two RCTs used mixed suture within the 95% CI axis and are distributed symmetrically.
materials. This result suggests that the publication bias is minimal
In OBSs, nearly half of the participants had upper gastro- and acceptable.
intestinal surgery. The overall risk of bias was moderate A similar efficacy was found when the cases were restricted
(Supplemental File 3). Two studies were small studies with to class 2 clean-contaminated or colorectal surgeries. As
fewer than 100 participants in each treatment. shown in Fig. 3, a superior effect of antimicrobial-coated su-
It is worth noting that 2 RCTs had industry sponsorship tures was also found in surgeries with wound class 2 (RR 0.66,
during the studies.26,27 95% CI 0.44 to 0.98, p = 0.04). Figure 4 shows the results
when the surgeries were limited to colorectal surgeries. A total
Surgical Site Infection of 9 RCTs were assessed, including 2 emergency surgeries
and 7 elective surgeries. The incidence of incisional SSI was
In the digestive surgery with mixed wound class, the over- 144/1234 (11.7%) with antimicrobial-coated sutures and 178/
all incidence of incisional SSIs was 365/3488 (10.5%) in 1199 (14.8%) with non-coated sutures. A superior effect of
the RCTs and 261/2215 (11.8%) in the OBSs. In the results antimicrobial-coated sutures in colorectal surgery was found
of the RCTs, the incidences of incisional SSI related to (RR 0.69, 95% CI 0.49 to 0.98, p = 0.04).
J Gastrointest Surg

Table 1 Characteristics of included studies

Study Year Type of study Surgical timing Type of surgery Wound class Intervention Control Location of intervention Incidences of SSI, n(%) p value

Intervention Control

Mingmalairak23 2009 RCT Emergent Appendectomy Mixed VP V Fascia 5/50 (10.0) 4/50 (8.0) 0.73
Rasic24 2011 RCT Elective Colorectal surgery Class II VP V Peritoneum/fascia 4/91 (4.4) 12/93 (12.9) 0.04
Baracs25 2011 RCT Elective Colorectal surgery Class II PP P Fascia/skin 23/188 (12.2) 24/197 (12.2) 0.99
Matsumoto32 2011 OBS Elective Gastric cancer Mixed VP V Intra-peritoneum/fascia 6/85 (7.1) 13/107 (12.1) 0.24
Nakamura4 2012 RCT Elective Colorectal surgery Class II VP V Fascia 9/205 (4.4) 18/203 (8.9) 0.11
Class III 0/1(0) 1/1(100) 1.00
Justinger26 2013 RCT Elective Mixed digestive surgery Mixed PP P Peritoneum/fascia 30/431 (7.0) 38/328 (9.1) 0.03
Colorectal surgery Mixed 17/143 (11.9) 19/100 (19.1) 0.12
Class IIsurgery Class II 14/162 (8.6) 16/97 (16.5) 0.06
Hoshino33 2013 OBS Mixed Digestive tract surgery Mixed VP V Fascia 25/296 (8.4) 65/379 (17.2) < 0.01
Diener27 2014 RCT Elective Colorectal surgery (extracted) Mixed PP P Fascia 58/334 (17.4) 54/331 (16.3) 0.72
Okada34 2014 OBS Elective Pancreaticoduodenectomy Class II VP V Fascia 4/88 (4.5) 16/110 (14.5) 0.02
Fraccalvieri35 2014 OBS Elective Colorectal surgery Class II VP P Unknown 35/240 (14.6) 70/240 (29.2) < 0.01
Ruiz-Tovar29 2015 RCT Emergent Fecal peritonitis Class IV VP V Fascia 5/50 (10.0) 18/51 (35.3) < 0.01
Mattavelli28 2015 RCT Elective Colorectal surgery Class II VP,PP V,P Peritoneum/fascia/skin 18/140 (12.9) 15/141 (10.6) 0.56
Umemura30 2016 RCT Elective Digestive tract surgery Class II PP P Subcutaneous 7/73 (9.6) 16/72 (22.2) 0.04
Nakamura36 2016 OBS Elective Laparoscopic colon cancer Class II PP P Peritoneum/fascia/skin 7/382 (1.8) 20/288 (6.9) < 0.01
Renko31 2017 RCT Mixed Pediatrics abdominal surgery Mixed Mixed Mixed Unknown 1/236 (0.4) 5/223 (2.2) 0.09

