j o u r n a l o f s u r g i c a l r e s e a r c h 2 0 1 ( 2 0 1 6 ) 1 0 5 e1 1 7

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.JournalofSurgicalResearch.com

Efficacy of triclosan-coated sutures for reducing

risk of surgical site infection in adults:
a meta-analysis of randomized clinical trials

Jiao Guo, MD,a,1 Ling-Hui Pan, MD, PhD,b,1 Yun-Xi Li, MD,c,1
Xiang-Di Yang, MD,a Le-Qun Li, MD, PhD,d Chun-Yan Zhang, MD,a,*
and Jian-Hong Zhong, MDd,**
a
Experimental Department, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, PR China
b
Anesthesia Department, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, PR China
c
Cancer Registry Department, People’s Hospital of Fusui County, Fusui, PR China
d
Hepatobiliary Surgery Department, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, PR China

article info abstract

Article history: Background: Surgical site infection (SSI) is the third most frequent type of nosocomial in-
Received 30 May 2015 fections. Triclosan-coated sutures are often used to reduce the risk of SSI, but studies
Received in revised form examining this have given conflicting results. Therefore, this meta-analysis was performed
19 September 2015 to assess the efficacy of triclosan-coated sutures for reducing risk of SSI in adults.
Accepted 7 October 2015 Methods: PubMed, EMBASE, Google Scholar, and ClinicalTrials.gov were searched to identify
Available online 23 October 2015 randomized clinical trials evaluating triclosan-coated sutures for preventing SSI on pa-
tients 18 y or older.
Keywords: Results: Thirteen randomized clinical trials involving 5256 participants were included.
Surgical site infection Triclosan-coated sutures were associated with lower risk of SSI than uncoated sutures across
Triclosan all surgeries (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.65e0.88, P < 0.001). Similar
Suture proportions of patients experienced wound dehiscence with either type of suture (RR 0.97,
Antimicrobial 95% CI 0.49e1.89, P ¼ 0.92). Subgroup analysis showed lower risk of SSI with triclosan-coated
Antiseptic sutures in abdominal surgeries (RR 0.70, 95% CI 0.50e0.99, P ¼ 0.04) and group with prophy-
lactic antibiotic (RR 0.79, 95% CI 0.63e0.99, P ¼ 0.04). However, such risk reduction was not
observed in cardiac surgeries, breast surgeries, or group without prophylactic antibiotic.
Conclusions: Triclosan-coated sutures can decrease the incidence of SSI in abdominal sur-
geries and might not interfere with wound healing process. Nevertheless, further studies
are needed to examine whether triclosan-coated sutures are effective at preventing SSI in
non-abdominal surgeries and to further study the interaction of antibiotic prophylaxis with
triclosan-coated sutures.
ª 2016 Elsevier Inc. All rights reserved.

* Corresponding author. Experimental Department, Affiliated Tumor Hospital of Guangxi Medical University, He Di Rd. #71, Nanning
530021, PR China. Tel.: þ86 771-5330855 (office); fax: þ86 771-5312000.
** Corresponding author. Hepatobiliary Surgery Department, Affiliated Tumor Hospital of Guangxi Medical University, He Di Rd. #71,
Nanning 530021, PR China. Tel.: þ86 771-5330855 (office); fax: þ86 771-5312000.
E-mail addresses: zcy_263@163.com (C.-Y. Zhang), zhongjianhong66@163.com (J.-H. Zhong).
1
These authors contributed equally to this work.
0022-4804/$ e see front matter ª 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jss.2015.10.015
106 j o u r n a l o f s u r g i c a l r e s e a r c h 2 0 1 ( 2 0 1 6 ) 1 0 5 e1 1 7
1. Introduction
Surgical site infection (SSI) is a persistent challenge in modern
surgery around the world. According to the US Centers for
Disease Control (CDC) National Nosocomial Infections Sur-
veillance system, SSI is the third most frequent nosocomial
infection in the United States, accounting for 14%e16% of in-
fections among hospitalized patients and 38% of infections in
surgical patients [1,2]. In European countries, the estimated
SSI incidence range varies from 1.5% to 20%, owing to differ-
ences among studies regarding how surgical procedures are
conducted and how SSI data are collected [3].
SSI leads not only to substantial morbidity and mortality,
but also to longer hospital stays and greater health-care costs
[4,5]. SSI can also influence patient quality of life and work
productivity because of time spent in hospital.
Although several risk factors have been associated with SSI
[1,2,6], contamination of suture materials appears to be one of
the most frequent causes [7e9], whereas a less frequent cause
is the presence of contaminated foreign material in the
wound. Once the suture material is contaminated, the prog-
ress of SSI becomes complicated, and local anti-infection
mechanisms are often ineffective [10,11] because microbes
in the sutures can reinfect the site even after cleaning or
systemic antibiotic treatment.
To reduce the risk of suture contamination and therefore of
SSI, suture materials can be coated with antibacterial agents
such as triclosan (polychloro phenoxy phenol), a broad-
spectrum antimicrobial that affects gram-positive and gram-
negative bacteria [8,12,13]. Triclosan has been widely used
for more than 30 y in consumer and health-care products,
including toothpaste, soap, hand hygiene products, and sur-
gical scrubs [14]. It appears to be safe and effective against
bacteria [13,14]. Since the US Food and Drug Administration
approved in 2002, the first coated surgical suture, which was
coated with antimicrobial polyglactin 910 (VICRYL Plus, Ethi-
con, NJ), a variety of triclosan-coated sutures have been
licensed and are widely used, including triclosan-coated
poliglecaprone 25 antimicrobial suture (MONOCRYL Plus;
Ethicon) and triclosan-coated polydioxanone antimicrobial
suture (PDS Plus; Ethicon).
Numerous studies in vivo and in vitro have shown that
triclosan-coated sutures are associated with significantly
lower risk of SSI than uncoated sutures [15e21]. On the other
hand, some clinical trials have suggested that coating sutures
with triclosan does not reduce risk of SSI [22e28], and that
such sutures may fail more often than conventional uncoated
ones, leading to wound dehiscence [29].
To provide a comprehensive assessment of the available ev-
idence, we meta-analyzed randomized clinical trials (RCTs)
comparing triclosan-coated with uncoated sutures for prevent-
ing SSI and wound dehiscence after various surgeries in adults.
2. Methods
This meta-analysis was carried out and reported based as
closely as possible on the guidelines of the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses statement
[30].
2.1. Search strategy
Two authors (J.G. and J.H.Z.) independently searched PubMed,
EMBASE, Google Scholar, and Clinicaltrials.gov using the
following keywords: triclosan, antimicrobial, antiseptic, surgical
site infection, surgical site infections, and suture. Searches were
not restricted based on publication type, language, or date.
The reference lists of identified studies and review articles
were manually searched to identify additional potentially
eligible studies.
2.2. Study selection
To be included in our meta-analysis, studies had to be RCTs
with patients aged 18 y or older comparing the clinical efficacy
of triclosan-coated sutures with traditional uncoated sutures
for one or more types of surgery. For studies involving over-
lapping or identical patient populations, only the most recent
study was included. Studies were included only if they were
full-length original research reports, not abstracts, or non-
peer-reviewed RCTs. Studies were excluded if anti-SSI in-
terventions were undertaken besides using coated sutures.
Studies were assessed for eligibility and selected indepen-
dently by two authors (J.G. and J.-H.Z.), with disagreements
resolved by discussion.
2.3. Data extraction
Two authors (J.G. and J.H.Z.) independently extracted the
following data from included RCTs: first author’s name, coun-
try, date of publication, total numbers of patients and numbers
in each suture group, study design and blinding, surgical
procedures, operating time, length of follow-up, incidences of
SSI and wound dehiscence, and whether SSI was defined
according to US CDC criteria [1]. Outcomes based on intention-
to-treat analyses were extracted wherever possible; if
outcomes were not reported on an intention-to-treat basis,
then they were extracted on a per-protocol basis. Discrep-
ancies in data extracted by each author were resolved by
discussion.
2.4. Risk of bias and quality assessment
As described in detail previously [31], assessment of risk of
bias and methodological quality was conducted according
to Cochrane Handbook for Systematic Reviews of Intervention
[32], which contains several domains concerning bias of
selection, performance, detection, attrition, and reporting.
Studies with low risk of bias for all key domains were
considered to be of ow risk of bias, whereas studies with
unclear or high risk of bias for one or more key domains
were considered to be of unclear or high risk of bias,
respectively.
 j o u r n a l o f s u r g i c a l r e s e a r c h 2 0 1 ( 2 0 1 6 ) 1 0 5 e1 1 7 107

