VICRYL PLUS VERSUS CATGUT ON ORAL SURGICAL SITE- A COMPARATIVE STUDY
A dissertation submitted
in partial fulfilment of the requirements for the degree of
MASTER OF DENTAL SURGERY BRANCH III
ORAL AND MAXILLOFACIAL SURGERY
THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY CHENNAI-600 032
2017 - 2020
"No one who achieves success does so without acknowledging the help of others. The wise and confident acknowledge this help with gratitude."
- Alfred North Whitehead
The writing of this dissertation has been one of the most significant academic challenges I have ever had to face. Without the support, patience and guidance of the following people, this study would not have been completed on time. It is to them that I owe my deepest gratitude. First and foremost, my praises and thanks are hailed to the God, the Almighty, for His showers of blessings throughout my research work to complete the research successfully.
I thank our honourable Chairman Prof. Dr. K. R. ARUMUGAM, M.Pharm., and our Vice-chairman Prof. Dr. A. BABU THANDAPANI M.Pharm., Ph.D., for their valuable guidance and support throughout the research.
"The fruitful work of a teacher will be etched in a student's life;
beyond the sands of time." I offer my sincere thanks to the Principal Dr. K.
S. PREMKUMAR, M.D.S., FADI, Ph.D., Best Dental Science College, Madurai for their assistance as ethical committee heads and for their consistent guidance and unwavering support throughout this project.
I would like to express my deep and sincere gratitude to my teacher and research Guide, Dr. K. PRABHU SANKAR, M.D.S., Professor and Head, Department of Oral and Maxillofacial Surgery, for giving me the opportunity to do this research and providing valuable guidance throughout this research. It was a great privilege and honor to work and study under his guidance. I am extremely grateful for what he was taught me.
guide, Prof. Dr. V. USHA, M.D.S., Vice principal for her undying enthusiasm and selfless guidance which helped me complete this study. Her constructive criticism and valuable suggestions conferred upon me have encouraged me.
I would like to express my gratitude to Dr. M. VARUN, M.D.S., Reader for his guidance, encouragement and patience during the completion of this study. He has been an integral part of my post graduate course. I take this opportunity to thank him for his everlasting inspiration, innovative ideas, incessant encouragement, friendly guidance and thought provoking suggestions.
I wish to gratefully acknowledge the value and help of my Co-PG Dr.P.MUTHUKUMARAN and my juniors Dr. AR.NAGAPPAN,
M.MERIBA RUTH KAVINA for their constant support.
I also express my heartfelt thanks to my beloved wife DR.NEETHY JOY and My Son MILAN.V.JOHN for their loving support.
Lastly, I would like to thank my family for all their love and encouragement especially to my Parents, M.J.John and Elizabeth George who raised me with love and supported me in all my pursuits.
Finally, my thanks go to all my friends who have supported me to complete this research work and write-up directly or indirectly.
Above all, I owe it all to Almighty God for granting me the wisdom, health and strength to undertake this task and enabling me to its completion.
This agreement herein after the "Agreement" is entered into on this day Oct 2019, between the Best Dental College represented by its Principal having address at Best Dental Science College, Madurai-625104, (hereafter referred to as ,' the College') And
DR. K. PRABHU SANKAR aged 45 years working as Professor in Department of Oral and Maxillofacial Surgery at the College, having residence address at 23, Telephone rd, Aruppukottai-626101 ( herein after referred to as the Principal Investigator)
And
DR.VINU.M.JOHN aged 37 years currently studying as Post Graduate student in Department of Oral and Maxillofacial Surgery, Best Dental College and Hospital, Madurai-625104 (herein after referred to as the 'PG/Research student and co-investigator')
Whereas the PG/Research student as part of his curriculum undertakes to research on
"IMPACT OF USING ANTIBACTERIAL SUTURE
VICRYL PLUS VERSUS CATGUT ON ORAL SURGICAL SITE-
A COMPARATIVE STUDY"
for which purpose PG/Principal shall act as Principal Investigator and the college shall provide the requisite infrastructure based on availability and also provide facility to the PG/Research student as to the extent possible as a Co-investigator.issues including in particular the copyright and confidentially issues that arise in this regard.
Now this agreement witnessed as follows
1. The parties agree that all the Research material and ownership therein shall become the vested right of the college, including in particular all the copyright in the literature including the study, research and all other related papers.
2. To the extent that the college has legal right to do so , shall grant to license or assign the copyright so vested with it for medical and/or commercial usage of interested persons/entities subject to a reasonable terms/ conditions including royalty as deemed by the college.
3. The royalty so received by the college shall be shared equally by all the parties.
4. The PG Student and Principal Investigator shall under no circumstances deal with the copyright, Confidential information and know - how generated during the course of research/study in any manner whatsoever, while shall sole vest with the college.
5. All expenses pertaining to the research shall be decided upon by the Principal Investigator/ Co-Investigator or borne solely by the PG/Research Student. (Co- Investigator)
6. The college shall provide all infrastructure and access facilities within and in other institutes to the extent possible. This includes patient interactions, introductory letters, recommendation letters and such other acts required in this regard.
Abstract
AIM
The aim of this study was to compare the antibacterial effect of VICRYL PLUS suture (Polyglactin 910 coated with triclosan) and CATGUT suture, on oral surgical site analyzing the microbiological differences in terms of colonies forming unit’s organisms and species.
MATERIALS AND METHODS
The present study on "IMPACT OF USING ANTIBACTERIAL SUTURE VICRYL PLUS VERSUS CATGUT ON ORAL SURGICAL SITE- A COMPARATIVE STUDY"was conducted in the department of OMFS, Best Dental Science College in Madurai, over a period of 1 year (March 2018 to February 2019) on the patients willing for voluntary participation after obtaining informed consent.
The institutional scientific review board and ethical committee approved the protocol for this clinical comparative study.
Total 100 patients between the age group of 16-45 years who will report to Best Dental Science College, Madurai diagnosed with conditions requiring open surgical removal of lower third molars.
RESULTS
The total incidence for surgical site infection when using Vicryl plus suture for 50 cases accounted for only 6 cases ( 12%). Staphylococcus aureus and staphylococcus epidermidis were found to be the most common Gram Positive organism isolated and Klebsiella pneumonia was the most common Gram Negative organism isolated.
The total incidence of SSI when using Catgut suture for 50 cases accounted for 19 cases. (38 %). E.coli and Klebisella were most common gram negative organism isolated and Staphylococcus aureus and staphylococcus epidermidis were most common Gram positive organism isolated.
CONCLUSION
The comparative study revealed the reduction of surgical site infection to one third while using VICRYL PLUS suture in comparison with CATGUT suture in oral surgical site.
The VICRYL PLUS suture was found bactericidal against E.coli.
KEYWORDS
Vicryl Plus, Catgut, Suture Comparison, Surgical Site Infection.