SSI surgical site infection, RCT randomized controlled study, OBS observational study, VP vicryl plus®, V vicryl®, PP PDS plus®, P PDSII
J Gastrointest Surg

a)

b)

Matsumoto

Fig. 2 a Forest plot for incisional surgical site infection in randomized b Forest plot for incisional surgical site infection in observational studies
controlled trials (RCTs) for gastrointestinal surgery with a mixed wound (OBSs) for gastrointestinal surgery comparing antimicrobial-coated su-
class comparing antimicrobial-coated sutures versus non-coated sutures. tures versus non-coated sutures

The results related to suture materials are shown in non-coated sutures. A superiority effect of antimicrobial-
Supplemental Files 5 and 6. In the analysis limited to coated poly-filament sutures was found (RR 0.45, 95% CI
mono-filament suture materials, the incidence of incisional 0.26 to 0.77, p = 0.004).
SSIs was 118/1025 (11.5%) with antimicrobial-coated su- Only one study was limited to dirty/infected surgeries and
tures and 131/928 (14.1%) with non-coated sutures. A su- included pan-peritonitis.30 The incidence of incisional SSIs
perior effect of antimicrobial-coated mono-filament sutures was 5/50 (10.0%) with antimicrobial-coated sutures and 18/
was not found (RR 0.79, 95% CI 0.54 to 1.17, p = 0.24). 51 (35.3%) with non-coated sutures. Although only one well-
In the analysis limited to poly-filament suture material, the designed study was included, a superior effect of
incidence of incisional SSI was 23/397 (5.8%) with antimicrobial-coated sutures in dirty/infected surgeries was
antimicrobial-coated sutures and 53/398 (13.3%) with found (RR 0.28, 95% CI 0.11 to 0.70, p < 0.01).

Fig. 3 Forest plot for incisional surgical site infection in randomized controlled trials (RCTs) for gastrointestinal surgery restricted to the clean-
contaminated wound class comparing antimicrobial-coated sutures with non-coated sutures
J Gastrointest Surg

Fig. 4 Forest plot for incisional surgical site infection in RCTs for overall colorectal surgeries comparing antimicrobial-coated sutures versus non-coated
sutures

Hospital Stay Length mixed surgeries were included in the OBSs. Almost half of the
total number of surgeries in the OBSs were upper gastrointes-
Supplemental File 7 shows the hospital stay results associated tinal surgeries. Daoud et al.37 suggested in a previous meta-
with antimicrobial coating in 5 RCTs that all involved colo- analysis that documented the benefits of antimicrobial sutures
rectal surgery. The mean length of the hospital stay was sim- in both clean-contaminated and contaminated surgical proce-
ilar with or without coating (MD − 5.00, 95% CI − 16.68 to dures but not dirty surgical procedures, which is relevant for
6.69, p = 0.40). colorectal surgery, that antimicrobial-coated sutures might be
useful for less contaminated surgeries that mainly involved
exposure to gram-positive pathogens; however, these sutures
Discussion may not be effective for colorectal surgery, which mainly in-
volves exposure to gram-negative or anaerobic pathogens.
We performed this meta-analysis including 10 RCTs and 5 Edmiston et al.38 reported that an important component of
OBSs limited to digestive surgery and demonstrated the effi- more than 25% of colorectal infections is gram-negative path-
cacy of antimicrobial-coated sutures on SSI prevention as a ogenesis and that triclosan-coated sutures were effective
working committee for Japanese guidelines. Recent global against both gram-positive and gram-negative pathogens in
guidelines from the WHO2 stated a conditional recommenda- an in vitro model. Although the industrial report stated that
tion for the use of antimicrobial-coated sutures in all surgeries, the polydioxanone sutures with triclosan exhibited in vitro
including clean surgeries. However, it is challenging to ana- activity against Staphylococcus aureus, MRSA, Escherichia
lyze all surgeries together because the procedure, back- coli, Staphylococcus epidermidis, MRSE, and Klebsiella
grounds, or wound classes are quite different. In recent similar pneumoniae, the effects were relatively decreased against
reports, Sandini et al. 19 also analyzed the effect of gram-negative pathogens compared gram-positive pathogens,
antimicrobial-coated sutures in colorectal surgery. Their find- but the difference was not significant.39 The results from the
ings failed to demonstrate a significant protective effect of OBSs and these subtle differences may explain the discrepant
antimicrobial-coated sutures against SSI. However, they in- results of this analysis. Further trials are necessary to deter-
cluded studies that contained class 1 wounds. Henriksen et mine the efficacy of antimicrobial-coated sutures during dirty/
al.18 recently reported that triclosan-coated sutures decreased infected colorectal surgery because only one study included a
the risk of SSI in a meta-analysis of 8 RCTs. However, the situation with a dirty/infected wound, although the efficacy of
analysis also included two studies that included clean wounds. the antimicrobial-coated sutures was found in an RCT.
Our analysis was limited to digestive surgery with either a Regarding safety, 5 RCTs included statements about
mixed wound classification greater than 2 or restricted class mortality.26,27,29–31 There was no relationship between the use
2 wounds; thus, the SSI incidences in clean surgeries in these of antimicrobial-coated sutures and mortality. All deaths were
studies were excluded. In addition, the results of this meta- caused by sepsis. Four RCTs mentioned adverse events.23,27,28,31
analysis showed the preventive efficacy of SSIs by using There was also no relationship between using antimicrobial-
antimicrobial-coated sutures in both digestive surgeries and coated sutures and adverse events. In 2 RCTs, no allergic reac-
colorectal surgeries in several wound classes. tions were observed during follow-up periods.23,27
Regarding the surgical procedures, most procedures that In all analyses, the antimicrobial-coated sutures were effi-
were included in the RCTs were colorectal surgeries, whereas cacious; however, the results of SSI prevention were different
J Gastrointest Surg

