Triclosan-coated Sutures Research Articles

Surgical site infections: a scoping review on current intraoperative prevention measures.

Surgical site infections (SSIs) remain a significant cause of morbidity for surgical patients worldwide and with growing rates of antibiotic resistance, the development of new nonantimicrobial techniques to target SSI reduction is crucial. This review aimed to explore available nonantibiotic intraoperative interventions to reduce the risk of SSI. A literature search was undertaken using Medline, Web of Science, Embase, and Cochrane Library databases. Any study published from 1 January 1980 to 1 September 2021 that described any nonantibiotic intraoperative physical technique aiming to reduce SSI rates, with a primary or secondary outcome of SSI rates, was included. A total of 45 articles were included in the final scoping review. The current nonantibiotic intraoperative interventions advised for use include chlorhexidine skin preparation with alcohol, pressurised wound irrigation, Triclosan-coated sutures for skin closure, and negative pressure wound therapy. Many other widely used surgical practices do not have the supporting evidence to validate their routine use in clinical practice to reduce SSI rates. We identified several techniques that can be used in the operating theatre to provide additional opportunities to reduce SSI rates. However, strict adherence to current established SSI prevention guidelines remains the mainstay of ensuring SSI rates remain low.

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

BackgroundMost 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.MethodObservational 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.Results488 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).ConclusionTCBS was associated with a lower incidence of incisional SSI compared to standard sutures in a cohort of patients undergoing elective laparoscopic colorectal cancer surgery.Graphical abstract

Alcoholic chlorhexidine skin preparation or triclosan-coated sutures to reduce surgical site infection: a systematic review and meta-analysis of high-quality randomised controlled trials

WHO and the UK's National Institute for Health and Care Excellence recommend alcoholic chlorhexidine skin preparation and triclosan-coated sutures to prevent surgical site infections (SSIs). Existing meta-analyses that include studies at high risk of bias, combined with the recent publication of large, randomised trials, justify an updated meta-analysis of high-quality randomised controlled trials (RCTs). We aimed to test the rates of SSI according to skin preparation solutions (ie, alcoholic chlorhexidine vs aqueous povidone-iodine) and types of sutures (ie, coated vs uncoated). In this systematic review and meta-analysis, we searched MEDLINE, Embase, Pubmed, and Cochrane Library databases, with no language restrictions, to identify high-quality RCTs testing either alcoholic chlorhexidine skin preparation (vs aqueous povidone-iodine) or triclosan-coated sutures (vs uncoated sutures), or both, published from database inception to Sept 1, 2021. Patients who received clean-contaminated, contaminated, or dirty surgery were included. We predefined the characteristics of a high-quality trial through an expert consensus process to develop an enhanced Cochrane risk of bias-2 tool specifically for RCTs with a primary outcome of SSI. Data were extracted from published reports. Meta-analysis was performed using a random-effects model and heterogeneity was assessed using the I2 statistic. This systematic review and meta-analysis was prospectively registered in PROSPERO, CRD42021267220. Of 942 studies identified, 933 were excluded. Four high-quality RCTs (n=7467 patients) were included that tested alcoholic chlorhexidine. No significant difference in SSI rates was noted between alcoholic chlorhexidine and aqueous povidone-iodine (17·9% [667 of 3723 patients] vs 19·8% [740 of 3744 patients]; odds ratio 0·84 [95% CI 0·65-1·06]; p=0·21, I2=53·1%). Five high-quality RCTs were included that tested triclosan-coated sutures (n=8619 patients), with no significant difference noted between triclosan-coated and uncoated sutures (16·8% [733 of 4360 patients] vs 18·4% [784 of 4259 patients]; OR 0·90 [95% CI 0·74-1·09]; p=0·29, I2=36·4%). Contrary to previous meta-analyses, this study did not show a benefit from either alcoholic chlorhexidine skin preparation or triclosan-coated sutures, both of which are more expensive than other readily available alternatives. Global and national guidance should be reconsidered to remove recommendations for their routine use. National Institute for Health Research (NIHR) Global Health Research Unit.