ABBREVIATIONS ACRONYM
SSI Surgical Site Infection
I3M Impacted Third Molar
K.pneumonia Klebsiella pneumonia S.Aureus Staphylococcus Aureus S.Epidermidis Staphylococcus Epidermidis
E.Coli Escherichia Coli
MRSA Methicillin Resistant Staphylococcus Aureus
CONTENTS PAGE NO
Introduction 1-7
Aims and Objectives 8
Review of literature 9-20
Materials & Methods 21-25
Clinical Photographs 26-27
Results & Statistical Analysis 28-35
Discussion 36-48
Summary 49-51
Conclusion 52-53
Bibliography Annexure
S.NO ANNEXURE LIST
1. Institution Review Board Dissertation Approval Letter 2. Informed Consent Form 2
3. Thesis Case Sheet
1. Vicryl Plus Suture Patient Photographs 26
2. Catgut Suture Patient Photographs 27
LIST OF TABLES
Graph No.1 S.Pneumonia Vicryl Plus and Catgut Comparison 31 Graph No.2 S.aureus Vicryl Plus and Catgut Comparison 32 Graph No.3 S.epidermidis Vicryl Plus and Catgut Comparison 33 Graph No.4 E.Coli Vicryl Plus and Catgut Comparison 34 Graph No.5 Significant difference seen between groups total 35
1
INTRODUCTION
Sutures have the longest history, one of the most widely used and have received the most attention. One of the first written references in history to suturing materials is seen in Egyptian literature (16th century BC) in Edwin Smiths’s papyrus in which the following line is inscribed: “If thou examines a man having a wound in the top of his eyebrow, draw together for him the gash with stitching.’
Ancient populations of various continents were using giant ants as
“suturing devices”. These rather big insects (like Oecophylla smaragdina and Ecitonburchelli) have powerful claws. The ants, held close to the wound would strongly bite both edges of the gap, drawing them close together. The
“manipulator” of the insect would then decapitate it, leaving the head with its bite, in place on the wound, thus maintaining the edges close together. The use of the jaws of ants was also mentioned in the Samhita, and later in the medieval Arabic medical literature.
Another natural way of treating gaping wounds was by using vegetable thorns or animal spikes, crossing bothedges of the gap and, by using vegetable fibers around it or by placing them as a figure of eight bringing the edges of the wound close together. Such techniques were first used in Africa, around the 10th century BC. Much later some metal devices specifically designed for this use were also found being used by the Greeks and by the Mycenaean. These so called “fibulae” were similar to our actual safety pins and were placed in a
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similar way to hold tissues together. Presently there are various type of suture materials.
Classification of sutures
Absorbability Construction Composition Absorbable
Polyglycolic acid, polyglactin 910, polydiaxanone, poliglecaprone 25
Monofilament Polypropylene, polydiaxanone, poliglecaprone 25
Natural fibre Catgut, silk
Non-absorbable Polypropylene, nylon, polyester
Multifilament Braided (e.g. silk, polyester,
polyglactin 910)
Twisted (e.g.
catgut)
Synthetic Nylon, poliglecaprone 25, polypropylene, polyglycolic acid, polyglactin 910, polydiaxanone Metallic Stainless steel
Sutures are a vital part of nearly every surgical procedure, designed to close and stabilize wound margins and to aid in allowing undisturbed wound healing (Wikesjö et al., 1992; Minozziet al., 20091 Suture functions to approximate tissue edges, which promotes healing and at the same time limits further deep
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contamination. Most surgical infections potentially impairing wound healing are intimately related to sutures (Horan et al.,1992).
Sutures can be a source of surgical wound contamination owing to bacterial adherence to them and the suture acting as a means of transmitting bacteria to oral tissues. The adherence of bacteria is highly variable and is dependent not only on the specific microbial species and suture structure, but also on the chemical composition of suture material. Among the different suture materials, this phenomenon is more pronounced with multifilament threads.1
Once the suture material becomes contaminated, biologic agents, chemical agents or other methods of wound decontamination become ineffective owing to bio film formation. Handling of sutures within the oral cavity as well as their removal may also induce bacteria to spread with greater risk of more serious complications for patients with chronic illnesses, such as diabetes and heart diseases. Therefore contaminated sutures are a real risk with any surgical procedures.
In the oral cavity, sutures are placed within tissues of high vascularity and in moist bacteria rich environment with infectious potential. Bacteria and necrotic debris lodge on the suture material and invade the suture track (Selvig et al., 1998), and retain infection and delay the healing cascade (Kim, 2002; Morrow and Rubinstein, 2002). The physicochemical characteristics of a suture material influence its ability to attract bacteria and consequently promote wound infection (Chu and Williams, 1984).
Bacteria adhere to various types of sutures with different affinities (Katz et al., 1981)
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The surgical extraction of impacted third molars (I3M) still remains one of the most commonly performed surgical procedures in Oral Surgery. The wound comes under clean contaminated wound category. Surgical site infection (SSI) is one of the postoperative local complications that may arise in this surgical procedure.
Postoperative infection rate after I3M extraction is around 5% (1). The incidence of SSI is related to intrinsic patient factors (immune-depression, diabetes mellitus, local or systemic infections, etc.) and extrinsic factors (such as smoking, surgical antiseptic measures, wound contamination in clean, contaminated or dirty surgeries.
In addition to placing antimicrobial solutions and antibiotic formulations into surgical incisions, there has been recent enthusiasm with the development of antimicrobial coated sutures as a possible adjunct in reducing the rate of SSI.
Unfortunately, the use of antimicrobial sutures in clinical trials has shown variable efficacy making a recommendation on their use difficult. This susceptibility of sutures to infection led to the introduction of sutures treated with triclosan, a broad-spectrum antibacterial agent, which are claimed to have antibacterial properties (Rothenburger et al., 2002).
Catgut was used since the 15th century. Its name comes from the fibres used as string chords in a specific contemporary musical instrument, a sort of pocket violin called “kit”. This first type of “catgut” kept being used in the same form until the 19th century; by then intestinal tissue of animals started to be chemically modified for surgical use.
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Catgut suture is made by twisting together strands of purified collagen taken from the serosal or submucosal layer of the small intestine of healthy ruminants (cattle, sheep, goats) or from beef tendon. The natural plain thread is precision ground in order to achieve a monofilament character and treated with a glycerol-containing solution. The suture is sterilized with a sterilizing fluid containing ethylene oxide, isopropyl alcohol and distilled water. Catgut suture is straw-colored, and is available in sizes USP 6-0 (1 metric) to USP 3 (7 metric). Although the name implies the usage of guts of cats, there is no record of feline guts being used for this purpose.