according to whether the suture materials were mono-filament in digestive surgery, further RCTs with well-designed strategies
or poly-filament materials. Mono-filament sutures had an ad- for handling several confounding factors, as mentioned in the
vantage for preventing SSI over poly-filament suture above limitations, are needed before recommending
material.40,41 Biofilms may form on poly-filament sutures antimicrobial-coated sutures for routine clinical use. Fewer lim-
more easily since they have a wider surface than mono- itations are needed before guidelines can be created not only for
filament suture materials. Therefore, the coating had a more SSI prevention but also for cost-effectiveness.
marked effect in poly-filament sutures, which agrees with the
findings of Henriksen et al.18 Author Contribution Conception and design: M. Yoshida and T Mayumi
Literature search: J Shimizu, Y Mohri, and C Yamashita
The limitations of this study are stated below. First, a cost
Analysis and interpretation: M Uchino and T Mizuguchi
analysis was not performed in any RCT, as mentioned above. Literature assessment and review: H Ohge, S Haji, J Shimizu, Y
Second, this meta-analysis included the results of pediatric Mohri, C Yamashita, Y Kitagawa, K Suzuki, M Kobayashi, M
surgery, which described the wound class, but not the surgical Kobayashi, and F Sakamoto
Writing of the article: M Uchino
procedure or type of suture material. Combining the results
Critical revision of the article: H Ohge, T Mayumi, and K Hirata
from pediatric patients and adults could result in heterogeneity Final approval of the article: M Uchino, T Mizuguchi, H Ohge, S Haji,
in the overall assessment of SSI incidence. However, a similar J Shimizu, Y Mohri, C Yamashita, Y Kitagawa, K Suzuki, M Kobayashi,
result was found in an analysis limited to adult patients. Third, M Kobayashi, F Sakamoto, M Yoshida, T Mayumi, and K Hirata
we did not analyze the data according to skin closure proce-
dure. The SSI preventive efficacies are different among the Funding information This work was supported in part by the Japan
Surgical Infection Society.
different skin closure methods. It has recently been suggested
that the subcutaneous buried suture has more preventive effi-
Compliance with Ethical Standards
cacy than closure with a skin stapler or the conventional
interrupted skin suture. Moreover, continuous suturing has a Conflict of Interest The authors declare that they have no conflicts of
greater advantage for SSI prevention than interrupted sutures, interest.
even during subcutaneous suturing, although the efficacies
were controversial in several studies. Essentially, we should
evaluate the efficacy of antimicrobial-coated suture material References
with regard to the procedures of wound closure in further
studies. Fourth, publication bias was not sufficiently assessed. 1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR.
In two RCTs,4,28 the surgeons were not blinded to the selection Guideline for prevention of surgical site infection, 1999 Hospital
of suture material. Although the results did not favor the coat- Infection Control Practices Advisory Committee. Infect Control
Hosp Epidemiol 1999;20:250–278; quiz 279-280.
ed suture material, two RCTs had industry sponsorship.26,27 In
2. Weiss CA 3rd, Statz CL, Dahms RA, Remucal MJ, Dunn DL,
addition, these RCTs included clean wound classes in abdom- Beilman GJ. Six years of surgical wound infection surveillance at
inal closure, which were all analyzed together in a previous a tertiary care center: review of the microbiologic and epidemiolog-
meta-analysis. This superiority of antimicrobial-coated sutures ical aspects of 20,007wounds. Arch Surg 1999;134:1041–1048.
in available single-center trials should be interpreted with cau- 3. Olson MM, Lee JT Jr. Continuous, 10-year wound infection sur-
veillance. Results, advantages, and unanswered questions. Arch
tion because most multicenter trials (all but one) failed to dem- Surg 1990;125:794–803.
onstrate the superiority of antimicrobial-coated sutures. 4. Nakamura T, Kashimura N, Noji T, Suzuki O, Ambo Y, Nakamura
Undescribed or unknown industrial or any other bias might F, Kishida A. Triclosan-coated sutures reduce the incidence of
be even greater in single center trials. Fifth, we analyzed dirty/ wound infections and the costs after colorectal surgery: a random-
infected, contaminated and clean-contaminated cases together ized controlled trial. Surgery 2013;153:576–583.
5. Khuri SF. Multivariable predictors of postoperative surgical site
in our analyses of colorectal surgery or suture materials, be- infection after general and vascular surgery: results from the patient
cause each wound classification had too small a sample size safety in surgery study. J Am Coll Surg 2007;204:1178–1187.
for analysis. 6. Cheadle WG. Risk factors for surgical site infection. Surg Infect
In conclusion, our findings demonstrate a significant preven- 2006;7:S7–11.
tive efficacy of antimicrobial-coated sutures on the occurrence 7. Malone DL, Genuit T, Tracy JK Gannon C, Napolitano LM.
Surgical site infections: reanalysis of risk factors. J Surg Res
of incisional SSIs after both digestive surgery and colorectal 2002;103:89–95.
surgery, even when the analysis is restricted to the clean- 8. NICE Guidance. Surgical site infection (CG74). http://guidance.
contaminated wound class and especially when poly-filament nice.org.uk/CG74 (accessed Jan 28, 2014).
suture material is used. However, we failed to prove an effect 9. Alexander JW, Kaplan JZ, Altemeier WA. Role of suture materials
on shortening the hospital stay length. Moreover, regarding in the development of wound infection. Ann Surg 1967;165:192–
199.
dirty/infected surgery, only one well-designed study proved 10. Katz S, Izhar M, Mirelman D. Bacterial adherence to surgical su-
the efficacy of antimicrobial-coated sutures. Although these tures. A possible factor in suture induced infection. Ann Surg
results support the efficacy of antimicrobial-coated sutures even 1981;194:235–242.
J Gastrointest Surg