2.5. Statistical analysis
The primary outcome was incidence of SSI, and secondary
outcomes were occurrence of wound dehiscence, qualitative
analysis of treatment costs, length of hospital stay, operating
time, and causative organism. Pooled data extracted from
eligible trials were quantitatively analyzed using RevMan 5.2
software (Cochrane Collaboration). Heterogeneity among
pooled studies was tested using the chi-squareebased Q test
and the I2 statistic. P > 0.1 for the Q test indicated no statis-
tically significant heterogeneity among included studies. In
the event that P  0.1, the extent of heterogeneity was
assessed using the I2 value: an I2 less than 25% was defined as
low heterogeneity; I2 between 25% and 50%, moderate het-
erogeneity; and I2 greater than 50%, high heterogeneity.
Pooled studies were meta-analyzed using a fixed-effect model
in the absence of significant heterogeneity among studies;
otherwise, a random-effect model was used. Risk ratios (RRs)
and associated 95% confidence intervals (CIs) were used to
estimate dichotomous outcomes. Meta-analyses were dis-
played graphically in the form of forest plots, with P < 0.05
considered to be statistically significant. Subgroup analyses
were performed based on length of follow-up, antibiotic pro-
phylaxis, surgery type, and suture type.
Sensitivity analyses were carried out by repeating meta-
analyses after systematically deleting each of the pooled
studies and examining whether the results changed signifi-
cantly. Funnel plots were generated, and Egger’s test [33e35]
was performed to assess the potential for publication bias in
our meta-analysis.
3. Results
3.1. Description of studies
Systematic searches of the literature identified 438 studies
about triclosan-coated sutures, of which 378 were excluded on
the basis of the titles and abstracts. Of the remaining 60
studies, 38 were excluded because they were not original re-
ports of clinical RCTs. Two publications [27,36] published in
different languages were based on the same population, so
they were considered one study. Four RCTs [37e40] that were
apparently published only as abstracts were excluded, as were
two RCTs [41,42] involving pediatric patients. Two RCTs [43,44]
were further excluded owing to low level of RCT. In the end, 13
RCTs [23e25,27e29,45e51] were included in the meta-
analysis. The process of study selection is shown in Figure 1.

Fig. 1 e PRISMA flow diagram of study identification, screening and inclusion. PRISMA, Preferred Reporting Items for
Systematic Reviews and Meta-Analyses. (Color version of figure is available online.)
 108
Table 1 e Characteristics of RCTs comparing rates of SSI site infection in adult patients treated with triclosan-coated or uncoated sutures.
Study Country Sample size Study Blinding Suture types Surgical procedure Wound CDC Length of
(Study/control) design (coated/uncoated) description criteria follow-up

Deliaert et al. 2009 [29] Netherlands 52 (26/26) Single-center Double VICRYL Plus/VICRYL Breast reduction Clean NR 4 wk
Baracs et al. 2011 [27] Hungary 385 (188/197) Multicenter NR PDS plus/PDS Ⅱ Colorectal surgery Clean-contaminated NR 30 d
Galal and Egypt 450 (230/220) Multicenter Double VICRYL Plus/VICRYL General surgery (78%), Clean, Y 30 d (1 y if
El-Hindawy 2011 [45] plastic surgery (19%), Clean-contaminated prosthesis)

j o u r n a l o f s u r g i c a l r e s e a r c h 2 0 1 ( 2 0 1 6 ) 1 0 5 e1 1 7
other (3%) Contaminated
Rasic et al. 2011 [46] Croatia 184 (91/93) Single-center Double VICRYL Plus/VICRYL Colorectal surgery NR NR NR
Williams et al. UK 150 (75/75) Single-center Double VICRYL Plus/VICRYL; Breast cancer surgery NR Y 6 wk
2011 [47] MONOCRYL Plus/MONOCRYL
Zhang et al. 2011 [48] China 101 (51/50) Multicenter Open-label VICRYL Plus/Chinese Modified radical Clean Y 90 d
silk suture mastectomy
Isik et al. 2012 [24] Turkey 510 (170/340) Single-center Double VICRYL Plus/VICRYL Cardiac surgery NR Y 30 d
Seim et al. 2012 [25] Norway 323 (160/163) Single-center Open-label VICRYL Plus/VICRYL Vein harvesting NR NR 4 wk
for CABG
Turtiainen et al. Finland 276 (139/137) Multicenter Double VICRYL Plus/VICRYL; Lower limb NR Y 30 d
2012 [28] MONOCRYL Plus/MONOCRYL revascularization
Justinger et al. Germany 856 (485/371) Single-center Double PDS Plus/PDS Ⅱ Laparotomy (various Clean Y 2 wk
2013 [49] abdominal procedures) Clean-contaminated
Contaminated
Septic
Nakamura et al. Japan 410 (206/204) Single-center Double VICRYL Plus/VICRYL Colorectal surgery Clean Y 30 d
2013 [50] Clean-contaminated
Contaminated
Dirty
Thimour-Bergstrom Sweden 374 (184/190) Single-center Double VICRYL Plus/VICRYL; Leg incision after vein NR Y 60 d
et al. 2013 [51] MONOCRYL Plus/MONOCRYL harvesting for CABG
Diener et al. 2014 [23] Germany 1185 (587/598) Multicenter Double PDS Plus/PDS Ⅱ Elective midline Clean Y 30 d
abdominal laparotomy Clean-contaminated
Contaminated
Dirty

CABG ¼ coronary artery bypass grafting; CDC criteria ¼ US Centers for Disease Control and Prevention criteria for definition of SSI; MONOCRYL ¼ poliglecaprone 25 suture; MONOCRYL Plus ¼ triclosan-
coated poliglecaprone 25 antimicrobial suture; NR ¼ not reported; PDS ¼ polydioxanone suture; PDS Plus ¼ triclosan-coated polydioxanone antimicrobial suture; VICRYL ¼ polyglactin 910 suture;
VICRYL Plus ¼ triclosan-coated polyglactin 910 antimicrobial suture; Y ¼ reported.
 j o u r n a l o f s u r g i c a l r e s e a r c h 2 0 1 ( 2 0 1 6 ) 1 0 5 e1 1 7 109

Table 2 e Risk of bias summary.

