Abstract
Objectives
To determine if triclosan-impregnated suture decreases surgical site infection rates after tibial plateau leveling osteotomy (TPLO) in dogs.
Sample population
There were 116 dogs with naturally occurring cranial cruciate ligament disease presenting for treatment with TPLO.
Procedures
Written consent was obtained by all clients in order to be included in this study. Dogs were randomly assigned a suture type immediately before the start of anesthesia. Infection rates were compared between the suture groups, as were the gender, duration of anesthesia, duration of surgery, age of dog, weight, length of incision, and stifle side. Direct examination by a veterinarian was conducted at 24 h, 10 to 14 d, and 8 to 12 wk after surgery. If the dogs did not return for direct examination, owners were contacted by a veterinarian and phone interviews were conducted.
Results
Overall, 12.9% of the incisions were diagnosed with a surgical site infection (SSI). The SSI rate for dogs that received the triclosan suture was 5.35% (3/56), and the rate for dogs that received the regular suture was 19.64% (11/56), with P = 0.016. The duration of anesthesia, duration of surgery, age, weight, length of incision, and right versus left stifle did not show a significant difference in infection rates. The suture type did have a significant effect, and triclosan-impregnated suture had a decreased infection rate when compared to regular suture. Gender also had a significant effect, with P = 0.032.
Conclusion
Triclosan-impregnated suture decreased SSI when used for closure in dogs undergoing TPLO. Triclosan-impregnated suture may be considered a material of choice to close surgical wounds at risk of SSI when implants are used.
Résumé
Comparaison prospective, randomisée, en double aveugle des matériaux de suture avec et sans triclosan chez les chiens subissant une ostéotomie de nivellement du plateau tibial
Objectifs
Déterminer si la suture imprégnée de triclosan diminue les taux d’infection du site opératoire après une ostéotomie de nivellement du plateau tibial (TPLO) chez le chien.
Échantillon de population
Il y avait 116 chiens avec une pathologie naturelle du ligament croisé crânial se présentant pour un traitement avec TPLO.
Procédures
Un consentement écrit a été obtenu par tous les clients afin d’être inclus dans cette étude. Les chiens ont été répartis au hasard à un type de suture immédiatement avant le début de l’anesthésie. Les taux d’infection ont été comparés entre les groupes de suture, de même que le sexe, la durée de l’anesthésie, la durée de la chirurgie, l’âge du chien, le poids, la longueur de l’incision et le côté du grasset. Un examen direct par un vétérinaire a été effectué à 24 h, 10 à 14 j et 8 à 12 semaines après la chirurgie. Si les chiens ne revenaient pas pour un examen direct, les propriétaires étaient contactés par un vétérinaire et des entretiens téléphoniques étaient menés.
Résultats
Dans l’ensemble, 12,9 % des incisions ont été diagnostiquées avec une infection du site opératoire (SSI). Le taux de SSI pour les chiens ayant reçu la suture au triclosan était de 5,35 % (3/56) et le taux pour les chiens ayant reçu la suture régulière était de 19,64 % (11/56), avec P = 0,016. La durée de l’anesthésie, la durée de la chirurgie, l’âge, le poids, la longueur de l’incision et le grasset droit versus le gauche n’ont pas montré de différence significative dans les taux d’infection. Le type de suture avait un effet significatif et la suture imprégnée de triclosan avait un taux d’infection réduit par rapport à la suture ordinaire. Le sexe avait également un effet significatif, avec P = 0,032.
Conclusion
La suture imprégnée de triclosan a diminué le SSI lorsqu’elle était utilisée pour la fermeture de l’incision chez les chiens subissant une TPLO. La suture imprégnée de triclosan peut être considérée comme un matériau de choix pour fermer les plaies chirurgicales à risque de SSI lorsque des implants sont utilisés.
(Traduit par Dr Serge Messier)
Introduction
A surgical site infection (SSI) has been defined by the Centers for Disease Control and Prevention as an infection of the incision, organ, or space that occurs after surgery (1). Development of an SSI can lead to increased cost, the need for extensive wound management, antibiotic treatment, and sometimes, implant removal. The tibial plateau leveling osteotomy (TPLO) procedure was developed over 25 y ago, but it still has a high SSI rate for a clean orthopedic procedure. Surgical site infections after TPLO range from 2.5 to 18.8%, and most commonly the infections occur within the first 86 d after surgery (2–9). Typical infection rates for clean surgical procedures are 3.6 to 5.8% (10). Many efforts have been made to identify and reduce SSIs, including those involving prophylactic antibiotics, antiseptic prophylaxis during skin preparations, method of incision closure (external sutures versus intradermal patterns), use of a bandage, and use of locking screws and implants (2–11).