11. Leaper D, Assadian O, Hubner NO, McBain A, Barbolt T, 24. Rasić Z, Schwarz D, Adam VN, Sever M, Lojo N, Rasić D, Matejić
Rothenburger S, Wilson P. Antimicrobial sutures and prevention T. Efficacy of antimicrobial triclosan-coated polyglactin 910
of surgical site infection: assessment of the safety of the antiseptic (Vicryl* Plus) suture for closure of the abdominal wall after colo-
triclosan. Int Wound J 2011;8:556–566. rectal surgery. Coll Antropol 2011;35:439–443.
12. GLOBAL GUIDELINES FOR THE PREVENTION OF 25. Baracs J, Huszár O, Sajjadi SG, Horváth OP. Surgical site infections
SURGICAL SITE INFECTION. http://apps.who.int/iris/ after abdominal closure in colorectal surgery using triclosan-coated
bitstream/10665/250680/1/9789241549882-eng.pdf. Accessed 1 absorbable suture (PDS Plus) vs. uncoated sutures (PDS II): a ran-
December 2016. domized multicenter study. Surg Infect (Larchmt) 2011;12:483–
13. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, 489.
Kelz RR, Reinke CE, Morgan S, Solomkin JS, Mazuski JE, 26. Justinger C, Slotta JE, Ningel S, Gräber S, Kollmar O, Schilling
Dellinger EP, Itani KMF, Berbari EF, Segreti J, Parvizi J, MK. Surgical-site infection after abdominal wall closure with
Blanchard J, Allen G, Kluytmans JAJW, Donlan R, Schecter WP; triclosan-impregnated polydioxanone sutures: results of a random-
Healthcare Infection Control Practices Advisory Committee. ized clinical pathway facilitated trial (NCT00998907). Surgery
Centers for Disease Control and Prevention Guideline for the 2013;154:589–595.
Prevention of Surgical Site Infection, 2017. JAMA Surg 27. Diener MK, Knebel P, Kieser M, Schüler P, Schiergens TS,
2017;152:784–791. Atanassov V, Neudecker J, Stein E, Thielemann H, Kunz R, von
14. Wisconsin Division of Public Health Supplemental Guidance for Frankenberg M, Schernikau U, Bunse J, Jansen-Winkeln B,
the Prevention of Surgical Site Infections: An Evidence-Based Partecke LI, Prechtl G, Pochhammer J, Bouchard R, Hodina R,
Perspective January 2017 (Revised 5/2017). https://www.dhs. Beckurts KT, Leißner L, Lemmens HP, Kallinowski F, Thomusch
wisconsin.gov/publications/p01715.pdf. Accessed February 3, O, Seehofer D, Simon T, Hyhlik-Dürr A, Seiler CM, Hackert T,
2018 Reissfelder C, Hennig R, Doerr-Harim C, Klose C, Ulrich A,
15. Ban KA, Minei JP, Laronga C, Harbrecht BG, Jensen EH, Fry DE, Büchler MW. Effectiveness of triclosan-coated PDS Plus versus
Itani KM, Dellinger EP, Ko CY, Duane TM. American College of uncoated PDS II sutures for prevention of surgical site infection
Surgeons and Surgical Infection Society: Surgical Site Infection after abdominal wall closure: the randomised controlled PROUD
Guidelines, 2016 Update. J Am Coll Surg 2017;224:59–74. trial. Lancet 2014;384:142–152.
16. Anderson DJ, Podgorny K, Berrios-Torres SI, Ratzler DW, 28. Mattavelli I, Rebora P, Doglietto G, Dionigi P, Dominioni L,
Dellinger EP, Greene L, et al. Strategies to prevent surgical site Luperto M, La Porta A, Garancini M, Nespoli L, Alfieri S,
infections acute care hospitals: 2014 update. Infect Control Hosp Menghi R, Dominioni T, Cobianchi L, Rotolo N, Soldini G,
Epidemiol 2014;35:605–627. Valsecchi MG, Chiarelli M, Nespoli A, Gianotti L. Multi-Center
Randomized Controlled Trial on the Effect of Triclosan-Coated
17. A summary of selected new evidence relevant to NICE clinical
Sutures on Surgical Site Infection after Colorectal Surgery. Surg
guideline 74 BPrevention and treatment of surgical site infection^
Infect (Larchmt) 2015;16:226–235.
(2008). Evidence update 43 (June 2013). London/Manchester:
29. Ruiz-Tovar J, Alonso N, Morales V, Llavero C. Association be-
National Institute for Health and Care Excellence (NICE); 2013