Study Random Allocation Blinding Blinding of Incomplete Selective Other
sequence concealment of participants outcome outcome data reporting bias
generation (selection and personnel assessment (attrition (reporting
(selection bias) (performance (detection bias) bias)
bias) bias) bias)

Deliaert et al. 2009 [29] ? þ þ þ þ  þ

Baracs et al. 2011 [27] þ ? ? ?  þ þ
Galal and El-Hindawy2011 [45] þ þ þ þ þ þ þ
Rasic et al. 2011 [46] þ þ ? ? þ ? ?
Williams et al. 2011 [47] þ þ þ þ þ  þ
Zhang et al. 2011 [48] þ þ   þ þ 
Isik et al. 2012 [24] ? ? ? ? þ ? þ
Seim et al. 2012 [25] ? þ   þ þ þ
Turtiainen et al. 2012 [28] ? þ þ þ þ þ þ
Justinger et al. 2013 [49] þ þ þ þ  þ þ
Nakamura et al. 2013 [50] þ þ þ þ þ þ þ
Thimour-Bergstrom et al. 2013 [51] þ þ þ þ þ þ þ
Diener et al. 2014 [23] þ þ þ þ þ þ þ

þ ¼ low risk;  ¼ high risk; ? ¼ unclear risk.

Altogether, the included studies in our meta-analysis
involved 5256 adult participants, 2592 of whom were ran-
domized to be treated with triclosan-coated sutures, and
2664 to be treated with uncoated sutures. Six trials
[24,25,29,45,46,50] compared VICRYL Plus sutures with VICRYL
sutures, three trials [23,27,49] compared PDS Plus sutures with
PDS Ⅱ sutures, whereas the remaining four trials [28,47,48,51]
compared two types of coated sutures with the correspond-
ing uncoated sutures. Eight RCTs [24,25,29,46,47,49e51] were
conducted at a single center, whereas five [23,27,28,45,48]
were conducted at multiple centers. Follow-up ranged from
2 wk to 1 y, with most studies reporting outcomes at 30 d in
accordance with CDC criteria. Five RCTs [23,27,46,49,50]
involved abdominal surgeries, three RCTs [24,25,51] regarded
cardiac surgeries, three RCTs [29,47,48] concerned breast
surgeries, and two RCTs [28,45] referred to other surgeries.
Detailed characteristics of the included studies are
summarized in Table 1.
Table 2 summarizes assessment results of risk of bias and
methodological quality. Of the 13 studies included, nine trials
reported random sequence generation and selective report-
ing, 11 trials reported allocation concealment and incomplete
outcome data, and 10 trials reported blinding of participants,
personnel, and outcome assessment. According to Cochrane
Handbook for Systematic Reviews of Intervention [32], five RCTs
[23,45,47,50,51] were assessed to be high quality, four RCTs
[25,27,48,49] were considered to be low quality, whereas the
remaining four RCTs [24,28,29,46] were classified to be
moderate-quality. Consequently, the qualities of included
RCTs were acceptable.
3.2. Risk of SSI with triclosan-coated versus uncoated
sutures
All the included RCTs [23e25,27e29,45e51] reported SSI out-
comes. Triclosan-coated sutures significantly reduced the

Fig. 2 e Forest plot of meta-analysis comparing the incidence of SSI in patient groups treated with triclosan-coated or
uncoated sutures. (Color version of figure is available online.)
110 j o u r n a l o f s u r g i c a l r e s e a r c h 2 0 1 ( 2 0 1 6 ) 1 0 5 e1 1 7

Table 3 e Summary of subgroup analyses stratified by length of follow-up, type of surgery or type of suture, and antibiotic
prophylaxis.
Group or subgroup No. of No. of SSI, n/N Relative risk of P* I2 (%)
studies participants SSI (95% CI)
Coated Uncoated
sutures sutures

Overall 13 5256 262/2592 349/2664 0.76 (0.65e0.88) 0.0002 25

Follow-up length
>30 d 3 625 35/310 57/315 0.63 (0.43e0.93) 0.02 0
30 d 9 4447 223/2191 280/2256 0.79 (0.63e0.98) 0.03 34
Not reported 1 184 4/91 12/93 0.34 (0.11e1.02) 0.05 d
Type of surgery
Abdominal 5 3020 154/1557 193/1463 0.70 (0.50e0.99) 0.04 52
Breast 3 303 12/152 19/151 0.64 (0.33e1.26) 0.20 0
Cardiac 3 1207 48/514 74/693 0.77 (0.54e1.08) 0.13 0
Other 2 726 48/369 63/357 0.72 (0.35e1.48) 0.37 75
Antibiotic prophylaxis
Received 8 3769 211/1931 254/1838 0.79 (0.63e0.99) 0.04 29
Not received 2 426 23/210 38/216 0.63 (0.39e1.01) 0.05 d
Not reported 3 1061 28/451 57/610 0.60 (0.38e0.94) 0.03 5
Type of suturey
VICRYL plus versus VICRYL 6 1929 55/883 100/1046 0.62 (0.43e0.90) 0.01 23
PDS plus versus PDS 3 2426 141/1260 162/1166 0.81 (0.59e1.13) 0.22 50
Mixed suture 4 901 66/449 87/452 0.78 (0.58e1.04) 0.09 0

PDS ¼ polydioxanone suture; VICRYL ¼ polyglactin 910 suture; VICRYL Plus ¼ triclosan-coated polyglactin 910 antimicrobial suture.
*
Based on the Z test.
y
Suture types are defined in Table 1.