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

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

Surgical site infection prevention bundle in elective colorectal surgery

Surgical Site Infections (SSIs) are responsible for a significant economic burden as well as intangible costs suffered by the patient, with up to 60% deemed preventable. Colorectal patients are disproportionally affected by SSI due the risk of wound contamination with bowel content. We aimed to reduce the rate of superficial SSI after elective colorectal surgery using a bundle of evidence-based interventions. An SSI prevention bundle was implemented in elective colorectal surgery, comprised of triclosan-coated sutures, 2% chlorhexidine skin preparation and use of warmed carbon dioxide (CO2) during laparoscopic procedures. The SSI reduction strategy was prospectively implemented and compared with historical controls. Our primary outcome measure was the overall rate of superficial SSI. Centres for Disease Control and Prevention criteria, which use microbiological evidence in conjunction with clinical features were used as the definition of SSI. The overall SSI rate was 27.4% in the pre-bundle group (N= 208) and 12.5% in the patients who received the SSI prevention bundle (N= 184) (adjusted odds ratio 0.38; confidence interval 0.21-0.67; P<0.001). The median time to SSI diagnosis was postoperative day 8. Overall patient length of stay (LOS) was unchanged from six days at baseline following implementation of the bundle. We have shown successful implementation of an SSI prevention bundle which has reduced superficial SSI rate. We recommend this SSI prevention bundle becomes standard practice in elective colorectal surgery and plan to extend the bundle to emergency general surgery.

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

IntroductionAcute 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...

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Comparative evaluation of the efficacy of a novel tetracycline-coated suture with triclosan-coated and noncoated sutures on bacterial load reduction: A prospective in vitro study.

Surgical site infection (SSI) is one of the common postoperative complications observed after various periodontal surgeries, and sutures play a vital role in its causation. Thus, the aim of this study is to evaluate and compare the efficacy of a novel tetracycline-coated suture with triclosan-coated and nonantibacterial-coated sutures on bacterial load reduction to prevent SSI by measuring the zone of inhibition. Twenty systemically healthy individuals with moderate chronic periodontitis were included in this study. Fresh unstimulated saliva was collected from each patient and inoculated on three different blood agar plates. Sutures were divided into three groups (Group A: Tetracycline-coated suture, Group B: Triclosan-coated suture, Group C [control group]: Nonantibacterial-coated suture). The antibacterial efficacy of each suture was evaluated by performing agar diffusion test. The zone of inhibition around each suture was calculated, and statistical analysis was performed for the same using Kruskall-Wallis ANOVA test and Mann-Whitney U-test. On intergroup comparison, there was a statistically highly significant difference seen for the zone of inhibition between the groups (P < 0.01) with the highest values in Group A (14.45 mm), followed by Group B (1.4 mm) and least in Group C (0 mm). Tetracycline-coated suture is more efficacious than triclosan-coated suture to reduce bacterial load and further prevent SSIs. However, in vivo clinical trial is must to prove the same.

Perioperative Interventions to Reduce Surgical Site Infections: A Review.

Surgical site infections (SSIs) contribute to increased health care costs and morbidity after procedures as well as prolonged length of stay. Perioperative personnel can use a variety of interventions to help reduce SSI incidence; however, all strategies are not effective for all patients (eg, antibiotic prophylaxis). Results of randomized controlled trials show that some SSI reduction strategies are generally effective, including preoperative skin antisepsis with an alcohol-based agent, closing surgical wounds with triclosan-coated suture, and applying a negative pressure wound therapy device to open and closed wounds. Study results do not show that irrigating clean wounds with crystalloid solutions containing antibiotics or routinely using plastic drapes with or without impregnated iodophor or silver nylon-impregnated dressings significantly reduces SSI incidence. Perioperative leaders should support the implementation of strategies to prevent SSIs and work with interdisciplinary team members to develop an SSI prevention bundle that will meet the needs of their patients.