The word catgut is derived from the term kitgut or kitstring (the string used on a kit, or fiddle). Mis-interpretation of the word kit as referring to a young cat led to the use of the term catgut. Surgical gut is in fact made from the submucosa of sheep intestine or the serosa of bovine intestine and is approximately 90% collagen.[3]
Perhaps another possible explanation of the name is the combination of the words cattle and gut. B Braun Medical AG, a German Multi National company first industrialized catgut suture and Catgut is a brand registered with B Braun. Catgut Chrome (B Braun) suture is a variant treated with chromic acid salts. This treatment produces roughly twice the stitch-holding time of plain catgut, but greater tissue inflammation occurs. Full tensile strength is extended to 18–21 days. It is brown rather than straw-colored, and has improved smoothness due to the dry presentation of the thread (plain catgut is wet). It is otherwise similar to plain catgut.
Catgut is a monofilament absorbable suture with good tensile strength that retains optimum strength to bold tissues together. It is smooth and pliable, has good knotting property and disappears completely between 60 and 120 days depending on
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its size. The advent of newer synthetic sutures has prompted some surgeons to start writing the epitaph for catgut. The cost effectiveness of catgut coupled with good results will be an advantage in the economic aspect particularly in developing countries.
In 2003 Coated Vicryl® Plus Antibacterial Sutures are introduced.
Antimicrobial suture technology involves the coating or impregnation of synthetic, absorbable, polymeric sutures with the antiseptic, triclosan. This suture—the first antibacterial version made commercially available with triclosan, which prevents bacteria from congregating on the suture—is shown to significantly lower the risk of developing a surgical site infection by almost one third. Triclosan is a broad-spectrum phenol family antiseptic, used for more than 30 years as a safe and effective antimicrobial agent, against the most common pathogen agents that cause SSI:
Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa and Escherichia coli and methicillin-resistant Staphylococcus aureus (MRSA). It seems to act by inhibiting enzymes involved in bacteria’s fatty acid synthesis. The antimicrobial efficacy of this material in reducing both bacterial adherence to the suture and microbial viability have been proven in vitro and in animal models.2
Pharmacokinetic studies in animals and humans have shown that triclosan is rapidly absorbed, well distributed in the body, metabolized in the liver, and excreted by the kidneys, with no indication of accumulation over time. Biocompatibility studies showed that coated polyglactin 910 suture with triclosan is non-cytotoxic, non-irritating.
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Several experimental studies have shown that these bacteria are inhibited from adhering to triclosan coated or -impregnated sutures together with an antimicrobial effect. The safe amount of triclosan required for an optimal antimicrobial effect is 472μg/m in coated polyglactin sutures. These amounts are miniscule compared with the concentrations of triclosan encountered from other commercial or environmental sources.3
Braided polyglactin 910 coated with the antimicrobial triclosan (Vicryl Plus Ethicon, Johnson & Johnson Company, Somerville, NJ) is the suture material most frequently studied.
The aim of this study was to compare the antibacterial effect of Polyglactin 910 coated with triclosan (Vicryl Plus suture) and CATGUT suture, analyzing the microbiological differences in terms of colonies forming unit’s organisms and species.
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AIM
The aim of this study was to compare the antibacterial effect of VICRYL PLUS suture (Polyglactin 910 coated with triclosan) and CATGUT suture, on oral surgical site analyzing the microbiological differences in terms of colonies forming unit’s organisms and species.
OBJECTIVE
To evaluate the antibacterial effect of VICRYL PLUS suture with CATGUT suture and analyzing the microbiological differences in terms of colony forming units, organisms and species.
To compare quantitatively the adherence of microflora to the antiseptic coated suture Vicryl plus and catgut suture after surgical removal of third molar through microbiological evaluation techniques.
To evaluate the incidence of surgical site infection and soft tissue healing postoperatively after surgical removal of lower third molars, in which surgical site sutured with antiseptic (Triclosan) coated Vicryl plus suture material and catgut.
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REVIEW OF LITERATURE
R. J. Shaw, T. W. Negus, T. K. Mellor (1996) did a prospective clinical evaluation of the longevity of resorbable sutures in oral mucosa, gut, polyglycolic acid, polygalactin910 an irradiated form of polyglacatin 910, Vicryl Rapide demonstrates more rapid loss in other clinical situations and may be more suitable.
Ronald C. King, James J. Crawford (1998) studied on Bacteremia following intraoral suture removal is relatively low (5%), this study suggests that intraoral suture removal is not a benign procedure for those persons who are considered high-risk cardiac patients.47
LtCol AlokSharma,,Maj SandeepMebrotra (2002) reported the Experience with Buried Subcuticular Catgut Sutures in Operative Wounds In selected clean cases of elective surgery and concluded that skin closure with catgut by buried subcuticular suture gives gratifying results. The suture is easily available to surgeons in peripheral hospitals and is immensely economical compared to its synthetic counterparts. Its handling is good with no snagging and accurate knotting.
Storch et al (2002) reported a reduction of 96.7% with Vicryl® Plus suture after 48 hours in strains of S. aureus.19
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Chuanchuen et al (2003) concluded in his studies that he lack of bactericidal effects on P. aeruginosa may be explained by the natural resistance of this bacterium to triclosan, which has been attributed to efflux pumps that are present in this bacterium.15
Ford et al (2005) found polyglactin 910 with triclosan to result in less pain, though the areas in which this suture material was used were less sensitive than the oral cavity. These results may have been conditioned by the absence of blinding to the suture material employed, since the filaments were of different colors.21
Charles E Edmiston, Michael P Goheen, (2006) studied Bacterial Adherence to Surgical Sutures: Can Antibacterial The in vitro model demonstrated a considerable reduction (p 0.01) in Gram-positive and Gram- negative bacterial adherence to a triclosan-coated braided suture, which was associated with decreased microbial viability (p 0.001). Because bacterial contamination of suture material within a surgical wound may increase the virulence of a surgical site infection, treating the suture with triclosan provides an effective strategy for reducing perioperative surgical morbidity.18
A.Gomenso et al(2007) conducted a study to assess the efficacy of coated Vicryl Plus Antibacterial suture in two animal models of general surgery. The result concluded that antiseptic coated sutures normalize the wound healing process and had anti-inflammatory effect. 27
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Guiliana Banche et al (2007) conducted a study regarding microbial adherence on various intraoral suture materials in patients undergoing dental surgery. In the study silk sutures were compared with different types of sutures and the results concluded that silk has the least affinity towards adhesion of bacteria compared with considerable proliferation with non resorbable multifilament sutures (Supramid, synthofil, Ethibond Excel, Ti-cron). The study also found that greater quantity of bacteria was founded on non-resorbable sutures than absorbable ones.24
Gomez-Alonso , F.J. Garcıa-Criado , F.C. ParrenManchado , J.E.
