Toxicology and carcinogenesis study of triclosan administered dermally to B6C3F1/N mice.

Triclosan is a broad-spectrum antimicrobial agent to which humans are widely exposed. Very limited data are available regarding the dermal toxicity and the carcinogenic potential of triclosan. In this study, groups of 48 male and 48 female B6C3F1/N mice were untreated or were dermally administered 0 (vehicle), 1.25, 2.7, 5.8, or 12.5 mg triclosan/kg body weight/day (mg/kg/day) in 95% ethanol, 7 days per week for 2 years. Vehicle control animals received 95% ethanol only; untreated, naive control mice were not dosed. There were no significant differences in survival among the groups. The highest dose of triclosan decreased the body weights of mice in both sexes, but the decrease was ≤8%. (Abstract Abridged).

Is barbed better? Evaluation of triclosan-coated barbed suture on wound complications following emergency laparotomy.

INTRODUCTION: Emergent laparotomy is associated with significant wound complications including surgical site infections (SSIs) and fascial dehiscence. Triclosan-coated barbed (TCB) suture for fascial closure has been shown to reduce local complications but primarily in elective settings. We sought to evaluate the effect of TCB emergency laparotomy fascial closure on major wound complications. METHODS: Adult patients undergoing emergency laparotomy were prospectively evaluated over 1 year. Patients were grouped into TCB versus polydioxanone (PDS) for fascial closure. Subanalysis was performed on patients undergoing single-stage laparotomy. Primary outcomes were SSI and fascial dehiscence. Multivariate analysis identified independent factors associated with SSI and fascial dehiscence. RESULTS: Of the 206 laparotomies, 73 (35%) were closed with TCB, and 133 (65%) were closed with PDS. Trauma was the reason for laparotomy in 73% of cases; damage-control laparotomy was performed in 27% of cases. The overall rate of SSI and fascial dehiscence was 18% and 10%, respectively. Operative strategy was similar between groups, including damage-control laparotomy, wound vac use, skin closure, and blood products. Surgical site infection events trended lower with TCB versus PDS closure (11% vs. 21%, p = 0.07), and fascial dehiscence was significantly lower with TCB versus PDS (4% vs. 14%, p < 0.05). Subanalysis of trauma and nontrauma cases showed no difference in SSI or fascial dehiscence. Multivariable analysis found that TCB decreased the likelihood of fascial dehiscence (odds ratio, 0.07; p < 0.05) following emergency laparotomy. Increased odds of fascial dehiscence were seen in damage-control laparotomy (odds ratio, 3.1; p < 0.05). CONCLUSION: Emergency laparotomy fascial closure with TCB showed significantly decreased rates of fascial dehiscence compared with closure with PDS and a strong trend toward lower SSI events. Triclosan-coated barbed suture was independently associated with decreased fascial dehiscence rates after emergency laparotomy. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

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

BACKGROUND: Surgical 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. METHODS: FALCON 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. FINDINGS: Between 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. INTERPRETATION: This 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. FUNDING: National Institute for Health Research (NIHR) Global Health Research Unit Grant, BD.

Biomarkers for the toxicity of sublethal concentrations of triclosan to the early life stages of carps.

Accumulation, contents of protein, non-enzymatic antioxidant glutathione (GSH and GSSG), lipid peroxidation product (melondialdehyde-MDA) and organic acids (fumarate, succinate, malate and citrate), and activities of neurological (acetylcholinesterase-AChE), detoxification (glutathione S-transferase-GST) and metabolic (lactate dehydrogenase-LDH, aspartate transaminase-AST and alanine transaminase-ALT) enzymes were recorded in the hatchlings of Cyprinus carpio, Ctenopharyngodon idella, Labeo rohita and Cirrhinus mrigala after 7 and 14 days exposure and 10 days post exposure (recovery period) to sublethal concentrations (0.005, 0.01, 0.02 and 0.05 mg/L) of triclosan, a highly toxic and persistent biocide used in personal care products. Accumulation was maximum between 7-14 days at 0.01 mg/L for C. carpio and L. rohita but at 0.005 mg/L for C. idella and C. mrigala. No triclosan was observed at 0.005 mg/L in C. carpio and C. mrigala after recovery. Significant decline in protein, glutathione and acetylcholinesterase but increase in glutathione S-transferase, lactate dehydrogenase, aspartate transaminase, alanine transaminase, melondialdehyde and organic acids over control during exposure continued till the end of recovery period. Integrated biomarker response (IBR) analysis depicted higher star plot area for glutathione and glutathione S-transferase during initial 7 days of exposure, thereafter, during 7-14 days of exposure and the recovery period, higher star plot area was observed for acetylcholinesterase, aspartate transaminase, alanine transaminase and organic acids. Higher star plot area was observed for protein in all the species throughout the study. The study shows that L. rohita is most sensitive and glutathione, acetylcholinesterase, aspartate transaminase and alanine transaminase are the biomarkers for the toxicity of sublethal concentrations of TCS.