BJS.04PreciSSIon: A collaborative initiative to reduce incidence of SSI after elective colorectal surgery

Abstract Aims Surgical Site Infection (SSI) is common after colorectal surgery where rates are reported as high as 30%. The aim of this project was to assess whether a collaborative approach to implement a 4-point care bundle could reduce SSI rates across a group of hospitals. Methods PreciSSIon is a Quality Improvement Project (QIP) involving 7 NHS hospitals, with a design based on the Institute for Healthcare Improvement’s Breakthrough Series collaborative model. The Public Health England SSI surveillance questionnaire was used to measure patient-reported SSI at 30 days post-op. An evidence based bundle of care was introduced including: 2% chlorhexidine skin preparation; dual ring wound protectors; triclosan-coated sutures for wound closure; and a second dose of antibiotics after 4 hours. Results All hospitals had implemented the care bundle by February 2020. By December 2020 6/7 hospitals had reduced SSI. Mean patient questionnaire response rate = 84.8%. Mean compliance with each of the above bundle components are as follows: 91%; 72%; 85%; and 92% respectively. Conclusions Implementing an evidence based care bundle, using a collaborative approach to QIP, was effective in reducing the rates of patient-reported SSI following colorectal surgery. The success of this project in the West of England suggests that similar methodology could be used to improve patient outcomes in other regions.

SP3.1.3 Use of a Care Bundle to reduce Surgical Site Infection after Emergency Laparotomy

Abstract Aim Surgical Site Infection (SSI) is common after abdominal surgery. A care bundle was introduced to sustainably reduce SSI after elective colorectal surgery. This study aimed to implement an expanded care bundle after emergency laparotomy. Methods Quality improvement methodology was used. SSI was measured by direct assessment of the wound in patients in hospital at 30 days. For discharged patients, the PHE SSI surveillance questionnaire was used to measure patient-reported SSI 30 days post-operatively. The care bundle included: 2% chlorhexidine skin preparation; dual ring wound protectors; triclosan-coated sutures for wound closure; second dose of antibiotics &amp;gt;4 hours, betadine to the wound and glove change before closure. Bundle compliance was measured and fed back to surgical teams. Results Baseline SSI was 13.5% (178 patients) which reduced to 8.5% (118 patients) following bundle introduction. Response rate was 60%. Compliance with antibacterial sutures was measured for patients whose wounds were closed; 10% received negative pressure dressings. Mortality within 30 days was 9%. Length of stay reduced from mean 22.6 to 12.45, median 13.5 to 9 days. Conclusion The care bundle reduced SSI after emergency laparotomy. Measuring SSI is more difficult after emergency surgery due to higher death rate, longer length of stay and use of laparostomy. Other challenges include difficulty using wound protectors for some procedures e.g. adhesiolysis and changing practice from use of skin clips.

Reducing surgical site infections in low-income and middle-income countries (FALCON): a pragmatic, multicentre, stratified, randomised controlled trial