GarcıaSanchez(2007) conducted a study on the efficacy of Coated VICRYL Plus Antibacterial suture (coated Polyglactin 910 suture with Triclosan) in two animal models of general surgery and reported the bactericidal efficacy of PGAB against gram-positive, and bacteriostatic effect against E. coli.He in turn obtained a reduction of about 87% with Vicryl® Plus suture previously infected with S.
epidermidis and E. coli.17.
Marco et al (2007) in a study using rats, reported a 66% reduction in cultures positive for S.epidermidis.
Rozzelle et al (2008) a neurosurgery group in New York, evaluated Vicryl Plus in a prospective, double-blinded, randomized controlled trial assigning patients undergoing CSF shunt implantation to closure with either Vicryl or Vicryl
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Plus. Indeed, they revealed a much better SSI rate in the study group versus the control group, 4.3% versus 21%.14
Akinojoguniya(2009) postulated that the wound swab from the local site of suspected infection should be cultured and should be send along. The specimen should be inoculated on two plates of blood agar, one for incubation in 37 degrees Celsius aerobically preferably in air plus five to ten percent carbon dioxide and other for incubation anaerobically in nitrogen hydrogen plus five to ten percent carbon dioxide. The Agar plate also has antibiotic walls to identify sensitivity. The culture plates are examined after overnight incubation at 37 degrees Celsius for 18 to 24 hours. If no growth plate should be re incubated for another 24 hours. Most infections can be managed well by using standard disc diffusion and antibiotic susceptibility data ( Kirby-Bauer disc diffusion antibiotic susceptibility technique) and providing dosage of standard amount of antibiotics as required.49
Deliaert et al (2009) have postulated that one potential cofactor in the development of SSI is the actual use of suture material. This group sought to evaluate the efficacy of triclosan-coated sutures in reducing the incidence of SSI.
In a study including 26 patients undergoing breast reduction surgery, one breast was randomized to standard suture material, whereas the opposite breast was closed using triclosan-coated sutures. Sixteen treatment breasts developed dehiscence but only seven dehiscence’s were observed in control breasts.29
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Brendan D. Masini, MD, Daniel J. Stinner, Scott M. Waterman,, and Joseph C. Wenke (2011)conducted a study on Bacterial Adherence to Suture Materials .This study gives data to guide the selection of suture materials.
Absorbable braided suture should not be used in closure of contaminated wounds or wounds at risk for developing infection. The antibiotic impregnated absorbable braided suture was similar to the other suture types; however, it is at risk for reverting to the properties of its untreated counterpart over time. The bacterial adherence of suture materials should be taken into account by all practitioners when closing wounds or debriding infected wounds.
Ibrahim Gaial(2011) conducted a study on impact of using Triclosan- antibacterial sutures on incidence of surgical site infection. The study concluded that use of Triclosan coated antibacterial suture lead to a reduction of surgical site infection.30
Zhang et al (2011) sought to evaluate the cosmetic results of Vicryl Plus in patients undergoing mastectomy. Comparison was made to Chinese silk. The Vicryl Plus suture resulted in much better cosmetic outcomes than Chinese silk.
This study also showed a trend toward less SSI when Vicryl plus was used.
Galal et al (2011) have broadened the use of Vicryl Plus in their study to include an extensively varied array of operations with multiple different incision configurations in clean, clean-contaminated, and contaminated surgical incisions.
In this study, a direct comparison was made between Vicryl Plus used in the study
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group of 230 patients with standard Vicryl suture used in the control group of 220 patients. Again, the reduction in SSI rates was approximately half in the study group compared with the control group, 7% versus 15%, respectively.
Rasic et al (2011), a Croatian group, evaluated the effectiveness of Triclosan- coated suture for closure of the abdominal wall in colorectal cancer cases. Ninety- one patients underwent closure with Triclosan-coated suture versus a control group of 93. Indeed, closures utilizing Triclosan suture showed a reduction in SSI from 13.2% to 4.3%.2
Williams et al (2011) compared 150 patients undergoing breast surgery. Of 75 patients closed with Triclosan suture, 15.2% developed SSI, whereas of the 75 patients closed with standard suture, 22.9% developed SSI. Although not substantial, this trend showing benefit of the coated suture was suspected to fail statistical significant because of the power of the study.5
Ibrahim Galal, Khaled El-Hindawy (2011)studied impact of using triclosan-
antibacterial sutures on incidence of surgical site infection and concluded that use of the triclosan-coated polyglactin 910 antimicrobial suture lead to reduction of surgical site infection and has an impact on saving health care resources. The triclosan-coated polyglactin 910 antimicrobial suture could save $1,517,727 yearly in this single center.1
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Isik et al (2012) randomized both sternal surgical incision closures and lower extremity harvest site closures. Overall, the incidence off SSI dropped from 5.6%
to 5.3% when Triclosan-treated suture was employed. Although a trend toward fewer SSIs was observed in both sternal surgical incisions and lower extremity incision sites, neither arm reached statistical significance.6
Turtianien et al (2012) randomized lower extremity surgical incision closures in patients undergoing lower extremity revascularization procedures. In this study, the Triclosan group showed more SSI (22.3%) versus the control group (21.9%).8
Seim et al (2012) evaluated lower extremity surgical incisions alone in patients undergoing coronary bypass surgery. Not only did they not show lower rates of SSI in the Triclosan treated group, they may have even observed a slight trend to more SSI with the Triclosan suture closed surgical incisions on the other side of the spectrum.10
Biswajat (2012) conducted a study with the objective prevalence of staphylococcus aureus and methicillin resistant staphylococcus aureus ( MRSA) in surgical site infections. This study was conducted on 66 patients who underwent surgery in the department of oral and maxillofacial surgery. Pus samples were collected with two sterile swabs and processed in the microbiological department.
Result of 66 pus samples, the most common organism which was isolated was staphylococcus aureus with 34(51.5 percent) isolates. Of this 14(41.2 percent) were methicillin resistant staphylococcus aureus (MRSA)50
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Ibrahim Galal, Khaled El-Hindawy, (2012) studied on Impact of using triclosan-antibacterial sutures on incidence of surgical site infection and concluded theUse of the triclosan-coated polyglactin 910 antimicrobial suture lead to reduction of surgical site infection and has an impact on saving health care resources. The triclosan-coated polyglactin 910 antimicrobial suture could save
$1,517,727 yearly in this single center.1
MarjoRenko, Niko Paalanne, TerhiTapiainen, MattiHinkkainen (2013) conducted a study on Triclosan-containing sutures versus ordinary sutures for reducing surgical site infections in children and concluded that the use of triclosan-containing sutures effectively reduced the occurrence of all SSIs compared with normal sutures. The results accord with the results of meta- analyses of previous studies in adults. Use of triclosan containing sutures is a simple way to reduce SSIs.