Effect of Triclosan-Coated Suture on Surgical Site Infection of Abdominal Fascial Closures.

Background: Surgical site infections (SSIs) are a serious problem after abdominal surgery. This study aimed to compare closure of fascia with triclosan-coated monofilament polydioxanone (PDS) or standard PDS in decreasing the incidence of SSIs in patients who underwent abdominal surgery. Methods: In this randomized study, a total of 890 consecutive patients undergoing laparotomy for any gastrointestinal pathology were allocated to closure of the fascia with triclosan-coated PDS (treatment group; TG) or standard PDS (control group; CG). Patients were assessed every day during the hospital stay for SSIs and at the first, second, and fourth week after discharge. The surgical site was assessed in terms of superficial, deep incisional, or organ/site SSI. Results: The main important finding was that SSIs were reduced as much as 24% by using triclosan-coated PDS. Surgical site infections occurred in 200 patients (22.4%), with 105 being early (in the first week) and 95 occurring late. Eighty five of the SSIs (19.1%) were noted in patients in the TG, whereas 115 of them (25.8%) were in the CG (p = 0.016). The infections were superficial in 126 patients, deep incisional in 48 patients, and organ/site in 26 patients. Most of patients (n = 651) had clean-contaminated sites. In subgroup analysis, SSI rates with triclosan-coated PDS were lower in clean, clean-contaminated, and contaminated incisions (0 in the TG versus 24.2% in the CG; p = 0.009; 13.6% in the TG versus 24.3% in the CG, p = 0.001; and 16.6% in the TG versus 27.8% in the CG; p < 0.0001, respectively). Conclusions: Closure of the fascia with triclosan-coated PDS decreased SSI rates as much as 24%. Also, SSIs were decreased significantly at clean, clean-contaminated, and contaminated sites. Therefore, triclosan-coated PDS might be recommended for fascial closure as a means of decreasing SSIs.

Low-dose exposure to triclosan disrupted osteogenic differentiation of mouse embryonic stem cells via BMP/ERK/Smad/Runx-2 signalling pathway.

Triclosan (TCS) has been used widely in personal care products for its broad-spectrum antimicrobial activity. The detection of TCS in the umbilical cord sera, amniotic fluid, and placenta, has raised concerns about the risk to foetal development. In the current study, the embryonic stem cells test (EST) were utilized primarily for the evaluation of the adverse effects of TCS on cardiogenesis and osteogenesis in vitro. TCS was predicted to be weakly embryotoxic in cardiogenesis and strongly embryotoxic in osteogenesis. The 50% inhibition value of osteogenic differentiation was 110 times lower than that of cardiac differentiation, which suggested that the development of the skeletal system was more sensitive to TCS-induced disruption. The mechanism through which TCS exerted toxicity on osteogenesis was studied further. Decreased calcification in ESC-derived osteoblasts was observed after exposure to TCS at a low dose, equal to the human internal exposure level. TCS was observed to specifically target ERK activation, rather than JNK or p38. Further, the downregulation of p-Smad-1, together with strong inhibition on Runx-2 and Bglap-2 expression, was observed via BMP/ERK/Smad signalling when cells were exposed to TCS. The change in Runx-2 induced by a low-dose TCS highlighted a specific target for exploring its adverse effect on skeletal development.