SummaryBackgroundSurgical site infection (SSI) is the most common postoperative complication worldwide. WHO guidelines to prevent SSI recommend alcoholic chlorhexidine skin preparation and fascial closure using triclosan-coated sutures, but called for assessment of both interventions in low-resource settings. This study aimed to test both interventions in low-income and middle-income countries.MethodsFALCON was a 2 × 2 factorial, randomised controlled trial stratified by whether surgery was clean-contaminated, or contaminated or dirty, including patients undergoing abdominal surgery with a skin incision of 5 cm or greater. This trial was undertaken in 54 hospitals in seven countries (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa). Patients were computer randomised 1:1:1:1 to: (1) 2% alcoholic chlorhexidine and non-coated suture, (2) 2% alcoholic chlorhexidine and triclosan-coated suture, (3) 10% aqueous povidone–iodine and non-coated suture, or (4) 10% aqueous povidone–iodine and triclosan-coated suture. Patients and outcome assessors were masked to intervention allocation. The primary outcome was SSI, reported by trained outcome assessors, and presented using adjusted relative risks and 95% CIs. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03700749.FindingsBetween Dec 10, 2018, and Sept 7, 2020, 5788 patients (3091 in clean-contaminated stratum, 2697 in contaminated or dirty stratum) were randomised (1446 to alcoholic chlorhexidine and non-coated suture, 1446 to alcoholic chlorhexidine and triclosan-coated suture, 1447 to aqueous povidone–iodine and non-coated suture, and 1449 to aqueous povidone–iodine and triclosan-coated suture). 14·0% (810/5788) of patients were children and 66·9% (3873/5788) had emergency surgery. The overall SSI rate was 22·0% (1163/5284; clean-contaminated stratum 15·5% [454/2923], contaminated or dirty stratum 30·0% [709/2361]). For both strata, there was no evidence of a difference in the risk of SSI with alcoholic chlorhexidine versus povidone–iodine (clean-contaminated stratum 15·3% [223/1455] vs 15·7% [231/1468], relative risk 0·97 [95% CI 0·82–1·14]; contaminated or dirty stratum 28·3% [338/1194] vs 31·8% [371/1167], relative risk 0·91 [95% CI 0·81–1·02]), or with triclosan-coated sutures versus non-coated sutures (clean-contaminated stratum 14·7% [215/1459] vs 16·3% [239/1464], relative risk 0·90 [95% CI 0·77–1·06]; contaminated or dirty stratum 29·4% [347/1181] vs 30·7% [362/1180], relative risk 0·98 [95% CI 0·87–1·10]). With both strata combined, there were no differences using alcoholic chlorhexidine or triclosan-coated sutures.InterpretationThis trial did not show benefit from 2% alcoholic chlorhexidine skin preparation compared with povidone–iodine, or with triclosan-coated sutures compared with non-coated sutures, in preventing SSI in clean-contaminated or contaminated or dirty surgical wounds. Both interventions are more expensive than alternatives, and these findings do not support recommendations for routine use.FundingNational Institute for Health Research (NIHR) Global Health Research Unit Grant, BD.

Prevention of surgical site infection in low-resource settings

WHO defines universal health coverage (UHC) as “access to needed essential health services, without financial hardship”. 1 WHOUniversal Health Coverage. https://www.who.int/healthsystems/universal_health_coverage/en/Date: 2021 Date accessed: May 4, 2021 Google Scholar UHC requires about US$100 per head for an essential package of 218 interventions, and approximately $50 per head for a basic package of 108 of the highest priority interventions. 2 Schäferhoff M Martinez S Ogbuoji O Sabin ML Yamey G Trends in global health financing. BMJ. 2019; 365l2185 Crossref PubMed Scopus (12) Google Scholar Yet, estimates in 2016 suggested that only nine of the 49 low-income and middle-income countries (LMICs) could afford the essential package, and that 16 countries could afford the 108 highest priority interventions of the basic package. 2 Schäferhoff M Martinez S Ogbuoji O Sabin ML Yamey G Trends in global health financing. BMJ. 2019; 365l2185 Crossref PubMed Scopus (12) Google Scholar At an average government spend on health in low-income countries of only $9 per head in 2018 (1·2% of Gross National Product), literally every cent counts. 3 WHOGlobal spending on health: weathering the storm. WHO, Geneva2020 Google Scholar Reducing surgical site infections in low-income and middle-income countries (FALCON): a pragmatic, multicentre, stratified, randomised controlled trialThis trial did not show benefit from 2% alcoholic chlorhexidine skin preparation compared with povidone–iodine, or with triclosan-coated sutures compared with non-coated sutures, in preventing SSI in clean-contaminated or contaminated or dirty surgical wounds. Both interventions are more expensive than alternatives, and these findings do not support recommendations for routine use. Full-Text PDF Open Access

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

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). 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. 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. 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.