incidence of SSI (RR 0.76, 95% CI 0.65e0.88, P < 0.001), and this
meta-analysis was not affected by significant heterogeneity
(P ¼ 0.20, I2 ¼ 25%; Fig. 2). Sensitivity analysis further showed
that deleting any single data set did not significantly affect the
degree of heterogeneity or the pooled RR for risk of SSI.
Subgroup analysis was performed according to participant
characteristics and interventions, including length of follow-
up, antibiotic prophylaxis, and type of surgery or sutures
(Table 3; Fig. 3). In analysis stratified by surgery type, the
beneficial effect of triclosan-coated sutures was significant in
abdominal surgeries based on data pooled from five trials
[23,27,46,49,50] (RR 0.70, 95% CI 0.50e0.99, P ¼ 0.04). In contrast
to the case with abdominal surgeries, the risk of SSI was
similar with either type of suture in cardiac surgeries
[24,25,51] (RR 0.77, 95% CI 0.54e1.08, P ¼ 0.13), breast surgeries
[29,47,48] (RR 0.64, 95% CI 0.33e1.26, P ¼ 0.20), and other sur-
geries [28,45] (RR 0.72, 95% CI 0.35e1.48, P ¼ 0.37).
In analysis stratified by suture type, data pooled from six
RCTs [24,25,29,45,46,50] comparing VICRYL Plus with VICRYL
showed significantly lower SSI risk with coated sutures (RR
0.62, 95% CI 0.43e0.90, P ¼ 0.01). Pooled result of studies
[28,47,48,51] comparing two types of coated sutures versus the
corresponding uncoated sutures suggested that the risk of SSI
was similar between the two groups (RR 0.78, 95% CI 0.58e1.04,
P ¼ 0.09). For RCTs [23,27,49] that studied PDS Plus versus PDS
Ⅱ, risk of SSI also did not decrease with coated sutures (RR 0.81,
95% CI 0.59e1.13, P ¼ 0.22).
In analysis stratified by length of follow-up based on data
pooled across all types of surgery, the reduction of SSI risk
with triclosan-coated sutures was significant regardless of
whether follow-up was longer than 30 d (RR 0.63, 95% CI
0.43e0.93, P ¼ 0.02) or shorter than 30 d (RR 0.79, 95% CI
0.63e0.98, P ¼ 0.03).
In analysis stratified by antibiotic prophylaxis, the risk of
SSI was significantly decreased for RCTs with patients who
received antibiotic [23,25,27,28,46,47,49,50] (RR 0.79, 95% CI
0.63e0.99, P ¼ 0.04). According to data of two RCTs with pa-
tients who did not receive antibiotic [29,51], the risk of SSI did
not decrease with a bordered P value (RR 0.63, 95% CI
0.39e1.01, P ¼ 0.05). The sensitivity analysis showed that the
risk of SSI became similar between the two groups when the
study of Justinger et al. [49] (RR 0.86, 95% CI 0.72e1.03, P ¼ 0.11),
Rasic et al. [46] (RR 0.83, 95% CI 0.68e1.01, P ¼ 0.06), Williams
et al. [47] (RR 0.79, 95% CI 0.62e1.01, P ¼ 0.06) or Nakamura et al.
[50] (RR 0.83, 95% CI 0.67e1.03, P ¼ 0.09) was removed. The
result of sensitivity analysis in group with use of prophylactic
antibiotic is summarized in Table 4, and the detailed infor-
mation of antibiotic prophylaxis is summarized in Table 5.
3.3. Risk of wound dehiscence with triclosan-coated
versus uncoated sutures
Four RCTs [23,29,46,51] reported data on wound dehiscence,
which were meta-analyzed using a random-effect model
because of moderate heterogeneity (I2 ¼ 70%). Risk of wound
dehiscence was similar between coated and uncoated sutures
groups (RR 0.97, 95% CI 0.49e1.89, P ¼ 0.92; Fig. 4). Sensitivity
analysis showed that deleting each of the four data sets one by
one did not significantly affect the pooled RR.
3.4. Treatment cost, length of hospital stay, operating
time, and causative organism in patients treated with
triclosan-coated versus uncoated sutures
Subsets of the 13 RCTs compared the use of coated and
uncoated sutures in terms of treatment cost [27,45,50],
 j o u r n a l o f s u r g i c a l r e s e a r c h 2 0 1 ( 2 0 1 6 ) 1 0 5 e1 1 7 111

Fig. 3 e Forest plot of meta-analysis comparing the incidence of SSI in different subgroups of patients treated with triclosan-
coated or uncoated sutures. (Color version of figure is available online.)
112 j o u r n a l o f s u r g i c a l r e s e a r c h 2 0 1 ( 2 0 1 6 ) 1 0 5 e1 1 7

Table 4 e Sensitivity analysis in subgroup with use of prophylactic antibiotic from studies included in the meta-analysis.
No. of studies Study removed No. of SSI, n/N Relative risk of P* I2 (%)
removed participants SSI (95% CI)
Coated Uncoated
sutures sutures

0 None 3769 211/1931 254/1838 0.79 (0.63e0.99) 0.04 29

1 Baracs et al. 2011 [27] 3384 188/1743 230/1641 0.76 (0.59e0.97) 0.03 35
1 Rasic et al. 2011 [46] 3585 207/1840 242/1745 0.83 (0.68e1.01) 0.06 18
1 Williams et al. 2011 [47] 3619 201/1856 240/1763 0.79 (0.62e1.01) 0.06 38
1 Seim et al. 2012 [25] 3446 195/1771 237/1675 0.77 (0.60e0.99) 0.04 38
1 Turtiainen et al. 2012 [28] 3493 180/1792 224/1701 0.75 (0.58e0.96) 0.02 31
1 Justinger et al. 2013 [49] 2913 180/1446 212/1467 0.86 (0.70e1.06) 0.16 10
1 Nakamura et al. 2013 [50] 3359 202/1725 235/1634 0.83 (0.67e1.03) 0.09 22
1 Diener et al. 2014 [23] 2584 124/1344 158/1240 0.74 (0.56e0.98) 0.03 30
*
Based on the Z test.

length of hospital stay [23,28,46,49,50], operating time
[23,25,28,46,49e51], and causative organism [24,27,50,51]
(Tables 6 and 7). Three RCTs [27,45,50] concluded that
triclosan-coated sutures might reduce treatment costs,
owing to lower SSI incidence and shorter hospital stay
compared with uncoated sutures. More specifically, Baracs
et al. [27] reported that SSI increased treatment costs, based
on their findings that the average number of nursing days
was significantly longer for SSI patients than that for
patients with normal wound healing (15 versus 9), concurrent
with different dressings in the two groups (32.7 units versus
5.2 units). The study of Galal and El-Hindawy [45] docu-
mented that triclosan-coated sutures could save $1,517,727
yearly concerning 30,000 surgeries performed annually in
their hospital. And furthermore, Nakamura et al. [50] indi-
cated that triclosan-coated sutures could save at least
$42,444 concerning 410 patients in their study period. The
mean length of hospital stay was similar between coated and

Table 5 e Data on antibiotic prophylaxis from studies included in the meta-analysis.