[Triclosan-coated sutures in colorectal surgery : Assessment and meta-analysis of the recommendations of the WHO guideline]. / Triclosan-beschichtete Nahtmaterialien in der kolorektalen Chirurgie : Bewertung und Metaanalyse zu den Empfehlungen der WHO-Richtlinie.

BACKGROUND: In the global guidelines for the prevention of surgical site infections (SSI), the World Health Organization (WHO) recommends the general use of triclosan-coated sutures irrespective of the type of surgical intervention. OBJECTIVE: Can this recommendation on the use of triclosan-coated sutures be confirmed by a meta-analysis specifically for colorectal surgery? METHODS: Randomized and non-randomized clinical trials comparing triclosan-coated and uncoated sutures for the efficacy in reducing the SSI rate in colorectal surgery were identified by a systematic literature review. In addition, various quality criteria were set for the studies to be included: SSI definition according to the Centers for Disease Control and Prevention (CDC), a priori sample size calculation and a maximum SSI rate of 20%. The odds ratios were pooled using a fixed and random effects model, the 95% confidence intervals (CI) were calculated and subgroup analyses were carried out. RESULTS: Included in the meta-analysis were 3 prospective randomized trials (RCT) and 3 non-randomized trials involving a total of 2957 subjects. The average SSI rate was 6.90% (76/1101) in the triclosan group and 9.11% (169/1856) in the control group, resulting in an odds ratio of 0.62 (95% CI: 0.29-1.31). Subgroup analysis showed a decreased risk for SSI in monocentric trials (OR = 0.39, 95% CI: 0.25-0.60) but an increased SSI risk in multicenter trials (OR = 1.75, 95% CI: 1.11-2.77). CONCLUSION: Against the background of a moderate to high risk of bias and the partially contradictory findings of the studies, the general recommendation of the WHO on the use of triclosan-coated sutures for colorectal surgery could not be confirmed.

Effects of a toothpaste containing 0.3% triclosan in the maintenance phase of peri-implantitis treatment: 2-Year randomized clinical trial.

OBJECTIVE: To evaluate the effects of a toothpaste containing 0.3% triclosan in volunteers that have been treated for peri-implantitis and were enrolled in a maintenance program. MATERIAL AND METHODS: Subjects presenting at least one implant with peri-implantitis were selected. They received anti-infective surgical therapy, and sixty days post-surgery (baseline) were randomized into two groups, brushing twice/day for 2 years (a) with a toothpaste containing 0.3% triclosan+2.0% PVM/MA copolymer (GantrezTM )+1,450 ppm fluoride (test) or (b) with a toothpaste containing 1,450 ppm fluoride (control). They received clinical and microbiological monitoring at baseline, 3, 6, 12, 18, and 24 months, and professional maintenance every 3 months. RESULTS: A total of 102 subjects were enrolled (test: 48; control: 54). The control group showed loss of clinical attachment (CA) around treated implants over the course of the study (p < 0.05), while the test group was stable for this parameter. The difference between groups (0.55 mm) for CA change between baseline and 24 months (primary outcome variable) was statistically significant (p < 0.05). Red complex pathogens were only reduced in the test group at 24 months. The implants with no history of peri-implantitis in the test group had a significant reduction in the percentage of sites with bleeding on probing and in mean probing depth, throughout the study (p < 0.05). This improvement was not observed in the control group. CONCLUSION: A toothpaste containing 0.3% triclosan was more effective than a toothpaste without triclosan in maintaining a healthy peri-implant environment around treated implants and implants with no history of peri-implantitis during a 2-year maintenance program (ClinicalTrials.govNCT03191721).

The Efficacy of Antimicrobial-Coated Sutures for Preventing Incisional Surgical Site Infections in Digestive Surgery: a Systematic Review and Meta-analysis.