tween Triclosan-Coated Sutures for Abdominal Wall Closure and
(http://www.nice.org.uk/guidance/cg74/evidence, accessed 24 July
Incisional Surgical Site Infection after Open Surgery in Patients
2016).
Presenting with Fecal Peritonitis: A Randomized Clinical Trial.
18. Henriksen NA, Deerenberg EB, Venclauskas L, Fortelny RH, Surg Infect (Larchmt) 2015;16:588–594.
Garcia-Alamino JM, Miserez M, Muysoms FE. Triclosan-coated 30. Umemura A, Suto T, Nakamura S, Endo F, Kimura Y. Does anti-
sutures and surgical site infection in abdominal surgery: the microbial triclosan-coated PDS PLUS or subcutaneous closure re-
TRISTAN review, meta-analysis and trial sequential analysis. duce surgical site infections? A controlled clinical trial of class II
Hernia 2017;21:833–841. abdominal surgeries. Nihon Geka Kannsennshou Gakkai Zasshi
19. Sandini M, Mattavelli I, Nespoli L, Uggeri F, Gianotti L. 2016;13:265–270.
Systematic review and meta-analysis of sutures coated with triclo- 31. Renko M, Paalanne N, Tapiainen T, Hinkkainen M, Pokka T,
san for the prevention of surgical site infection after elective colo- Kinnula S, Sinikumpu JJ, Uhari M, Serlo W. Triclosan-containing
rectal surgery according to the PRISMA statement. Medicine sutures versus ordinary sutures for reducing surgical site infections
(Baltimore) 2016;95:e4057. in children: a double-blind, randomised controlled trial. Lancet
20. Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori Infect Dis 2017;17:50–57.
TG, Banerjee SN, Edwards JR, Tolson JS, Henderson TS. Surgical 32. H Matsumoto, R Kawabata, H Imamura, T Kishimoto, J Kajiwara,
wound infection rates by wound class, operative procedure, and M Kamiyamazaki, M Nishihara, T Fujimoto, Y Nakamura, T
patient risk index. National Nosocomial Infections Surveillance Yamamoto, H Takemoto, K Oda, S Kamigaki, M Fukunaga, H
System. Am J Med 1991;91:152S–158S. Osato, H Furukawa. Impact of the use of triclosan-coated antibac-
21. Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman terial sutures on the incidence of surgical site infections after gastric
AD, Savovic J, Schulz KF, Weeks L, Sterne JA, Cochrane Bias cancer surgery. Ichiritsusakaibyouin Igaku Zasshi 2012;14:2–6.
Methods Group, Cochrane Statistical Methods Group (2011) The 33. Hoshino S, Yoshida Y, Tanimura S, Yamauchi Y, Noritomi T,
Cochrane collaboration’s tool for assessing risk of bias in Yamashita Y. A study of the efficacy of antibacterial sutures for
randomised trials. BMJ 343:d5928. surgical site infection: a retrospective controlled trial. Int Surg
22. Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, Norris S, 2013;98:129–132.
Falck-Ytter Y, Glasziou P, DeBeer H, Jaeschke R, Rind D, 34. Okada N, Nakamura T, Ambo Y, Takada M, Nakamura F, Kishida
Meerpohl J, Dahm P, Schunemann HJ. GRADE guidelines: 1. A, Kashimura N. Triclosan-coated abdominal closure sutures re-
Introduction—GRADE evidence profiles and summary of findings d u c e t h e i n c i d e n c e o f s u rg i c a l s i t e i n fe c t i o n s a f t e r
tables. J Clin Epidemiol 2011;64:383–394. pancreaticoduodenectomy. Surg Infect (Larchmt) 2014;15:305–
23. Mingmalairak C, Ungbhakorn P, Paocharoen V. Efficacy of antimi- 309.
crobial coating suture coated polyglactin 910 with tricosan (Vicryl 35. Fraccalvieri D, Kreisler Moreno E, Flor Lorente B, Torres García A,
plus) compared with polyglactin 910 (Vicryl) in reduced surgical Muñoz Calero A, Mateo Vallejo F, Biondo S. Predictors of wound
site infection of appendicitis, double blind randomized control trial, infection in elective colorectal surgery. Multicenter observational
preliminary safety report. J Med Assoc Thai 2009;92:770–775. case-control study. Cir Esp 2014;92:478–484.
J Gastrointest Surg