Fernando Cruz,Gustavo Cruz et al (2013) conducted a study on Sutures coated with antiseptic pomade to prevent bacterial colonization and concluded that the the iodoform antiseptic pomade was effective in reducing bacterial colonization on silk braided sutures after oral surgery.26
Shlomo Matalon , Avital Kozlovsky, AndaKfir, ShifraLevartovsky et al (2013) compared the effect of commonly used sutures on inflammation inducing pathogens : The absorbable Vicryl Plus exhibited a bactericidal effect against the Staphylococcus strains, which was unaffected by aging. With P. aeruginosa, there
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was only an initial delay in bacterial growth and reported that Vicryl Plus had sustained bactericidal effect against the Staphylococcus strains but not against P.
aeruginosa. None of the other sutures presented any antibacterial properties.40
Nakamura et al (2013) of Japan randomized 410 patients undergoing elective colorectal surgery to abdominal wall closures with Triclosan suture versus control and revealed a substantial reduction in SSI rates by more than half.
Thimour Bergstrom etal (2013) revealed promising data in the lower extremity harvest site incisions of cardiac surgery patients. In this study, SSI was defined in three ways: 1) By CDC definition, 2) Culture proved, 3) Surgical incisions treated with antibiotics. In all three categories, substantially lower SSI rates were observed when the leg incisions were closed using the Triclosan sutures.
Mohammed (2013) conducted in this retrospective study of incidence of bone infections and antibiotic sensitivity patterns in patients which involves the analysis of medical records of 651 patients. The medical records of patients with wound infections showed that 77.9 percent of wound sites are contaminated with various bacteria contaminates notably staphylococcus aureus followed by klebsiella spp in the decreasing order of frequency. The most common infection site was surgical sites with amoxicillin, gentamicin and ceftriaxone being the most commonly prescribed antibiotics for the treatment of resulting infections based on culture and sensitivity results.
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Masaki Ueno, Wataru Saito, MegumuYamagatet al (2013) studied weather Triclosan-coated sutures reduce wound infections after spinal surgery and concluded that the use of antibacterial-coated suture material may decrease operative infections. Together with effective and persistent skin antisepsis, meticulous operative technique, and appropriate antimicrobial prophylaxis, the use of antibiotic-coated suture material may help prevent infections in different kinds of orthopedic surgery, including infection control surgery.
Cristina Serrano , Luis García-Fernande , Juan Pedro Fernandez-B azquez (2014)concluded that two major antibacterial strategies have been applied to sutures and biomaterials in general : passive coatings based on cationic biopolymers that prevent bacterial attachment, or active strategies that release active compounds into the tissue and kill suspended bacteria mainly silver, antimicrobial peptides or antibiotics While passive strategies are preferred in terms of biocompatibility, active strategies are often more effective.
Sergi Sala-Pérez, Marta López-Ramírez, MilvaQuinteros-Borgarello, Eduardo Valmaseda-Castellón et al (2016) compared Antibacterial suture vs silk for the surgical removal of impacted lower third molars and concluded that the greatest antibacterial effect of Monocryl Plus suture was observed after 72 hours. According to most authors, there is no doubt that this antibacterial suture can provide little safety in the control of SSI.
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Patrick B. O Nealand Kamal M.F. Itani (2016 )studied on Antimicrobial Formulation and Delivery in the prevention of Surgical Site Infection and stated that the use of topical antimicrobial and antiseptic agents such as antibacterial irrigations, local antimicrobial application, antimicrobial-coated sutures, antibacterial wound sealants, and antimicrobial impregnated dressings in the prevention of SSI is questionable .
Tytti Pokka, SohviKinnula, Juha-Jaakko Sinikumpu, MattiUhari, Willy Serlo (2016) reported that Surgical site infections (SSIs) are a pervasive problem in surgery. Sutures coated or impregnated with triclosan might reduce the occurrence of SSIs, but evidence of their efficacy is limited, especially in children.
MarjoRenko, Niko Paalanne, TerhiTapiainen, MattiHinkkainen, Tytti Pokka, SohviKinnula, uha-Jaakko Sinikumpu, MattiUhari, Willy Serlo(2016) compared Triclosan-containing sutures versus ordinary sutures for reducing surgical site infections in children and concluded that use of triclosan- containing sutures effectively reduced the occurrence of all SSIs compared with normal sutures. The results accord with the results of meta-analyses of previous studies in adults. Use of triclosan containing sutures is a simple way to reduce SSIs in children.
Katy L. Townsend, William Lear, Bria L. Robertson, Jamie J.
Kruzic(2016) This study suggests that there is not a significant benefit of using polyglactin 910 buried dermal absorbable sutures in a simple interrupted pattern in
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addition to nylon superficial sutures for producing strong wounds after both 10 and 42 days.
D. J. Leaper1, C. E.Edmiston, C. E. Holy et al(2017) did Meta-analysis of the potential economic impact following introduction of absorbable antimicrobial sutures .Using random-effects event estimates of SSI the mean savings per surgical procedure from using antimicrobial sutures were significant.46
Tabrizi, H. Mohajerani, F. Bozorgmeh (2018) compared Polyglactin 910 suture with Polyglactin 910 coated with triclosan in dental implant surgery.
Analysis of the data did not demonstrate any significant difference in the incidence of surgical site infection between the two groups (P = 0.5). The incidence of surgical site infection in fresh socket implant placement was higher than that in delayed implant placement, irrespective of the type of suture used (P = 0.001). Triclosan-coated Vicryl sutures did not decrease the incidence of surgical site infection in dental implant surgery.
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MATERIALS AND METHODS
The present study to compare the antibacterial effect of Polyglactin 910 suture coated with triclosan (Vicryl Plus suture) and CATGUT suture, analyzing the microbiological differences in terms of colonies forming unit’s organisms and species was conducted in the department of OMFS, Best Dental Science College in Madurai, over a period of 1 year (March 2018 to February 2019) on the patients willing for voluntary participation after obtaining informed consent. The institutional scientific review board and ethical committee approved the protocol for this clinical comparative study.
Total 100 patients between the age group of 16-45 years who will report to Best Dental Science College, Madurai diagnosed with conditions requiring open surgical removal of lower third molars.
INCLUSION CRITERIA
· Patients who need surgical removal of lower third molars
· Age group 16-45 years
22
EXCLUSION CRITERIA
· Patients suffering from systemic illness predisposing them to immunocompromised state (diabetesmellitus, long-term steroid therapy, hemostatic alterations)
· Pregnant patients
· Patients with acute infectious conditions in the oral cavity e.g. Acute abscess, Acute necrotizing ulcerative gigivitis,etc
· Drug abusers, patient with moderate alcohol consumption.
STUDY DESIGN
The patients requiring surgical removal of lower third molar chosen as per above inclusion and exclusion criteria. The commercially available antibacterial
suture (polygalactin 910 coated with triclosan) –VICRYL PLUS and CATGUT suture will be used in these patients for suturing purpose randomly. Patient is asked to maintain good oral hygiene. All patients complied with a pharmaceutical protocol, including amoxicillin 500 mg TID, Metrogyl 400 mg BD, Aceclofenac and paracetamol, pantoprazole post operatively.