Use of triclosan-coated suture material as prevention of surgical site infections (literature review)

According to international data, the incidence of infections in the field of surgery in children and adults varies from 2.0 to 20.0 %. The occurrence of the above infections is influenced by many factors: the presence of comorbidities, ASA index, surgical wound class, NNIS risk index. Important factors include the quality of the suture. According to experts of the World Health Organization, 40.0–60.0 % of infections in the field of surgery can be prevented. The first microbiological study of suture (polyglactin 910) with triclosan was published in 2002. According to international studies, the use of a triclosan reduces the adhesion of bacteria to the suture, the viability of microbes and the release of inflammatory mediators. Triclosan actively prevents the colonization of the filament, in addition, concentrations sufficient to suppress the growth and reproduction of pathogens are maintained in the environment for a long time, resulting in the prevention of the development of infectious complications.

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

SummaryBackgroundSurgical site infections (SSIs) are one of the most frequently reported types of hospital-acquired infection and are associated with substantial clinical and economic burden.AimTo 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).MethodsA 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.Findings5,081 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).ConclusionThe 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.

Real-World Outcomes of Patients Undergoing Open Colorectal Surgery with Wound Closure Incorporating Triclosan-Coated Barbed Sutures: A Multi-Institution, Retrospective Database Study

PurposeOpen colorectal surgery is associated with a high rate of postoperative wound complications. This is a single-arm study of real-world outcomes of triclosan-coated barbed suture (Ethicon’s STRATAFIXTM Symmetric PDSTM Plus Knotless Tissue Control Device [SSPP]) used in open colorectal surgery.MethodsRetrospective cohort study using the Premier Healthcare Database. The study included patients who underwent an inpatient open colorectal surgery with wound closure using SSPP (size 0 or 1 to increase the likelihood the suture was used in fascia) between October 2015–September 2019 (N=593). Wound complications, hospital length of stay, total hospital costs (2019 US$), and all-cause readmissions post-discharge were measured. Post-hoc multivariable analyses compared wound complications between non-elective admissions and elective.ResultsThe overall incidence of wound complications within 30-days post-procedure was 7.1%, with the majority of those being surgical site infections (SSI) (6.0%). Mean operation time was 190 (standard deviation [SD]=64.4) mins, postoperative length of stay was 8.1 (SD=11.9) days, 30-day readmission rate was 11.8%, and total hospital costs were $31,693 (SD=$40,076). As compared with published literature on the rate of SSI in colorectal surgery, the 30-day rate of SSI in the present study (6.0%) fell within the range of 5.4% to 18.2% for open colorectal surgery and from 4.3% to 21.5% for combined open and minimally invasive procedures. Multivariable-adjusted incidence proportions of wound complications were slightly lower for non-elective admissions and did not differ significantly from those of elective admissions.ConclusionThe rate of wound complications observed in the present study falls within the range of rates previously reported in the literature, suggesting a safe and effective role for SSPP in open colorectal surgery. In post hoc analyses, the adjusted rate of wound complications was similar between non-elective and elective admissions. Head-to-head studies are required to determine comparative advantages or disadvantages for SSPP versus other sutures.

Chitosan-Coated Surgical Sutures Prevent Adherence and Biofilms of Mixed Microbial Communities.

Sutures are widely used materials for closing the surgical wounds, and being an inert material, sutures are often colonized with drug-resistant polymicrobial biofilms. Surgical site infection (SSI) isa hospital-acquired infection caused by bacteria and fungi specifically in the sutured sites. Although most of the currently available sutures possess antibacterial property, their ability to prevent biofilm colonization by polymicrobial communities is underexplored. So, the present study shows that extracted chitosan (EC) from crab shells prevented the adherence of Staphylococcus epidermidis and Candida albicans, the predominant members that exist as mixed species at the site of SSI. In comparison with a commercial chitosan, EC showed profound inhibition of slime formation and mixed species biofilm inhibition. Intriguingly, EC-coated sutures could inhibit the growth of both bacterial and fungal pathogens when comparing with a commercial triclosan-coated suture which was active only against the bacterial pathogen. Scanning electron microscopy results revealed inhibition of C. albicans hyphal formation by the EC-coated sutures that is a crucial virulence factor responsible for tissue invasiveness. Collectively, the results of the present study showed that EC from crab shells (discarded material as a recalcitrant biowaste) could be used as an alternative to combat drug-resistant biofilms which are the prime cause for SSIs.