Surgical site infections after TPLO can be caused by many different bacterial pathogens and can occur through several different mechanisms, including break in sterility during surgery, endogenous infection, or self-trauma. Surgical site infections can develop at several different levels, including in soft tissue or implants, and cause osteomyelitis or septic arthritis. When implants are involved, such as with TPLO, infections can be even more challenging due to bacterial biofilms that develop on the implants. This leads to even more expense and typically the need for a 2nd surgery to remove the plates and screws and resolve the infection. The most common bacterial isolates with TPLO surgical site infections are Staphylococcus spp., with methicillin-resistant Staphylococcus pseudintermedius becoming an increasing concern (11). Suture material can also be a nidus for infections because it can decrease the number of bacteria needed to cause an SSI (12). In vitro studies have shown that triclosan-impregnated suture inhibits bacterial colonization by the following organisms for at least 7 to 29 d: Staph. aureus, Staph. epidermidis, methicillin-resistant Staph. aureus (MRSA), methicillin-resistant Staph. epidermidis, Escherichia coli, and Klebsiella pneumoniae (13–15). As many as 67% of all SSIs are confined to the incision, and it is thus reasonable to look for preventive measures involving incision closure (16,17).
Triclosan is a widely used antibacterial agent that weakens cell membranes in bacterial cells and inhibits replication (18). Triclosan interferes with bacterial fatty acid synthesis by blocking lipid biosynthesis through binding with the enoyl-acyl carrier protein reductase enzyme (18). In vivo and in vitro studies have been done using triclosan-impregnated suture, with positive results. An in vivo study undertaken in guinea pigs used triclosan-impregnated suture and control suture for implantation into the subcutaneous layer. Suture was inoculated with Staph. aureus; after 48 hours, the sutures were removed. It was demonstrated that the triclosan suture inhibited Staph. aureus colonization: The triclosan suture site had 559 colony-forming units (CFU), whereas the control suture had 16 831 CFU (13). Another in vitro study used clinical bacterial isolates and determined that triclosan-coated suture material inhibited the growth of Staph. pseudintermedius and E. coli, including the corresponding multi-drug resistant isolates (19). Another article that examined infection rates in human cardiac patients showed that, whereas 24 of 376 patients whose incisions were closed with a non-antibacterial suture developed complications, none of the 103 wounds closed with triclosan-coated suture material developed infection or dehiscence during the hospital stay or on follow-up visits (15). Finally, a study on rats showed a 66.6% reduction in the number of positive cultures when using triclosan-coated suture material (20).
In addition, several retrospective studies have been reported, including 1 study that examined infection and inflammation rates associated with triclosan-impregnated suture versus non-impregnated suture following TPLO surgeries in 283 dogs (5). The authors reported no difference in infection rates and that triclosan-impregnated suture actually had a higher inflammatory effect. Another retrospective study assessed the use of polyglactin 910 triclosan-coated suture to reduce infection rates after human spinal surgery. The SSI rates for spinal surgeries are higher when compared to other clean orthopedic surgeries in humans, with rates reaching 4.15% in high-risk patients. In that study, 250 patients underwent conventional wound closure with polyglactin 910 suture, and 200 patients underwent wound closure with triclosan-coated polyglactin 910 suture. There were 9 patients with wound infections; only 1 patient had a wound infection with triclosan-coated suture, and the difference between groups was significant (P = 0.020) (21). However, retrospective studies are subject to potential biases, and the inconsistent results of these studies warrant additional investigation to assess the efficacy of triclosan-impregnated suture.
The objective of this study was to perform a prospective, randomized, double-blinded study to determine the clinical effect of triclosan-impregnated suture material compared to non-triclosan-impregnated suture material on SSI development following TPLO in 116 dogs with cranial cruciate ligament (CCL) injury. We hypothesized that triclosan-impregnated sutures would reduce SSI infections.
