INFECTION CONTROL
about being in ‘despair’, of ‘wanting to die’. Many said that the whole family had been affected – one patient explained that he had been his wife’s carer, before he had contracted an SSI. After the infection, she was forced to move out of the family home and into social care. Patients also felt isolated. They didn’t
know who to talk to, and went ‘from pillar to post’ looking for help. Furthermore, patients who had previously experienced being passed from ‘pillar to post’ were subsequently admitted as emergencies. “There is a frequently cited figure that
SSIs cost the NHS £700 million each year to treat. This is meaningless. It is a big number that none of us can make any sense of. But it significantly underestimates the number of SSIs and the cost. When you look at SSI data, they usually refer to the direct cost (eg theatre time, drugs, dressings), it rarely includes indirect costs. “For example, a patient with delayed
discharge prevents another 33 new admissions, which means we are losing money if one person with an SSI is ‘bed blocking’. In addition, the costs usually include acute care; we rarely look at the cost in primary care or the cost impact in relation to productivity. A Spanish study found that the cost of one infection is around $100,000 and the healthcare cost is probably just 10% of that.” She added that one area of cost which is
never examined is the cost to the patient. One patient commented, as part of the qualitative research, that their husband had to get a second job so that they didn’t lose their house. Professor Tanner pointed out that
patients’ stories can be very powerful: “We took these stories back to our staff and said ‘it’s not just 4%; it isn’t about the cost of £15,000 to treat a colorectal patient’; children are waking up screaming during the night, people are losing their homes and families are being split up. “So what can be done? Obviously there
are interventions we can do, but we can also raise the profile; the importance of SSIs. This requires robust, valid surveillance,” she continued.
Prevention Dr Imran Ahmed, academic specialist registrar, University Hospitals Coventry and Warwickshire NHS Trust, commented: “Surgical site infection, as we have heard, has a significant impact on patients’ quality of life; SSIs not only prolong hospital stay but also lead to increased rates of admission and prolonged treatment regimes. There may also be further effects in terms of increased mortality and morbidity. In addition to this, SSI adds a significant cost burden to the NHS.” The cause of SSI is multifactorial he
pointed out. Patient factors may include diabetes and immunosuppression, while surgical factors may include inadequate maintenance of the sterile field or suture material, for example.
264 “We concluded that Triclosan-
impregnated sutures significantly reduced superficial SSI at 30 days,” commented Dr Ahmed. He explained that many of the randomised, controlled trials did not report on deep infections or wound dehiscence at 30 days – in fact, there were just four in total. He reported that there were 91 deep
infections out of 2000 patients in the Triclosan suture group, and 122 deep infections out of 2100 in the standard suture group. “The analysis favours the Triclosan
Methicillin-resistant Staphylococcus aureus causes a range of illnesses, including surgical site infections.
“Sutures can lead to SSIs when they
become coated with bacteria. As the suture passes through the skin, a biofilm can develop which is resistant to host defences and any antibacterial treatment. Given the significant impact of SSIs, on healthcare providers, and patients in particular, various methods have been developed to help combat these infections.” He explained that Triclosan-impregnated
sutures were first introduced in 2002, when they were given US Food and Drug Administration (FDA) approval. In vivo studies in rats found that these sutures caused a 66% reduction in positive cultures. There have been many randomised, controlled trials since their introduction: in 2012, a systematic review and meta-analysis by Chang et al. concluded that Triclosan- impregnated sutures did not decrease the rate of SSIs.1
However, Dr Ahmed pointed
out that five of the seven studies were deemed ‘high risk’ when they were critically analysed. Therefore, further meta-analyses have since been performed. In 2014, a meta-analysis conducted by Daoud, Edmiston and Leaper,2 including
15 randomised, controlled trials, confirmed that the use of Triclosan antimicrobial sutures did indeed reduce the incidence of SSI. “Since the publication of this study, there have been further high-quality randomised, controlled trials, so we wanted to conduct another meta-analysis, including increased patient numbers,” commented Dr Ahmed. The meta-analysis included any type of
surgery, as well as patients of all ages and any gender. The primary outcome examined was superficial infection after 30 days, and the secondary outcome included deep infection after 30 days. The results of the study included 17 randomised, controlled trials, with 8460 participants – some 4000 more than the previous systematic review. There were 304 superficial SSIs out of 4165 participants for the group which had the Triclosan-impregnated sutures, compared to 394 out of 4300 patients who had standard sutures.
suture, but just crosses the line of no statistical significance, but the difference is present,” said Dr Ahmed. “The message I want to get across is that these Triclosan- impregnated sutures significantly reduce the risk of superficial SSI at 30 days, and the difference is present but not significant for deep infections at 30 days.” He added that there were some
limitations to the meta-analysis as it only included English language studies or those where a translation was available. Therefore, one Hungarian study was excluded, which was a small randomised, controlled trial that showed no significance. It was also more difficult to reach a conclusion on the impact on deep infections as many studies did not include this information. Furthermore, there was some variation in the prophylactic antibiotic regimes between studies, which could have affected the infection rates, while the type of surgery performed could also have had an impact. In addition, the risk of bias in the studies has not been assessed. Examining the cost implications,
he reported that the Triclosan-impregnated sutures can reduce the risk of SSI by around 20%. As the cost of treating a deep wound infection in orthopaedics is estimated to cost around £100,000, Dr Ahmed calculated that the extra cost of using the Triclosan- impregnated sutures could be justified. In conclusion, he commented that
using the sutures would lead to “better quality of care; reduce the incidences of stories like Nora’s; there would be shorter hospital stays; and it has been proven to be cost-effective.”
References 1 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 (5): 854–9.
2 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 (1): 89–100.
Louise Frampton is Editor of The Clinical Service Journal. This report is reproduced here by kind permission.
MAY 2016 THE BIOMEDICAL SCIENTIST
CDC/National Institute of Allergy and Infectious Diseases (NIAID)
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60