The subjects will be divided in to 2 groups
Group A (50 patients)-surgical site receiving antibacterial suture vicryl plus suture.
Group B (50 Patients) -surgical site receiving catgut suture
23
On the 7th day postoperatively one entire stitch from operated site will be removed and sent for microbiological evaluation.
MATERIALS REQUIRED
· 3-0 Polyglactin 910 coated with triclosan ( VICRYL PLUS antibacterial suture)
· 3-0 CATGUT suture
· Needle holding forceps
· Suture cutting scissors
· Non toothed suture holding forceps
· Sterile containers
· Transport Medium-Glucose broth
· Culture Medium-Blood agar medium
PROCEDURE
Surgical procedure for the removal of impacted third molar will be done under all aseptic measures.
After surgically removing lower third molar each patient will be given interuptted sutures either with VICRYL PLUS or CATGUT randomly. The second procedure will be carried out after a minimum of 7 days after the first procedure and after the removal of suture .
24
On the 7th day one entire stich from the operated site will be removed and placed in glucose broth. The samples were prepared to culture the bacteria that had adhered to and grown on them. Harvested pieces were immediately placed in sterile tubes to maintain a viable bacterial culture. Each tube contained 1.0 mL buffer solution containing 4.2 mg sodium chloride (NaCl), 3.1 mg anhydrous dipotassium phosphate, 0.3ml bidistilled glycerin, and 0.7 mL distilled water. All samples were labeled and stored on ice in a thermal container until processed by the laboratory. The storage time did not exceed 6 hours after collection.
Each tube containing a sample was kept in constant mechanical flux at 12 rpm for 10 minutes, inducing deposits to be formed. The deposits were discarded and the suspension was then subjected to serial 10-fold dilutions. The first dilution of 101 was prepared by pipetting 1 mL of the suspension and diluting it in 9 mL saline solution (0.85% NaCl). From the first 101 dilution (1:10) subsequent dilutions were prepared (102 (1:100), 103 (1: 1,000), and so on, up to 1010) by transferring 1 mL of each dilution to obtain the next. The tubes were kept under constant homogenization. One milliliter of each dilution was plated on a medium of blood agar plus defibrinated sheep blood (5 mL blood agar per 100 mL base medium), reaching a pH of 6.8 .The plates were incubated at 37°C under microaerophilic conditions (5% CO2) for 48 hours. After 48 hours’ incubation, microbiological identification of specific organisms with antibiotic sensitivity done.
After incubation, the number of colony-forming units per milliliter (CFU/mL) was recorded with the aid of a colony counter. The 2 dilutions that grew 30-300
25
colonies were chosen, and an arithmetic mean between the 2 values was obtained. The final number of CFU/mL was determined by multiplying the mean number of colonies counted by the corresponding dilution factor.
Data were tabulated and submitted to a comprehensive statistical analysis. The Mann-Whitney U test at a significance level of 5% (P.05) was used to compare the bacterial contamination of the threads between the groups.
26
VICRYL PLUS SUTURE
27
CATGUT SUTURE
28
RESULTS AND STATISTICAL ANALYSIS
These present study were conducted on 100 patients to compare the antibacterial effect of VICRYL PLUS suture ( Polyglactin 910 coated with triclosan) and CATGUT suture, on oral surgical site following impacted third molar removal over a period of one year from March 2018 to February 2019. The study revealed the microbiological differences in terms of colonies forming unit’s organisms and species, susceptibilities’ to antibiotics, the incidence of bacteriological profile and the antibiotic sensitivity pattern. In our study 100 suture specimens were given for microbiological examination and culture and sensitivity - (50 patients whom Catgut sutures was placed and 50 patients) whom Vicryl plus sutures are placed. The study yielded following results.
· All positive culture samples yielded single microbial growth.
VICRYLPLUS SUTURE (OUT OF 50 CASES) 1. klebsiella pneumonia - 4 cases. (8 %) 2. staphylococcus aureus - 1 case. (2%) 3. staphylococcus epidermidis - 1 case. (2 %)
Staphylococcus aureus and staphylococcus epidermidis were found to be the most common Gram Positive organism isolated and Klebsiella pneumonia was the most common Gram Negative organism isolated.
The total incidence for surgical site infection when using Vicryl plus suture for 50 cases accounted for only 6 cases ( 12 %).
29 CATGUT SUTURE (OUT OF 50 CASES) 1. E.coli- 8 cases. (16 %)
2. Klebsiella pneumonia - 5 cases. (10 %) 3. staphylococcus aureus - 3 cases. (6%) 4. staphylococcus epidermidis - 3 cases. (6 %).
E.coli and Klebisella were most common gram negative organism isolated and Staphylococcus aureus and staphylococcus epidermidis were most common Gram positive organism isolated.
The total incidence of SSI when using Catgut suture for 50 cases accounted for 19 cases. (38%)
In our study the total incidence of SSI when using Vicryl plus suture was reduced to one third when compared with Catgut suture.
IN OUR STUDY OF ANTIBIOTIC SENSITIVITY TO GRAM POSITIVE AND GRAM NEGATIVE ISOLATES FROM SUTURE MATERIAL IS MENTIONED BELOW
GRAM POSITIVE
1.STAPHYLOCOCCUS EPIDERMIDIS
Highly sensitive - cefoperozone, amikacin, ceftriaxone, cefuroxime, cefotaxime, netilmicin sulphate.
Moderatively sensitive - gentamicin, doxycycline, ciprofloxacin, gatifloxacin, ofloxacin, levofloxacin.
30
Resistant - amoxyclav, clindamycin, clarithromycin, azithromycin, cephalexin.
2.STAPHYLOCOCCUS AUREUS
Highly sensitive - pipperacillin and tazobactum, ceftriaxone, netilmicin sulphate Moderatively sensitive - cefuroxime, cefozolin, gentamicin, gatifloxacin, ofloxacin Resistant - amoxyclav, erythromycin, clarithromycin.
GRAM NEGATIVE 1. E.COLI
Highly sensitive - cefotaxime, ceftriaxone, amikacin, cefoperozonesulbactum, impenem, meropenem, tobramycin, piperacillin and tazobactum, netilmicin sulphate.
Moderatively sensitive - amoxyvlav, cephalexin, doxycycline, cefepime, gentamicin.
Resistant - gatifloxacin, levofloxacin, ofloxacin, ciprofloxacin, linezolid, clindamycin.
2.KLEBISELLA PNEUMONIA
Highly sensitive - doxycycline, ceftriaxone, clindamycin ,cefperozone,cefepime.