BACKGROUND: Antimicrobial-coated sutures have recently become well known for preventing surgical site infections (SSIs). However, the evidence and recommendations from some organizations remain controversial. Therefore, we conducted a systematic review and meta-analysis to analyze the efficacy of antimicrobial-coated sutures for preventing SSIs in digestive surgery. METHODS: We performed a systematic review of literature published from 2000 to 2017 (registered on PROSPERO, No. CRD42017076780). We included studies defined as randomized controlled trials (RCTs) and observational studies (OBSs) for the prevention of SSIs and the reduction in hospital stay length associated with digestive surgery. RESULTS: In the 10 RCTs, the incidence rates of incisional SSIs were 160/1798 (8.9%) with coated sutures and 205/1690 (12.1%) with non-coated sutures. Overall, antimicrobial-coated sutures were superior for reducing the incidence of incisional SSI (risk ratio (RR) 0.67, 95% confidence intervals (CI) 0.48-0.94, p = 0.02) in RCTs for digestive surgery with the mixed wound class and surgeries limited to a clean-contaminated wound (RR 0.66, 95% CI 0.44-0.98, p = 0.04). A superior effect of antimicrobial-coated sutures was found in 9 RCTs that involved only colorectal surgeries (RR 0.69, 95% CI 0.49-0.98, p = 0.04). The mean hospital stay length was similar with coated or uncoated sutures in 5 RCTs involving colorectal surgery (mean difference (MD) - 5.00, 95% CI 16.68-6.69, p = 0.4). CONCLUSION: Antimicrobial-coated sutures are significantly more efficacious for preventing SSIs during digestive and colorectal surgery, even when restricted to clean-contaminated wounds. However, the hospital stay length was not affected.

Administration of low dose triclosan to pregnant ewes results in placental uptake and reduced estradiol sulfotransferase activity in fetal liver and placenta.

Sulfonation is a major pathway of estrogen biotransformation with a role in regulating estrogen homeostasis in humans and sheep. Previous in vitro studies found that triclosan is an especially potent competitive inhibitor of ovine placental estrogen sulfotransferase, with Kic of <0.1 nM. As the placenta is the main organ responsible for estrogen synthesis in pregnancy in both women and sheep, and the liver is another site of estrogen biotransformation, this study examined the effects of triclosan exposure of pregnant ewes on placental and hepatic sulfotransferase activity. Triclosan, 0.1 mg/kg/day, or saline vehicle was administered to late gestation fetal sheep for two days either by direct infusion into the fetal circulation or infusion into the maternal blood. On the third day, fetal liver and placenta were harvested and analyzed for triclosan and for cytosolic estradiol sulfotransferase activity. Placenta contained higher concentrations of triclosan than liver in each individual sheep in both treatment groups. There was a negative correlation between triclosan tissue concentration (pmol/g tissue) and cytosolic sulfotransferase activity (pmol/min/mg protein) towards estradiol. These findings demonstrated that in the sheep exposed to very low concentrations of triclosan, this substance is taken up into placenta and reduces estrogen sulfonation.

Immobilization of triclosan and erythrosine in layer-by-layer films applied to inactivation of microorganisms.

The use of layer-by-layer (LbL) deposition technique allows materials, such as drugs, to be self-assembled in multilayers with other electrolytes by combining their properties in a nanostructured system. Triclosan (TCS) is commonly used as a drug because of its bactericidal action, while erythrosine (ERY) has been used as a photosensitizer in photodynamic therapies because of its high light absorptivity in the visible region of the electromagnetic spectrum. The major advantage of investigating systems immobilized in LbL films is the benefit of characterizing the interaction through available substances in solid state techniques. It was possible to immobilize in LbL films, ERY, and ERY + TCS. The results show that the growth of the films was linear, indicating the deposition of the same amount of material from the first bilayer without substrate interference. The release analysis showed slow kinetics, which occurred more rapidly for ERY LbL films, probably due to apparent activation energy, which were higher for films with TCS. The combination of TCS, ERY, and laser light (532 nm) for photodynamic inactivation of the fungus Candida albicans was analyzed, and the results were promising for future studies in applications, such as coating surfaces of dental implants.

Impact of subchronic exposure to triclosan and/or fluoride on estrogenic activity in immature female rats: The expression pattern of calbindin-D9k and estrogen receptor α genes.