36. Nakamura T, Sato T, Takayama Y, Naito M, Yamanashi T, Miura H, 39. Ming X, Rothenburger S, Nichols MM. In vivo and in vitro anti-
Atsuko T, Yamashita K, Watanabe M. Risk Factors for Surgical Site bacterial efficacy of PDS plus (polidioxanone with triclosan) suture.
Infection after Laparoscopic Surgery for Colon Cancer. Surg Infect Surg Infect 2008;9:451–457.
(Larchmt) 2016;17:454–458. 40. Liu X, Nelemans PJ, Frenk LDS, Sengers H, Tuinder SMH, Steijlen
37. Daoud F, Edmiston CE Leaper D. Meta-analysis: Prevention of PM, Mosterd K, Kelleners-Smeets NWJ. Aesthetic outcome and
Surgical Site Infections Following Wound Closure with Triclosan- complications of simple interrupted versus running subcuticular
Coated Sutures: Robustness of New Evidence. Surg Infect 2014;15: sutures in facial surgery: A randomized controlled trial. J Am
165–181. Acad Dermatol 2017;77:911–919.
38. Edmiston CE, Goheen MP, Krepel C, Seabrook, GR, Johnson CP, 41. Osther PJ, Gjøde P, Mortensen BB, Mortensen PB, Bartholin J,
Lewis BD, Brown KR, Towne JB. Bacterial Adherence to Surgical Gottrup F. Randomized comparison of polyglycolic acid and
Sutures: Is There a Role for Antibacterial-Coated Sutures in polyglyconate sutures for abdominal fascial closure after laparoto-
Reducing the Risk of Surgical Site Infections? J Am Coll Surg my in patients with suspected impaired wound healing. Br J Surg
2006;203:481–489. 1995;82:1080–1082.

You might also like