Moderatively sensitive- cefotaxime, levofloxacin, cephalexin, cefuroxime, ofloxacin.
Resistant - clarithromicin, azithromycin, amikacin, linezolid, amoxyclav, ciprofloxacin.
31 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Absent Present
Vicryl plus suture Catgut suture
STATISTICAL ANALYSIS OF RESULTS:
S.Pneumonia
group P value
Vicryl plus suture
Catgut suture
absent 46(92%) 45(90%)
present 4(8%) 5(10%) 1.00
Total 50 50
32 0%
20%
40%
60%
80%
100%
120%
Absent Present
Vicryl plus suture Catgut suture Column1
S.aureus
group P value
Vicryl plus suture
Catgut suture
S.Aureus absent 49(98%) 47(94%) .617
present 1(2%) 3(6%)
Total 50 50
33 0%
20%
40%
60%
80%
100%
120%
absent present
study populAtion
Organisms
Vicryl plus suture Catgut suture
S. epidermidis
group P value
Vicryl plus suture
Catgut suture
S.Epidermidis absent 49(98%) 47(94%) .617
present 1(2%) 3(6%)
Total 50 50
34 E coli
group P value
Vicryl plus suture
Catgut suture
E.coli absent 50(100%) 42(44%) .006
present 0(0%) 8(16%)
Total 50 50
Significant difference seen between groups
0%
20%
40%
60%
80%
100%
120%
Absent Present
Vicryl plus sutureCatgut suture Catgut suture
35 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
absent present
Vicryl plus suture Catgut suture
group P value
Vicryl plus suture
Catgut suture
organism absent 44(88%) 32(64%) .009
present 6(12%) 18(36%)
Total 50 50
Significant difference seen between groups
36 DISCUSSION
Sutures are a vital part of nearly every surgical procedure, designed to close and stabilize wound margins and allow undisturbed wound healing (Wikesjö et al., 1992;
Minozzi et al.,2009)Suture functions to approximate tissue edges, which promotes healing and at the same time limits further deep contamination. Most surgical infections potentially impairing wound healing are intimately related to sutures (Horan et al.,1992)
In the oral cavity, sutures are placed within tissues of high vascularity in moist bacteria rich environment with infectious potential. Bacteria and necrotic debris lodge on the suture material and invade the suture track (Selvig et al., 1998), retain infection and delay the healing cascade (Kim, 2002; Morrow and Rubinstein, 2002).
The physicochemical characteristics of a suture material influence its ability to attract bacteria and consequently promote wound infection (Chu and Williams, 1984).
Bacteria adhere to various types of sutures with different affinities (Katz et al., 1981) The environment of the oral cavity has great potential for a suture infection.
There is a constant source of infectious pathogenic bacteria that, together with persistent moisture, allows bacteria to colonize on a suture, grow along its path and result in an infection in the healing tissues. Additionally, in the oral cavity, the sutures may be repeatedly moved by food and mastication, which may further enhance this risk. Thus, a suture material that can reduce the potential for colonization and growth of pathogenic bacteria may be preferred. Two-thirds of all cases of SSI appear in the zone of the incision. This probability is even greater in the presence of suture material
37
It has been estimated that with conventional sutures (such as the natural black silk), barely 100 cfu would be needed to induce SSI).4
The surgical extraction of impacted third molars (I3M) still remains one of the most commonly performed surgical procedures in Oral Surgery. The wound comes under clean contaminated wound category. Surgical site infection (SSI) is among the postoperative local complications that may arise in this surgical procedure.
Postoperative infection rate after I3M extraction is around 5% (1). The incidence of SSI is related to intrinsic patient factors (immune-depression, diabetes mellitus, local or systemic infections, etc.) and extrinsic factors (such as smoking, surgical antiseptic measures, wound contamination in clean, contaminated or dirty surgeries.
Microorganisms in surgical infections Staphylococcus aureus
Staphylococcus epidermidis Enterococcus spp
Escherichia coli
Pseudomonas aeruginosa Enterobacter spp
Klebsiella pneumonia .
Adjunctive local antiseptic/ antimicrobial agents such as antiseptic irrigation, topical antibiotics, and impregnated dressings have historically and continue to be sporadically employed by surgeons to prevent surgical site infection.Several studies have been published regarding efficacy of various antimicrobials
38
ANTIMICROBIAL AGENTS IN SURGICAL SITE INFECTION PREVENTION
Benefit of Locally Applied Antimicrobial Agents in the Prevention of Surgical Site
Infections / First author/year Intervention Predicted benefit (Yes/No)
Cheng 2005 Povidone-iodine irrigation in wound Yes
Deep infection only Harihara 2006 Povidone-iodine irrigation to skin
No
Mohd 2010 Dermacyn super-oxidized water irrigation Yes
Trend Takesue 2011 Electrolyzed sodium chloride irrigation Trend
results in impaired wound
healing
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Local antibiotics Clean-contaminated cases
Gruessner 2001 Gentamicin-laced collagen Yes
Charalambous 2003 Ampicillin irrigation Yes, but No incremental effect over IV alone
Haase 2005 Gentamicin-laced collagen No
Neri 2008 Topical rifamycin Yes
Bennett-Guerrero 2010 Gentamicin-laced collagen No, more SSI with the sponge.
De Bruin2010 Gentamicin-laced collagen Yes
Yetim 2010 Gentamicin-laced collagen Yes
Ruiz-Tovar 2012 Gentamicin/Clindamycin abdominal
irrigation Yes
Antimicrobial coated sutures
Rozelle 2008 Triclosan-coated suture (CSF shunt) Yes
Deliaert 2009 Triclosan-coated suture (Breast) No, more dehiscence with triclosan
Justinger 2009 Triclosan-coated suture (Laparotomy) Yes
Mingmalairak 2009 Triclosan-coated suture (Appendix) No, more SSI with
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triclosan
Galal 2011 Triclosan-coated suture (Multiple sites) Yes
Galal 2011 Triclosan-coated suture (Multiple sites) Yes
Turtianinen 2012 Triclosan-coated suture (Leg) No
Thimour-Bergstro ¨m 2013 Triclosan-coated suture (Leg)
Yes
Nakamura 2013 Triclosan-coated suture (Colon) Yes
Justinger 2013 Triclosan-coated suture (Laparotomy) Yes
Diener 2014 Triclosan-coated suture (Laparotomy) No
Wound sealants
Chambers 2010 Cyanoacrylate sealant Yes
Iyer 2011 Cyanoacrylate sealan Yes
Von Eckardstein 2011 Cyanoacrylate sealant Yes
Antimicrobial dressing
Storm-Versloot 2010 Silver-impregnated dressing No
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This susceptibility of sutures to infection led to the introduction of sutures treated with triclosan, a broad-spectrum antibacterial agent, which are claimed to have antibacterial properties (Rothenburger et al., 2002) . Triclosan is an antiseptic component with bacteriostatic action. At low concentrations, inhibits the growth of many non sporulating gram positive and gram negative bacterial species. The safe amount of triclosan required for an optimal antimicrobial effect is 472μg/m in coated polyglactin sutures. The amount added to these sutures reaches 1.5 μg/cm, and the range of minimum inhibitor concentrations (MICs) against the microorganisms that inhabit the oral cavity is 0.0017.8 μg/ml. In 2002, the United States Food and Drug Administration (FDA) authorized the use of polyglactin 910 coated with triclosan (Vicryl® Plus, Antibacterial suture). 5
Triclosan is a broad-spectrum phenol family antiseptic, used for more than 30 years as a safe and effective antimicrobial agent, against the most common pathogen agents that cause SSI: Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa and Escherichia coli and methicillin-resistant Staphylococcus aureus (MRSA).