This study explored the influence of triclosan (TCS) in the absence and presence of sodium fluoride (NaF) on estrogenic activity and thyroid function of adolescent female rats. The results indicated that the individual exposure to TCS evoked a significant decline in T3 and T4 but the levels of estradiol, FSH, and LH were significantly elevated beside marked up regulation of calbindin-D9k and estrogen α mRNA expression. On the other hand, the single exposure to NaF causes insignificant changes in thyroid hormones, but evoked a trend toward an increase in both estradiol and LH levels. No significant differences in the TSH level were recorded among the experimental groups. The joint exposure to TCS and NaF induced a significant improvement in thyroid and reproductive hormone levels. Overall, these findings revealed that exposure to TCS resulted in significant endocrine and reproductive alterations in immature female rats, while TCS + NaF coexposure resulted in lessening most effects.

Effect of the application of a bundle of three measures (intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples) on the surgical site infection after elective laparoscopic colorectal cancer surgery.

BACKGROUND: Surgical site infection (SSI) prevention bundles include the simultaneous use of different measures, which individually have demonstrated an effect on prevention of SSI. The implementation of bundles can yield superior results to the implementation of individual measures. The aim of this study was to address the effect of the application of a bundle including intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, on the surgical site infection after elective laparoscopic colorectal cancer surgery. METHODS: A prospective, randomized study was performed, including patients with diagnosis of colorectal neoplasms and plans to undergo an elective laparoscopic surgery. The patients were randomized into two groups: those patients following standard bundles (Group 1) and those ones following the experimental bundle with three additional measures, added to the standard bundle. Incisional and organ space SSI were investigated. The study was assessor-blinded. RESULTS: A total of 198 patients were included in the study, 99 in each group. The incisional SSI rate was 16% in Group 1 and 2% in Group 2 [p = 0.007; RR = 5.6; CI 95% (1.4-17.8)]. The organ-space SSI rate was 4% in Group 1 and 0% in Group 2 [p = 0.039; RR = 1.7; CI 95% (1.1-11.6)]. Median hospital stay was 5.5 days in Group 1 and 4 days in Group 2 (p = 0.028). CONCLUSIONS: The addition of intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, to a standard bundle of SSI prevention, reduces the incisional and organ-space SSI and consequently the hospital stay, after elective laparoscopic colorectal cancer surgery (ClinicalTrials.gov Identifier: NCT03081962).

Effect of the Abdominal Fascial Closure with Triclosan-Coated Sutures in Fecal Peritonitis, on Surgical Site Infection, and Evisceration: A Retrospective Multi-Center Study.

BACKGROUND: Surgical site infection (SSI) is a frequent complication in dirty surgery, reaching rates of up to 40%. The incidence of SSI might be influenced by the suture used for closure of the abdominal fascia. Sutures coated with antibacterial substances may reduce the bacterial load in the incision. PATIENTS AND METHODS: A retrospective study of patients with intra-operative diagnosis of fecal peritonitis undergoing a laparotomy in three Spanish hospitals was performed. Fascial closure consisted in running loop suture of Polyglactin (Vicryl loop®, Johnson & Johnson, New Brunswick, NY; group 1), running loop suture of triclosan-coated polyglactin (Vicryl plus loop®; group 2), running loop suture of polydioxanone (PDS loop® Johnson & Johnson; group 3), and running loop suture of triclosan-coated polydioxanone (PDS plus loop®; group 4). Incisional SSI and evisceration rates were assessed. RESULTS: One hundred four patients were included. There were no differences in age, gender, comorbidities, etiology of peritonitis, and mortality among groups. Surgical site infection rate was 34.6% in group 1; 8% in group 2; 33% in group 3; and 10% in group 4 (p = 0.029). The use of triclosan-coated sutures is associated with lower risk of SSI (risk ratio [RR]: 9; p = 0.003). Evisceration rate was 0% in groups 1 and 2; 15.2% in group 3; and 10% in group 4 (p = 0.05). All patients suffering from evisceration presented previous SSI. The use of monofilament sutures is associated with higher risk of evisceration (RR: 6.35; p = 0.033). CONCLUSION: Triclosan-coated sutures reduce SSI rate in fecal peritonitis, without differences between braided and monofilament type. The use of monofilament sutures is related to higher risk of evisceration, independent of a triclosan coating.

Solid lipid nanoparticles for targeted delivery of triclosan into skin for infection prevention.

