Abstract
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In the study by Zhuang et al. [2], patients undergoing laparotomy were divided into three groups. In the study group (150), surgical incisions were closed with triclosan-coated polydioxanone (PDS) sutures; in the PDS group (150) incisions were closed with regular PDS suture; and in the control group incisions were closed with a common suture. The incidence of SSI was 0% in the study and PDS group and there were 12 (8%) SSIs in the control group. In the final analysis, the authors have, despite the primary randomization into three groups, divided patients into two groups: the study group (150 triclosan-coated PDS) and the control group (150 common and 150 PDS sutures). They conclude that the incidence of SSI is 0% in the study group and 4% (12/300) in the control group. Our opinion is that this study shows no difference in the incidence of SSI when comparing the use of triclosan-coated PDS sutures with the use of regular PDS sutures.
In a randomized study with 184 laparotomy patients, Rasic et al. [3] found that the rate of SSI was lower in the triclosan-coated suture group compared with the control group (4.4% versus 12.9%). Limitations of this study are that the criteria of SSI was not specified and that the patients were followed up only during the hospitalization; not up to 30 post-operative days. The U.S. Centers for Disease Control and Prevention defines an infection as an SSI if it occurs within 30 post-operative days [4].
Galal et al. [5] reported that surgical incision closure with triclosan-coated sutures decreased the incidence of SSI after different surgical procedures in a trial with 450 patients at Cairo University Hospital in Egypt. We found it problematic that the results of only a single hospital were reported, although the study was multi-center. In addition, heterogeneous operative procedures ranging from lipoma removal to vascular surgery were included in the study.
Thimour-Bergström et al. [6] conducted a randomized double-blinded study including 374 coronary artery bypass surgery patients. They reported that leg surgical incision closure with triclosan-coated sutures reduces SSI rate after open vein harvesting. The study has some limitations that make us unable to agree with the authors' conclusion. First, the diagnosis of SSI should be made within 30 d of surgery [4]. In this study, the difference of incidence of SSI on the thirtieth post-operative day was only 4%. However, the authors reported diagnoses that were made on the sixtieth post-operative day. Furthermore, the primary diagnosis of SSI was made by a patient, not by a surgeon. Second, the authors reported the results of univariate analysis only. The number of bypasses was significantly lower in the triclosan group compared with the control group. It is possible that the number of bypasses, reflecting longer operation time, would have been an independent risk factor for SSI rather than use of non-triclosan suture if the multivariable analysis were performed. Third, the study was supported financially by Ethicon, Inc., Somerville, New Jersey, the company providing triclosan-coated sutures.
In the randomized study by Isik et al. [7] with 510 cardiac surgery patients, the incidence of both sternal and vein-harvesting SSI was 5.3% in the triclosan group and 5.6% in the control group. However, only sternal surgical incision infections (2.4% in the triclosan-group and 3.5% in the control group) were included in the meta-analysis.
These five studies with 1,968 patients comprise 41% of the population of the meta-analysis. Furthermore, Diener et al. [8] published a randomized controlled multi-center study recently with 1,185 patients (587 triclosan-coated and 598 non-triclosan coated). This study, not included in the meta-analysis, reported that the occurrence of SSI after abdominal wall closure did not differ between the triclosan-coated group and the control group. The meta-analysis would have resulted with the conclusion that the use of triclosan-coated sutures does not decrease the incidence of SSI if the study by Diener et al. [8] was included in the analysis and the studies of Zhuang et al. [2], Isik et al. [7], and Thimour-Bergström et al. [6] were interpreted as “non-triclosan–favoring” and the studies of Rasic et al. [3] and Galal et al. [5] were excluded from the analysis.