Surgical Infection Society Guidelines for Use of Antimicrobial Coated Suture to Reduce the Risk of Surgical Site Infection after Abdominal Surgery

Authors:
Anu Seshadri, Janice Lester, Jared Huston, Joseph Forrester, Najhi Farooqi, Nimitt Patel, Philip S. Barie

Body of Abstract:
Background: Abdominal surgery is common as are surgical site infections (SSIs). Triclosan (polychlorophenoxyphenol) is an antimicrobial antiseptic used in a variety of consumer products and has been used to treat a suture material including braided polyglactan 910, poliglecaprone 25, and polydioxanone. The Surgical Infection Society’s Therapeutics and Guidelines Committee convened to develop pragmatic recommendations for use of triclosan-coated suture in prevention of SSI after abdominal surgery.

Methods: A guidelines team with experience in surgical infectious disease, epidemiology, and systematic reviews for guidelines was established to determine the clinical question and study protocol. A research librarian designed and performed searches of three bibliographic databases: PubMed, Embase, and Web of Science. Methodology for this practice management guideline conforms to RIGHT Working Group standards. Covidence was used for study selection and quality and certainty of published evidence was evaluated using GRADE with strength of recommendations graded as strong or weak. The clinical question assessed was: “For adult patients undergoing abdominal surgery, does triclosan-coated suture reduce the risk of post-operative surgical site infection?”

Results: 3,616 studies were identified, with 30 studies involving 97,807 patients informing the clinical question response. Among included studies, 13 (43%) were RCTs and 17 (57%) were meta-analyses. 17 (57%) studies comprising 67,445 (69%) patients demonstrated reduction in SSI with 13 (43%) studies comprising 30,362 (31%) patients demonstrating no benefit. Estimated cumulative adjusted absolute risk reduction associated with triclosan-coated sutures, among studies demonstrating benefit, was 3.2% (standard deviation (SD) +/- 6.2%). One large multinational randomized controlled trial demonstrated no benefit in lower resource settings. Overall quality of evidence was high. Some concerns over risk of bias were identified for 22 studies although most commonly this was due to subgroup analyses informing the recommendation. We recommend triclosan-coated suture be used for incision closure after abdominal surgery for the small but significant reduction in SSI (Grade 1A). We suggest this benefit may not translate into lower resource settings. (Grade 1B).

Conclusions: Higher level evidence suggests a small, but significant benefit for triclosan-coated suture in reducing SSI risk following abdominal surgery. However, this benefit may not be fully realized in all practice settings. For surgeons, infection preventionists and health care systems, use of triclosan-coated suture comes down to a local cost-benefit analysis. Ultimately, the decision to use triclosan-coated suture to reduce risk of SSI should be made in the context of the cost of suture, the cost of a surgical site infection, anticipated infection rates for a procedure, and local availability.