Healthcare-associated infections (HAIs) are a concern for health service providers, exacerbated by poor delivery of antimicrobials to target sites within the skin. The dermal route is attractive for local and systemic delivery of drugs, however; permeation, penetration, and access to deeper skin layers are restricted due to the barrier function of the stratum corneum (SC). Solid lipid nanoparticles present several benefits for topical delivery for therapeutic applications, especially via the follicular route. Hair follicles, surrounded by a close network of blood capillaries and dendritic cells, are an important target for delivery of antimicrobials and present a unique microbial nidus for endogenous infections in situations where the barrier is disrupted, such as after surgery, for example, triclosan, a broad-spectrum antimicrobial agent, was encapsulated into nanoparticles using glyceryl behenate and glyceryl palmitostearate (GP) solid lipids, and incorporating Transcutol P, a known permeation enhancer at different ratios. Optimised formulation was stable over 90 d and in vitro permeation studies using full thickness porcine ear skin showed that the lipid-based nanoparticles enhanced delivery of triclosan into the skin and could direct the agent towards hair follicles, indicating their potential as a carrier system for antiseptic dermal delivery.

The role of antimicrobial sutures in preventing surgical site infection.

INTRODUCTION Healthcare associated infections (HCAIs) are falling following widespread and enforced introduction of guidelines, particularly those that have addressed antibiotic resistant pathogens such as methicillin resistant Staphylococcus aureus or emergent pathogens such as Clostridium difficile, but no such decline has been seen in the incidence of surgical site infection (SSI), either in the UK, the EU or the US. SSI is one of the HCAIs, which are all avoidable complications of a surgical patient's pathway through both nosocomial and community care. METHODS This report is based on a meeting held at The Royal College of Surgeons of England on 21 July 2016. Using PubMed, members of the panel reviewed the current use of antiseptics and antimicrobial sutures in their specialties to prevent SSI. FINDINGS The group agreed that wider use of antiseptics in surgical practice may help in reducing reliance on antibiotics in infection prevention and control, especially in the perioperative period of open elective colorectal, hepatobiliary and cardiac operative procedures. The wider use of antiseptics includes preoperative showering, promotion of hand hygiene, (including the appropriate use of surgical gloves), preoperative skin preparation (including management of hair removal), antimicrobial sutures and the management of dehisced surgical wounds after infection. The meeting placed emphasis on the level I evidence that supports the use of antimicrobial sutures, particularly in surgical procedures after which the SSI rate is high (colorectal and hepatobiliary surgery) or when a SSI can be life threatening even when the rate of SSI is low (cardiac surgery).

Triclosan-coated sutures for the prevention of surgical-site infections: a meta-analysis.

BACKGROUND: The scope of this article is to perform a meta-analysis of the studies that compare the use of triclosan-coated sutures (TCS) to uncoated sutures in prevention of surgical-site infections (SSIs). METHODS: A systematic search of randomized and non-randomized studies was carried out on Pubmed and Scopus databases until July 2016. RESULTS: The meta-analysis of 30 studies (19 randomized, 11 non-randomized; 15,385 procedures) gave evidence that TCS were associated with a lower risk of SSIs (risk ratio [RR] = 0.68; 95% confidence interval [CI] 0.57-0.81). Triclosan-coated sutures were associated with lower risk for SSIs in high-quality randomized studies (Jadad score 4 or 5). A lower risk for the development of SSIs based on wound classification was observed in clean, clean-contaminated, and contaminated but not for dirty procedures. No benefit was observed in specific types of surgery: colorectal, cardiac, lower limb vascular or breast surgery. Only a trend was found for lower risk for wound dehiscence, whereas no difference was observed for all-cause mortality. CONCLUSIONS: Further randomized studies are needed to confirm the role of TCS in specific surgical procedures and whether or not they are related with lower risk for mortality.

Investigation of the mechanism of triclosan induced mouse liver tumors.