Study Antibiotic prophylaxis

Antibiotic used Drug usage, Drug usage,

intravenously or not time used

Deliaert et al. 2009 [29] Not received Not received Not received
Baracs et al. 2011 [27] Second-generation cephalosporin Received, unknown 30 min before incision
and metronidazole
Galal and El-Hindawy 2011 [45] Not reported Not reported Not reported
Rasic et al. 2011 [46] Gentamicin 160 mg and Intravenously During induction of anesthesia
metronidazole 500 mg
Williams et al. 2011 [47] Augmentin (amoxicillin Intravenously Received, unknown
clavulanate) 1 g
Zhang et al. 2011 [48] Not reported Not reported Not reported
Isik et al. 2012 [24] Not reported Not reported Not reported
Seim et al. 2012 [25] Cefalotine 2 g Intravenously Before skin incision, and
continued with 3-h intervals to
a total of 8 g
Turtiainen et al. 2012 [28] In three centers: Cefuroxime 3 g; Intravenously In three centers: within 1 h before
In two centers: Cefuroxime 1.5 g; the incision;
In one center: Vancomycin. In two centers: 1 h before incision
and then every 8 h for the first
24 h after the operation;
In one center: unknown.
Justinger et al. 2013 [49] Standard antibiotics: Received, unknown 60 min before the incision
Metronidazole and ceftriaxone;
in case of allergy:
Metronidazole and clindmycin.
Nakamura et al. 2013 [50] Cephalosporin Intravenously 30 min before incision and every
3 h of operative time; and after
operative time for 48 h
Thimour-Bergstrom et al. 2013 [51] Not received Not received Not received
Diener et al. 2014 [23] Received, unknown Received, unknown Before the incision
 j o u r n a l o f s u r g i c a l r e s e a r c h 2 0 1 ( 2 0 1 6 ) 1 0 5 e1 1 7
Fig. 4 e Forest plot of meta-analysis comparing the incidence of wound dehiscence in patient groups treated with triclosan-
coated or uncoated sutures. (Color version of figure is available online.)
uncoated sutures groups in five studies [23,28,46,49,50]
involving 2727 patients, although it was significantly longer
by about 15 to 25 d in a study of 184 patients [46]. Use of
either type of suture was associated with similar operating
time in all the studies [23,25,28,46,49e51] reporting data on
that outcome. Four RCTs [24,27,50,51] suggested no much
difference in causative organism for SSI between the two
groups, and the most common organism differed in different
types of surgery.
3.5. Publication bias
The studies showed a symmetrical distribution in the funnel
plot, suggesting low risk of publication bias in our meta-
analysis (Fig. 5).
4. Discussion
This meta-analysis of 13 RCTs involving more than 5000
patients shows strong evidence that triclosan-coated su-
tures are associated with lower risk of SSI than conventional
uncoated sutures when used in adult surgery. Subgroup
analysis suggests that this risk reduction occurs at least in
abdominal surgery and may also apply in other types of
surgery, but larger high-level RCTs for non-abdominal pro-
cedures are needed to confirm this. Based on limited data of
four RCTs, which concerned only breast surgeries, abdom-
inal surgeries, and cardiac surgeries, incidence of wound
dehiscence was similar for patients treated with either kind
of suture, suggesting that triclosan coating might not
interfere with wound healing process. Limited evidence
suggests that triclosan-coated sutures might also be asso-
ciated with lower treatment costs in comparison with un-
coated sutures.
In addition to contamination of suture material, numerous
factors have been linked to the risk of SSI, including patient-
related factors such as age, gender, lifestyle, body mass
index, pre-existing infection, diabetes, comorbidities, and
surgical history; and procedure-related factors such as type of
surgery, pre-surgical preparation (hair removal, skin prepa-
ration, and hand/forearm antisepsis), management of infec-
ted or colonized surgical equipment, and antimicrobial
prophylaxis [1,2,6]. Triclosan-coated sutures with broad anti-
microbial activity were originally developed to reduce risk of
113
SSI [52], and our results suggest that they are indeed effective
in this regard.
In the current meta-analysis, the procedure-related factor
of antimicrobial prophylaxis was analyzed for the first time in
the subgroup analysis, and the results favored group with use
of prophylactic antibiotic in decreasing risk of SSI with coated
sutures. However, the results should be interpreted with
caution because the result of subgroup with use of prophy-
lactic antibiotic was influenced by the study of Justinger et al.
[49], Rasic et al. [46], Williams et al. [47], and Nakamura et al.
[50]. Furthermore, number of studies without use of prophy-
lactic antibiotic was limited with only two RCTs. Furthermore,
more RCTs with high quality are needed to verify the inter-
action between the use of triclosan-coated sutures and pro-
phylactic antibiotic in more detail in future studies.
We focused only on RCTs to ensure high-quality evidence,
and five of the 13 included trials with low risk of bias were
classified as high quality, whereas four trials with high risk of
bias were classified as low quality. The remaining four studies
had unclear risk of bias, suggesting moderate quality. The
literature contains many more non-RCTs that examine the
efficacy and safety of triclosan-coated sutures [26,53e61].
Nearly all such studies of which we are aware have come to
similar conclusions as our meta-analysis about triclosan
coating and risk of SSI in various types of surgery. On the other
hand, some studies, non-RCTs and RCTs alike, have found
similar risk of SSI between coated and uncoated sutures
[22e28]. Nearly half of these studies [22,24e26,28,53,58,61]
focused on non-abdominal surgeries, where we failed to
detect an association between coated sutures and reduced risk
of SSI. Other such studies are subject to methodological prob-
lems that complicate their analysis. For example, three studies
by Justinger et al. [56,57,62] involved a coated suture interven-
tion arm in which the type of coated suture was changed during
the course of the study, which may have affected the results.
Individual studies provide further insight into the antimi-
crobial efficacy of triclosan-coated sutures. An in vitro study of
Edmiston et al. [63] showed that coated sutures significantly
reduced adherence by both gram-positive and gram-negative
bacteria, and that the low triclosan concentrations in com-
mercial coated sutures were sufficient to inhibit bacterial
colonization of the suture material. Studies in two animal
models of SSI showed that VICRYL Plus sutures also reduced
concentrations of inflammatory mediators [20].
Our meta-analysis found similar wound dehiscence rates
among patients treated with triclosan-coated or uncoated
114 j o u r n a l o f s u r g i c a l r e s e a r c h 2 0 1 ( 2 0 1 6 ) 1 0 5 e1 1 7

sutures, suggesting that triclosan might not interfere with

91.3  18.6

185.2  90.9
Uncoated

167.2  3.0
wound healing or generate significant complications. This is
sutures

152  80
137  68
230  88
185  54
Operating time*, min

NR
NR
NR

NR
NR
NR
consistent with a study in animals [16] showing that
triclosan-coated sutures had no side effects on surgical per-
formance. The clinical trials of Justinger et al. [62] and Zhuang
et al. [44] also showed that triclosan-coated sutures were
95.5  17.3

179.3  87.1
associated with lower risks of incisional disruption and

170.5  3.0
sutures

158  71
138  65
238  93
181  51
Coated

incisional hernia. Reviews have suggested that the triclosan

NR
NR
NR

NR
NR
NR
coating on sutures elicits minimal toxicity [14,64]. Whereas
larger high-level RCTs are needed to examine and verify this
issue in clinical surgeries, owing to the fact that only four
RCTs reported data on wound dehiscence and these four
Uncoated

15.6  10.4
Length of hospital stay*, d

sutures

21.4  2.8

5.2  4.3

12.5  6.3
studies only concerned breast surgeries, abdominal surgeries
15  13
NR
NR
NR

NR
NR
NR
NR

NR and cardiac surgeries.

Table 6 e Data on incidence of SSI, wound dehiscence and other secondary outcomes from studies included in the meta-analysis.

Few RCTs and non-RCTs [27,42,45,50,53,61,65,66] reporting

data on treatment costs in our meta-analysis and literature
found that the treatment costs for patients with infection
were much higher than that for patients without infection,
15.2  11.6
sutures

1.2  1.3

5.5  6.5

13.0  7.4
Coated

11  18

owing to longer hospital stay, and other factors. And

NR
NR
NR

NR
NR
NR
NR

NR

furthermore, although triclosan-coated sutures cost more

than conventional uncoated ones, the overall treatment costs
were much lower for patients using coated sutures based on
their calculation and comparison between triclosan-coated
and uncoated sutures owing to lower incidence of SSI with
Uncoated
Wound dehiscence, n/N

sutures

13/190
81/598

triclosan-coated sutures. However, the results should be

7/26

7/93
NR
NR

NR
NR
NR
NR
NR
NR
NR

explained with caution, considering that the number of

studies evaluating this issue was limited especially the num-
ber of RCTs, and these studies documented the similar result
that triclosan-coated sutures significantly reduced the inci-
sutures
Coated

dence of SSI. Therefore, further high-level RCTs are needed to

11/184
66/587
16/26

1/91
NR
NR

NR
NR
NR
NR
NR
NR
NR

evaluate the issue of treatment costs.