Meta-Analysis of High Quality Randomised Controlled Trials Testing Alcoholic Chlorhexidine Skin Preparation or Triclosan Coated Sutures to Reduce Surgical Site Infection

Background: The World Health Organisation and the UK’s National Institute of Clinical Excellence recommend alcoholic chlorhexidine skin preparation and triclosan coated sutures to prevent surgical site infections (SSI). Existing meta-analyses that include high risk of bias studies combined with recent publication of large randomised trials together justify an updated meta-analysis of high quality randomised controlled trials (RCTs). Methods: A systematic review was performed to identify high quality RCTs testing either alcoholic chlorhexidine skin preparation (versus aqueous povidone-iodine) and/or triclosan coated sutures (versus uncoated sutures), until September 2021. Patients undergoing clean-contaminated, contaminated, or dirty surgery were included. We pre-defined the characteristics of a high quality trial through an expert consensus process that modified the Cochrane Risk of Bias tool specifically for RCTs with a primary outcome of SSI. Findings: Four high quality RCTs (n=7,467 patients) were included that tested alcoholic chlorhexidine. There was no significant difference in SSI rates between alcoholic chlorhexidine and aqueous povidone-iodine (17.9% vs 19.8%, OR 0.84, 95% CI 0.65-1.06, p=0.205). Five high quality RCTs were included that tested triclosan coated sutures (n=8,619 patients), with no significant difference between coated and uncoated sutures (16.7% vs 18.5%, OR 0.81, 95% CI 0.65-1.08, p=0.177). Stratified analyses demonstrated consistent results for clean-contaminated surgery, but only one trial was included that addressed contaminated/dirty surgery for either interventions. Interpretation: Contrary to previous meta-analyses, this study did not show benefit from either alcoholic chlorhexidine skin preparation or triclosan coated sutures, both of which are more expensive than other readily available alternatives. Global and national guidance should be reconsidered to remove strong recommendations for their routine use. Funding Information: National Institute for Health Research (NIHR) Global Health Research Unit. Declaration of Interests: The authors have no conflicts of interest to declare.

Prevention of Periprosthetic Joint Infection (PJI): A Clinical Practice Protocol in High-Risk Patients.

Background: Periprosthetic joint infection (PJI) represents 25% of failed total knee arthroplasties (TKA). The European Knee Associates (EKA) formed a transatlantic panel of experts to perform a literature review examining patient-related risk factors with the objective of producing perioperative recommendations in PJI high-risk patients. Methods: Multiple databases (Pubmed/MEDLINE, EMBASE, Scopus, Cochrane Library) and recommendations on TKA PJI prevention measures from the International Consensus Meetings on PJI from the AAOS and AAHKS were reviewed. This represents a Level IV study. Results: Strong evidence was found on poor glycemic control, obesity, malnutrition, and smoking being all associated with increased rates of PJI. In the preoperative period, patient optimization is key: BMI < 35, diet optimization, Hemoglobin A1c < 7.5, Fructosamine < 292 mmol/L, smoking cessation, and MRSA nasal screening all showed strong evidence on reducing PJI risk. Intraoperatively, a weight-based antibiotic prophylaxis, accurate fluid resuscitation, betadine and chlorhexidine dual skin preparation, diluted povidone iodine solution irrigation, tranexamic acid administration, and monofilament barbed triclosan-coated sutures for soft tissues closure all represented effective prevention measures. In the postoperative period, failure to reach normalization of ESR, CRP, D-dimer, and IL-6 six weeks postoperatively suggested early PJI. Conclusion: The current recommendations from this group of experts, based on published evidence, support risk stratification to identify high-risk patients requiring implementation of perioperative measures to reduce postoperative PJI.