Chronic dietary exposure to Triclosan (TCS) produced increased incidence of liver tumors in mice. The mechanism for liver tumor induction has been attributed to activation of either peroxisome proliferator activated receptor α (PPARα) or constitutive androstane receptor (CAR). To further define the mechanism of TCS induced liver tumors, male CD-1 and C57BL/6 mice were treated with TCS at 0, 10, 100 and 200 mg/kg diet/day for 14 or 28 days. In addition, a recovery group and positive control groups for CAR or PPARα activation with either phenobarbital or diethylhexyl-phthalate were included in the 14-day study. TCS induced a dose-dependent increase in relative liver weight and centrilobular hypertrophy in both strains of mice. Hepatocyte DNA synthesis (BrdU labeling) was also increased in a dose-related pattern. In comparison with previous studies, TCS induced a significant increase in CAR/PXR (Cyp2b10, Cyp3a11) and PPARα (Cyp4a10) responsive genes in both CD-1 and C57BL/6 mice. The corresponding enzyme activity for CAR (7-pentoxyresorufin-O-dealkylase) and PPARα (peroxisomal Acyl-CoA oxidase) were also significantly increased in a similar fashion. Oxidative stress related genes Gpx1 and Aox1 were increased in the C57BL/6 but not in CD-1 mice. The increases in gene expression and enzyme activities returned to control levels after 14-day recovery. The present results demonstrate that both CAR and PPARα activation are involved in the TCS induced mouse liver tumor.

Meta-analysis and trial sequential analysis of triclosan-coated sutures for the prevention of surgical-site infection.

BACKGROUND: Triclosan-coated sutures (TCS) were developed to reduce the risk of surgical-site infection (SSI). Level 1A evidence of effectiveness has been presented in various recent meta-analyses, yet well designed RCTs have not been able to reproduce these favourable results. The aim of this study was to evaluate all available evidence critically with comprehensive analysis to seek a more reliable answer regarding the effectiveness of TCS in the prevention of SSI. METHODS: PubMed, MEDLINE, Embase and Cochrane Library databases were searched from 1990 to November 2015 for RCTs that compared TCS with sutures that were exactly the same, but uncoated, in the prevention of SSI. Pooled relative risks (RRs) with corresponding 95 per cent confidence intervals were estimated using a random-effects model. Metaregression was used to substantiate subgroup effects, trial sequential analysis was employed to assess the risk of random error, and quality of evidence was determined using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. RESULTS: Twenty-one RCTs including 6462 patients were included. Risk of bias was serious. Pooled effects showed a RR of 0·72 (95 per cent c.i. 0·60 to 0·86; P < 0·001) for all publications. At a risk of 138 SSIs per 1000 procedures, the use of TCS reduced this by 39 (95 per cent c.i. 19, 55). Trial sequential analysis confirmed a RR reduction of 15 per cent for the use of TCS. CONCLUSION: GRADE assessment shows moderate-quality evidence that TCS are effective in reducing SSI. Trial sequential analysis indicates that the effect was robust, and additional data are unlikely to alter the summary effect.

Meta-analysis of the potential economic impact following introduction of absorbable antimicrobial sutures.

BACKGROUND: Despite several randomized trials, systematic reviews and meta-analyses that have demonstrated the effectiveness of antimicrobial (triclosan-coated or -impregnated) sutures (TCS), the clinical and economic impact of using these sutures compared with conventional non-antimicrobial-coated absorbable sutures (NCS) remains poorly documented. METHODS: An independent systematic review and meta-analysis of all published evidence from January 2005 to September 2016 comparing TCS with NCS was conducted. Surgical-site infection (SSI) was the primary outcome. The results of the meta-analysis were used in a decision-tree deterministic and stochastic cost model, using the National Health Service (NHS England)-based cost of inpatient admissions for infections and differential costs of TCS versus NCS. RESULTS: Thirty-four studies were included in the final assessment from an initial 163 identified citations; 20 of 34 studies were randomized, and 17 of 34 reported blinding of physicians and assessors. Using a random-effects model, the odds ratio for SSI in the TCS compared with NCS control groups was statistically significant (odds ratio 0·61, 95 per cent c.i. 0·52 to 0·73; P < 0·001). There was significant heterogeneity (I2 = 49 per cent). Using random-effects event estimates of SSI for TCS and NCS for each individual wound type, the mean savings per surgical procedure from using antimicrobial sutures were significant: £91·25 (90 per cent c.i. 49·62 to 142·76) (€105·09 (57·15 to 164·41); exchange rate 15 November 2016) across all wound types. CONCLUSION: The reviewed literature suggested that antimicrobial sutures may result in significant savings across various surgical wound types.