There also have been several meta-analyses [23,31,67e69]
evaluating the efficacy and safety of triclosan-coated sutures
previously. The study of Chang et al. [67] contained only seven
Uncoated
sutures

RCTs with small sample size and showed no advantage of

24/197
33/220

19/340
17/163
30/137
42/371
19/204
38/190
96/598
12/93
14/75
0/26

5/50

triclosan-coated sutures. The studies of Edmiston et al. [68]

SSI, n/N

and Daoud et al. [69] did not analyze in detailed aspects,

although they draw the same conclusion, which favored
triclosan-coated sutures. Although the study of Wang et al. [31]
sutures
Coated

23/188
17/230

16/160
31/139
31/485

23/184
87/587

involved large number of patients and evaluated the efficacy

10/75

9/170

9/206
0/26

4/91

2/51

of triclosan-coated sutures in more detailed aspects including

type of surgery, age and follow-up, the study contained non-
peer-reviewed RCTs and did not consider the role of antibi-
prophylaxis

otic prophylaxis. The recently published meta-analysis of

Not received

Not received
Antibiotic

Data are expressed as mean  standard deviation.

Diener et al. [23] contained only five RCTs without detailed

Received

Received
Received

Received
Received
Received
Received

Received

subgroup analysis. Our current meta-analysis with 13 RCTs

contained the newly published RCT of Diener et al. [23] which
NR

NR
NR

did not favor triclosan-coated sutures, and further we

analyzed in more detailed aspects, especially evaluated the
Thimour-Bergstrom et al. 2013 [51]

important factor of prophylactic antibiotic for the first time.

Galal and El-Hindawy 2011 [45]

Our meta-analysis provides strong evidence that

triclosan-coated sutures can reduce risk of SSI and might not
Turtiainen et al. 2012 [28]

Nakamura et al. 2013 [50]

interfere with wound healing process. The meta-analysis

Williams et al. 2011 [47]

Justinger et al. 2013 [49]

Deliaert et al. 2009 [29]

Diener et al. 2014 [23]

Baracs et al. 2011 [27]

Zhang et al. 2011 [48]

draws its strength from the large number of patients, the

Rasic et al. 2011 [46]

Seim et al. 2012 [25]

NR ¼ not reported.
Isik et al. 2012 [24]

diversity of medical centers from more than 12 developing

and developed countries, the range of surgery types, the high
quality of the study design and reporting and low heteroge-
neity in the data. Nevertheless further studies are needed to
Study

examine whether triclosan-coated sutures are effective at

*

preventing SSI in non-abdominal surgeries and to further

 j o u r n a l o f s u r g i c a l r e s e a r c h 2 0 1 ( 2 0 1 6 ) 1 0 5 e1 1 7 115

Table 7 e Data on causative organism for SSI from studies included in the meta-analysis.
Study Causative organism

Coated sutures Uncoated sutures

Baracs et al. 2011 [27] Pseudomonas aeruginosa Pseudomonas aeruginosa

Enterococcus faecium, Enterococcus faecium
E. coli, E. coli,
Enterococcus spp. Enterococcus spp.
S. epidermidis
Isik et al. 2012 [24] S. epidermidis S. epidermidis
Pseudomonas aeruginosa Staphylococcus aureus
Klebsielle pneumonaie Corynebacterium ssp
Candida albicans
Nakamura et al. 2013 [50] Bacteroides sp. Bacteroides sp.
Bacteroides fragilis Bacteroides fragilis
Enterococcus sp. Bacteroides ovatus
Enterobacter cloacae Bacteroides thetaiotaomicron
Enterococcus faecalis Enterococcus sp.
Staphylococcus aureus Enterobacter cloacae
Staphylococcus epidermidis Enterococcus faecalis
Peptostreptococcus magnus Enterococcus faecium
Pseudomonas aeruginosa
Methicillin-resistant Staphylococcus aureus
Thimour-Bergstrom et al. 2013 [51] Klebsiella Klebsiella
Enterococcus faecalis Enterococcus faecalis
Streptococcus mutans Streptococcus mutans
Staphylococcus aureus Staphylococcus aureus
Coagulase neg staphylococci Coagulase neg staphylococci
Pseudomonas aerginosa E. coli
Proteus mirabilis Serratia marcescens
Moraxella catarrhalis Citrobacter freundii

study the interaction of antibiotic prophylaxis with triclosan-
coated sutures.
This meta-analysis is guided by the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses statement
(Supplemental Table 1.doc).
Acknowledgment
This work was supported by funding from the National Nat-
ural Science Foundation of China (no. 81060173), the Guangxi
Science and Technology Development Projects (14124003-4),
the Medical and Health Care Appropriate Technology
Research and Development Projects of Guangxi Province (nos.
S201417 and S201417-01), and the Innovation Project of
Guangxi Graduate Education (no. YCSZ2015113). The funders
had no role in study design, data collection and analysis, de-
cision to publish, or preparation of the article.
Authors’ contributions: J.G. and J.-H.Z. had full access to all
data in the study and take responsibility for their integrity and
the accuracy of the data analysis. J.G., J.-H.Z. and C.-Y.Z.
conceived and designed the study. J.G., L.-H.P., Y.-X.L., and J.-
H.Z. performed experiments. J.G., X.-D.Y., and L.-Q.L. acquired
data. J.G., J.-H.Z., and C.-Y.Z. analyzed and interpreted data. J.-
H.Z., C.-Y.Z., L.-H.P., Y.-X.L., and L.-Q.L. provided administra-
tive, technical, or material support. J.G., J.-H.Z., L.-H.P., Y.-X.L.,
and X.-D.Y. wrote the article. J.G., J.-H.Z., C.-Y.Z., and L.-Q.L.
critically reviewed the article for important intellectual content.

Supplementary data

Supplementary data related to this article can be found at

http://dx.doi.org/10.1016/j.jss.2015.10.015.

Disclosure
Fig. 5 e Funnel plot for evaluating publication bias. RR,
relative risk; SE, standard error. (“Color version of figure is The authors report no proprietary or commercial interest in
available online.”) any product mentioned or concept discussed in this article.
116 j o u r n a l o f s u r g i c a l r e s e a r c h 2 0 1 ( 2 0 1 6 ) 1 0 5 e1 1 7