Sutures with antimicrobial effects have been proven to be beneficial in other contexts, such as the closure of sternal surgical wounds (Fleck et al., 2007). They may also be advantageous in the oral cavity. The Vicryl Plus suture may be more suitable for use in these conditions than the other suture types that were tested because of its antibacterial capacity
Catgut is a monofilament absorbable suture with good tensile strength that retains optimum strength to bold tissues together. It is smooth and pliable, has good
42
knotting property and disappears completely between 60 and 120 days depending on its size. The advent of newer synthetic sutures has prompted some surgeons to start writing the epitaph for catgut. The cost effectiveness of catgut coupled with good results will be an advantage in the economic aspect particularly in developing countries.
The aim of this study was to compare the antibacterial effect of Vicryl Plus suture (Polyglactin 910 coated with triclosan) and CATGUT suture, analyzing the microbiological differences in terms of colonies forming unit’s organisms and species.
Role of laboratory infection diagnosis and variety of laboratory test may be helpful indeterminate the timing of therapeutic intervention in patients with proven or suspected infection. The basic procedures usually include a naked eye examination of the specimen, microscopic examination of Gram stain and culture on aerobic and anaerobic blood Agar plates, on Mac Conkeys Agar and in cooked meat broth.
Generally, wound infections are characterized by leukocytosis. Laboratory helps in defining laws of infection in isolating a specific organism or a group of organism and providing data that supports the worthiness of antimicrobial treatment in terms of ensuring both the Killing of organism and minimal toxicity from the dry closure.
Gram stain is a simple procedure which pathogenic agents can be predicted and can guide us for empirical therapy.
According to akin Akinojoguniya(2009) the wound swab from the local site of suspected infection should be cultured and should be send along. The specimen
43
should be inoculated on two plates of blood agar, one for incubation in 37 degrees Celsius aerobically preferably in air plus five to ten percent carbon dioxide and other for incubation anaerobically in nitrogen hydrogen plus five to ten percent carbon dioxide. The Agar plate also has antibiotic walls to identify sensitivity. The culture plates are examined after overnight incubation at 37 degrees Celsius for 18 to 24 hours. If no growth plate should be re incubated for another 24 hours. Most infections can be managed well by using standard disc diffusion and antibiotic susceptibility data ( Kirby-Bauer disc diffusion antibiotic susceptibility technique) and providing dosage of standard amount of antibiotics as required.
The use of antimicrobials or antibiotics in wound infections has come in a long way in prophylactic therapeutic management. The role of antimicrobial therapy is to prevent or treat infections by reducing or eliminating pathogenic organism until the host own defenses can get rid of the last pathogen. The basic consideration in choosing and Antimicrobial is efficacy, toxicity, and cost effectiveness. Effective antimicrobial agent must be active against the pathogens causing the infections and must be able to reach the site of infections in adequate concentration and particular time. All antibiotics have potential toxicity. Toxic effects may be idiosyncratic such as allergy or the instance of bone marrow aplasia caused by chloramphenicol or result in damage to tissue and organs as renal toxicity or auto toxicity seen with aminoglycoside and amphotericin B.
Antimicrobial agents also exert selective pressure on microbial ecology of hospital that leads to resistant microbes lost in final consideration in the selection of antimicrobials.
44 Principles of antibiotic therapy
1. The organism should be sensitive to antibiotic chosen.
2. Antibiotics should be in dose that ensure adequate peak concentration and tissue penetration.
3. Antibiotics should come in contact with the organism.
4. Frequency of administrative is based on the half Life and the route of eliminations of antibiotics.
5. Choose a bactericidal antibiotic when appropriate.
6. Use synergistic therapy when appropriate.
7. Avoid antagonistic combination of antibiotics.
8. Choose the most appropriate and narrow spectrum antibiotics.
9. Adverse effects should be evaluated and risk benefit balanced.
Ensure proper duration of therapy to ensure eradication of pathological organism discussed by Aomar abubakar.
Storch et al. reported a reduction of 96.7% with Vicryl® Plus suture after 48 hours in strains of S.aureus.. Gómez Alonso et al. in turn obtained a reduction of about 87%
with Vicryl® Plus suture previously infected with S. epidermidis and E. coli.
Shlomo Matalon , Avital Kozlovsky, Anda Kfir, Shifra Levartovsky et al ( 2013 ) compared the effect of commonly used sutures on inflammation inducing pathogens : The absorbable Vicryl Plus exhibited a bactericidal effect against the Staphylococcus strains, which was unaffected by aging. With P. aeruginosa, there was only an initial delay in bacterial growth and reported that Vicryl Plus had sustained bactericidal effect against the Staphylococcus strains but not against P. aeruginosa. None of the other sutures presented any antibacterial properties.
45
Galal et al (2011) have broadened the use of Vicryl Plus in their study to include an extensively varied array of operations with multiple different incision configurations in clean, clean-contaminated, and contaminated surgical incisions. In this study, a direct comparison was made between Vicryl Plus used in the study group of 230 patients with standard Vicryl suture used in the control group of 220 patients. Again, the reduction in SSI rates was approximately half in the study group compared with the control group, 7% versus 15%, respectively.
Williams et al (2011) compared 150 patients undergoing breast surgery. Of 75 patients closed with Triclosan suture, 15.2% developed SSI, whereas of the 75 patients closed with standard suture, 22.9% developed SSI. Although not substantial, this trend showing benefit of the coated suture was suspected to fail statistical significant because of the power of the study.
Mohammed conducted in this retrospective study of incidence of bone infections and antibiotic sensitivity patterns in patients which involves the analysis of medical records of 651 patients. The medical records of patients with wound infections showed that 77.9 % of wound sites are contaminated with various bacteria contaminates notably staphylococcus aureus. followed by klebsiella spp in the decreasing order of frequency. The most common infection site was surgical sites with amoxicillin, gentamicin and ceftriaxone being the most commonly prescribed antibiotics for the treatment of resulting infections based on culture and sensitivity results.