references [21] Marco F, Vallez R, Gonzalez P, Ortega L, de la Lama J, Lopez-

Duran L. Study of the efficacy of Coated Vicryl Plus
Antibacterial suture in an animal model of orthopedic
surgery. Surg Infect (Larchmt) 2007;8:359.
[1] Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR.
[22] Chen SY, Chen TM, Dai NT, et al. Do antibacterial-coated
Guideline for prevention of surgical site infection, 1999.
sutures reduce wound infection in head and neck cancer
Centers for Disease Control and Prevention (CDC) Hospital
reconstruction? Eur J Surg Oncol 2011;37:300.
Infection Control Practices Advisory Committee. Am J Infect
[23] Diener MK, Knebel P, Kieser M, et al. Effectiveness of
Control 1999;27:97.
triclosan-coated PDS Plus versus uncoated PDS II sutures for
[2] Owens CD, Stoessel K. Surgical site infections:
prevention of surgical site infection after abdominal wall
epidemiology, microbiology and prevention. J Hosp Infect
closure: the randomised controlled PROUD trial. Lancet 2014;
2008;70(Suppl 2):3.
384:142.
[3] Leaper DJ, van Goor H, Reilly J, et al. Surgical site infectionda
[24] Isik I, Selimen D, Senay S, Alhan C. Efficiency of antibacterial
European perspective of incidence and economic burden. Int
suture material in cardiac surgery: a double-blind randomized
Wound J 2004;1:247.
prospective study. Heart Surg Forum 2012;15:e40.
[4] Coello R, Charlett A, Wilson J, Ward V, Pearson A, Borriello P.
[25] Seim BE, Tonnessen T, Woldbaek PR. Triclosan-coated sutures
Adverse impact of surgical site infections in English
do not reduce leg wound infections after coronary artery
hospitals. J Hosp Infect 2005;60:93.
bypass grafting. Interact Cardiovasc Thorac Surg 2012;15:411.
[5] Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ.
[26] Stadler S, Fleck T. Triclosan-coated sutures for the reduction
The impact of surgical-site infections in the 1990s:
of sternal wound infections? A retrospective observational
attributable mortality, excess length of hospitalization, and
analysis. Interact Cardiovasc Thorac Surg 2011;13:296.
extra costs. Infect Control Hosp Epidemiol 1999;20:725.
[27] Baracs J, Huszar O, Sajjadi SG, Horvath OP. Surgical site
[6] Fry DE. Fifty ways to cause surgical site infections. Surg
infections after abdominal closure in colorectal surgery
Infect (Larchmt) 2011;12:497.
using triclosan-coated absorbable suture (PDS Plus) vs.
[7] Alexander JW, Kaplan JZ, Altemeier WA. Role of suture
uncoated sutures (PDS II): a randomized multicenter study.
materials in the development of wound infection. Ann Surg
Surg Infect (Larchmt) 2011;12:483.
1967;165:192.
[28] Turtiainen J, Saimanen EI, Makinen KT, et al. Effect of
[8] Hranjec T, Swenson BR, Sawyer RG. Surgical site infection
triclosan-coated sutures on the incidence of surgical wound
prevention: how we do it. Surg Infect (Larchmt) 2010;11:289.
infection after lower limb revascularization surgery: a
[9] Masini BD, Stinner DJ, Waterman SM, Wenke JC. Bacterial
randomized controlled trial. World J Surg 2012;36:2528.
adherence to suture materials. J Surg Educ 2011;68:101.
[29] Deliaert AE, Van den Kerckhove E, Tuinder S, et al. The effect
[10] Uff CR, Scott AD, Pockley AG, Phillips RK. Influence of soluble
of triclosan-coated sutures in wound healing. A double blind
suture factors on in vitro macrophage function. Biomaterials
randomised prospective pilot study. J Plast Reconstr Aesthet
1995;16:355.
Surg 2009;62:771.
[11] Rodeheaver GT, Kurtz LD, Bellamy WT, Smith SL, Farris H,
[30] Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred
Edlich RF. Biocidal braided sutures. Arch Surg 1983;118:322.
Reporting Items for Systematic Reviews and Meta-analyses:
[12] Bamber AI, Neal TJ. An assessment of triclosan susceptibility
the PRISMA statement. Int J Surg 2010;8:336.
in methicillin-resistant and methicillin-sensitive
[31] Wang ZX, Jiang CP, Cao Y, Ding YT. Systematic review and
Staphylococcus aureus. J Hosp Infect 1999;41:107.
meta-analysis of triclosan-coated sutures for the prevention
[13] Jones RD, Jampani HB, Newman JL, Lee AS. Triclosan: a
of surgical-site infection. Br J Surg 2013;100:465.
review of effectiveness and safety in health care settings. Am
[32] Higgins JP, Green S, editors. Cochrane handbook for
J Infect Control 2000;28:184.
systematic reviews of interventions. Available from: http://
[14] Bhargava HN, Leonard PA. Triclosan: applications and safety.
www.cochrane-handbook.org; 2011. Updated March 2011.
Am J Infect Control 1996;24:209.
[33] Egger M, Davey Smith G, Schneider M, Minder C. Bias in
[15] Etter SW, Ragetly GR, Bennett RA, Schaeffer DJ. Effect of
meta-analysis detected by a simple, graphical test. BMJ 1997;
using triclosan-impregnated suture for incisional closure on
315:629.
surgical site infection and inflammation following tibial
[34] Egger M, Smith GD. Bias in location and selection of studies.
plateau leveling osteotomy in dogs. J Am Vet Med Assoc 2013;
BMJ 1998;316:61.
242:355.
[35] Sterne JA, Egger M, Smith GD. Systematic reviews in health
[16] Storch ML, Rothenburger SJ, Jacinto G. Experimental efficacy
care: investigating and dealing with publication and other
study of coated VICRYL plus antibacterial suture in guinea
biases in meta-analysis. BMJ 2001;323:101.
pigs challenged with Staphylococcus aureus. Surg Infect
[36] Huszar O, Baracs J, Toth M, et al. [Comparison of wound
(Larchmt) 2004;5:281.
infection rates after colon and rectal surgeries using
[17] Ming X, Rothenburger S, Yang D. In vitro antibacterial
triclosan-coated or bare suturesda multi-center,
efficacy of MONOCRYL plus antibacterial suture
randomized clinical study]. Magy Seb 2012;65:83.
(Poliglecaprone 25 with triclosan). Surg Infect (Larchmt) 2007;
[37] Defazio A, Datta MS, Nezhat C. Does the use of Vicryl Plus
8:201.
antibacterial suture decrease the incidence of umbilical
[18] Ming X, Rothenburger S, Nichols MM. In vivo and in vitro
infection when compared to Vicryl suture? Fertil Steril 2005;
antibacterial efficacy of PDS plus (polidioxanone with
84:S161.
triclosan) suture. Surg Infect (Larchmt) 2008;9:451.
[38] Khachatryan N, Dibirov M, Omelyanovsky V, Chupalov M,
[19] Ming X, Nichols M, Rothenburger S. In vivo antibacterial efficacy
Gasanova G. Prevention of postoperative infections in
of MONOCRYL plus antibacterial suture (Poliglecaprone 25 with
abdominal surgery using reabsorbable suture with
triclosan). Surg Infect (Larchmt) 2007;8:209.
antibacterial activity (Vicryl Plus) versus reabsorbable
[20] Gomez-Alonso A, Garcia-Criado FJ, Parreno-Manchado FC,
standard sutures. Surg Infect (Larchmt) 2011;12:A13.
et al. Study of the efficacy of Coated VICRYL Plus
[39] Mattavelli I, Nespoli L, Alfieri S, et al. Triclosan-coated suture
Antibacterial suture (coated polyglactin 910 suture with
to reduce surgical site infection after colorectal surgery. Surg
Triclosan) in two animal models of general surgery. J Infect
Infect (Larchmt) 2011;12:A14.
2007;54:82.
 j o u r n a l o f s u r g i c a l r e s e a r c h 2 0 1 ( 2 0 1 6 ) 1 0 5 e1 1 7
[40] Singh H, Emmert MY, Sakaguchi H, Neng Lee C, Kofidis T.
Antibacterial suture reduces surgical site infections in coronary
artery bypass grafting. Heart Surg Forum 2010;13:S85.
[41] Ford HR, Jones P, Gaines B, Reblock K, Simpkins DL.
Intraoperative handling and wound healing: controlled
clinical trial comparing coated VICRYL plus antibacterial
suture (coated polyglactin 910 suture with triclosan) with
coated VICRYL suture (coated polyglactin 910 suture). Surg
Infect (Larchmt) 2005;6:313.
[42] Rozzelle CJ, Leonardo J, Li V. Antimicrobial suture wound
closure for cerebrospinal fluid shunt surgery: a prospective,
double-blinded, randomized controlled trial. J Neurosurg
Pediatr 2008;2:111.
[43] Mingmalairak C, Ungbhakorn P, Paocharoen V. Efficacy of
antimicrobial coating suture coated polyglactin 910 with
tricosan (Vicryl plus) compared with polyglactin 910 (Vicryl)
in reduced surgical site infection of appendicitis, double
blind randomized control trial, preliminary safety report. J
Med Assoc Thai 2009;92:770.
[44] Zhuang CP, Cai GY, Wang YQ. Comparison of two absorbable
sutures in abdominal wall incision. J Clin Rehabilitative
Tissue Eng Res 2009;13:4045.
[45] Galal I, El-Hindawy K. Impact of using triclosan-antibacterial
sutures on incidence of surgical site infection. Am J Surg
2011;202:133.
[46] Rasic Z, Schwarz D, Adam VN, et al. Efficacy of antimicrobial
triclosan-coated polyglactin 910 (Vicryl* Plus) suture for
closure of the abdominal wall after colorectal surgery. Coll
Antropol 2011;35:439.
[47] Williams N, Sweetland H, Goyal S, Ivins N, Leaper DJ.
Randomized trial of antimicrobial-coated sutures to prevent
surgical site infection after breast cancer surgery. Surg Infect
(Larchmt) 2011;12:469.
[48] Zhang ZT, Zhang HW, Fang XD, et al. Cosmetic outcome and
surgical site infection rates of antibacterial absorbable
(Polyglactin 910) suture compared to Chinese silk suture in
breast cancer surgery: a randomized pilot research. Chin
Med J (Engl) 2011;124:719.
[49] Justinger C, Slotta JE, Ningel S, Graber S, Kollmar O,
Schilling MK. Surgical-site infection after abdominal wall
closure with triclosan-impregnated polydioxanone sutures:
results of a randomized clinical pathway facilitated trial
(NCT00998907). Surgery 2013;154:589.
[50] Nakamura T, Kashimura N, Noji T, et al. Triclosan-coated
sutures reduce the incidence of wound infections and the
costs after colorectal surgery: a randomized controlled trial.
Surgery 2013;153:576.
[51] Thimour-Bergstrom L, Roman-Emanuel C, Schersten H,
Friberg O, Gudbjartsson T, Jeppsson A. Triclosan-coated
sutures reduce surgical site infection after open vein
harvesting in coronary artery bypass grafting patients: a
randomized controlled trial. Eur J Cardiothorac Surg 2013;44:
931.
[52] Darouiche RO, Meade R, Mansouri M, Raad II. In vivo efficacy
of antimicrobial-coated fabric from prosthetic heart valve
sewing rings. J Heart Valve Dis 1998;7:639.
[53] Fleck T, Moidl R, Blacky A, et al. Triclosan-coated sutures for
the reduction of sternal wound infections: economic
considerations. Ann Thorac Surg 2007;84:232.
[54] Fraccalvieri D, Kreisler Moreno E, Flor Lorente B, et al.
Predictors of wound infection in elective colorectal surgery.
117
Multicenter observational case-control study. Cir Esp 2014;
92:478.
[55] Hoshino S, Yoshida Y, Tanimura S, Yamauchi Y, Noritomi T,
Yamashita Y. A study of the efficacy of antibacterial sutures
for surgical site infection: a retrospective controlled trial. Int
Surg 2013;98:129.
[56] Justinger C, Moussavian MR, Schlueter C, Kopp B, Kollmar O,
Schilling MK. Antibacterial [corrected] coating of abdominal
closure sutures and wound infection. Surgery 2009;145:330.
[57] Justinger C, Schuld J, Sperling J, Kollmar O, Richter S,
Schilling MK. Triclosan-coated sutures reduce wound
infections after hepatobiliary surgeryda prospective non-
randomized clinical pathway driven study. Langenbecks
Arch Surg 2011;396:845.
[58] Laas E, Poilroux C, Bezu C, et al. Antibacterial-coated suture
in reducing surgical site infection in breast surgery: a
prospective study. Int J Breast Cancer 2012;2012:819578.
[59] Okada N, Nakamura T, Ambo Y, et al. Triclosan-coated
abdominal closure sutures reduce the incidence of surgical
site infections after pancreaticoduodenectomy. Surg Infect
(Larchmt) 2014;15:305.
[60] Palma E, Brocanelli N, Luconi A, Cicolini G. [Comparison
between antibacterial coated suture vs standard suture to
prevent the surgical site infections]. Prof Inferm 2013;
66:17.
[61] Ueno M, Saito W, Yamagata M, et al. Triclosan-coated
sutures reduce wound infections after spinal surgery: a
retrospective, nonrandomized, clinical study. Spine J 2015;15:
933.
[62] Justinger C, Slotta JE, Schilling MK. Incisional hernia after
abdominal closure with slowly absorbable versus fast
absorbable, antibacterial-coated sutures. Surgery 2012;151:
398.
[63] Edmiston CE, Seabrook GR, Goheen MP, et al. Bacterial
adherence to surgical sutures: can antibacterial-coated
sutures reduce the risk of microbial contamination? J Am
Coll Surg 2006;203:481.
[64] Barbolt TA. Chemistry and safety of triclosan, and its use as
an antimicrobial coating on coated VICRYL* plus
antibacterial suture (coated polyglactin 910 suture with
triclosan). Surg Infect (Larchmt) 2002;3:S45.
[65] Stone J, Gruber TJ, Rozzelle CJ. Healthcare savings associated
with reduced infection rates using antimicrobial suture
wound closure for cerebrospinal fluid shunt procedures.
Pediatr Neurosurg 2010;46:19.
[66] Singh A, Bartsch SM, Muder RR, Lee BY. An economic model:
value of antimicrobial-coated sutures to society, hospitals,
and third-party payers in preventing abdominal surgical site
infections. Infect Control Hosp Epidemiol 2014;35:1013.
[67] Chang WK, Srinivasa S, Morton R, Hill AG. Triclosan-
impregnated sutures to decrease surgical site infections:
systematic review and meta-analysis of randomized trials.
Ann Surg 2012;255:854.
[68] Edmiston CE Jr, Daoud FC, Leaper D. Is there an evidence-
based argument for embracing an antimicrobial (triclosan)-
coated suture technology to reduce the risk for surgical-site
infections? A meta-analysis. Surgery 2013;154:89.
[69] Daoud FC, Edmiston CE Jr, Leaper D. Meta-analysis of
prevention of surgical site infections following incision
closure with triclosan-coated sutures: robustness to new
evidence. Surg Infect (Larchmt) 2014;15:165.