Materials and methods
Client consent was obtained for participation in the study. Data were collected from 2017 to 2019. To be eligible for this study, dogs must have had naturally occurring unilateral cranial cruciate ligament disease and been admitted for treatment with TPLO. The dogs had no current pyoderma and were not taking systemic antibiotics for minimum of 2 wk before surgery. All dogs had no blood work abnormalities and no underlying endocrine diseases such as hypothyroidism, diabetes, or Cushing’s disease. Last, to be considered for this study, the dogs had to be of appropriate size for using a 6 hole 3.5-millimeter dynamic compression TPLO plate. There were no limits on age, weight, sex, or breed for this study. All TPLOs were done by the same Board-certified veterinary surgeon. The suture used to close all layers of the incision was assigned using randomized allocation software, and the surgeon was unaware of the suture type before, during, or after surgery. During surgery, a scrub technician was handed the suture and the surgeon did not see the packaging. The surgery scrub technician recorded all information to ensure the surgeon was unaware of the suture type used in each dog at recheck examination. Additionally, information on signalment, surgery time, suture, anesthesia time, and incision length was recorded on separate paperwork.
Using a standard anesthesia protocol, each dog was premedicated with hydromorphone and midazolam, and anesthesia was induced using propofol and maintained with isoflurane and oxygen. An epidural using preservative-free morphine was administered preoperatively. After induction, Cefazolin (West-Ward, Memphis, Tennessee, USA) was administered at 22 mg/kg, IV while the dog was being prepared for surgery, and this dose was repeated every 90 min while the dog was under anesthesia. The dog was clipped in an appropriate manner for the procedure. The limb was pre-scrubbed with 2% chlorhexidine and alcohol for at least 5 min until the skin was clear of debris. The extremity was then laid on a clean, nonpermeable incontinence pad, and the dog was transferred to the operating room.
The dog was placed in dorsal recumbency, and a standard hanging leg preparation was completed using sterile gauze, chlorhexidine 2%, and alcohol. Routine 4-corner draping was used and the paw was draped with an impermeable dressing and then wrapped in a sterilized elasticized wrap (FlexWrap; Aspen Veterinary Resources, Greeley, Colorado, USA). All surgeries, from initial skin incision until final closure of the skin, were conducted by the same Board-certified surgeon. A scrub technician assisted the surgeon by handing instruments and suture material, and a surgical intern observed the surgery.
An incision was made along the medial aspect of the stifle, beginning at the distal pole of the patella and extending distally over the proximal tibia. All dogs had a mini craniomedial parapatellar arthrotomy to confirm the CCL tear and evaluate the meniscus. If the dog had a meniscal tear, then the torn portion was removed. Any intact menisci were not released and were left intact. The arthrotomy was closed in a simple continuous pattern using either 0-polydioxanone regular or triclosanimpregnated suture (Ethicon, Somerville, New Jersey, USA).
Following the arthrotomy closure, the osteotomy was conducted using a biradial saw (New Generation Devices, Naples, Florida, USA). The surgical site was lavaged with sterile saline during the osteotomy to prevent saw-induced thermal bone damage. The proximal segment was rotated caudally and stabilized using K-wire of appropriate size proximal to the patellar tendon insertion point. A 6-hole, 3.5-millimeter DCP TPLO plate (Veterinary Orthopedic Implants, St. Augustine, Florida, USA) was contoured and secured with 6 3.5-millimeter cortical bone screws. All incisions were closed using the same suture size and suture pattern. The fascia over the TPLO plate was closed using a 0-polydioxanone suture in a simple continuous pattern, and the skin was apposed using 3-0 poliglecaprone (Ethicon) in an intradermal pattern. If the dog was randomly selected to receive the triclosan suture (Ethicon), then both the polydioxanone and poliglecaprone sutures were coated with triclosan. The incision length was measured postoperatively by the surgeon and recorded. Surgical time was measured from the moment the scalpel started the incision until the placement of the last intradermal knot. Triple antibiotic ointment was applied to the surgical wound, which was then covered with gauze wound dressing (Telfa Dressing; Cardinal Health Medical Product and Supplies, Dublin, Ohio, USA) and dressing retention tape (Hypafix; Beiersdof-Jobst, Charlotte, North Carolina, USA) before the dog left the operating suite. Postoperative radiography was performed, and the dog was recovered from anesthesia.
All dogs remained hospitalized overnight. Orders were to sling-walk every 6 h; ice the incision every 6 h; and administer hydromorphone (Hydromorphone; Akron, Lake Forest, Illinois, USA), 0.05 to 0.2 mg/kg, IV, q6h and carprofen (Rimadyl; Zoetis, Kalamazoo, Michigan, USA), 2.2 mg/kg, SC, once. While hospitalized, each dog was fitted with and wore an Elizabethan collar (E-collar). In every dog, the gauze wound dressing (Telfa Dressing; Cardinal Health Medical Product and Supplies) was left in place overnight; if it was soiled, was wet, or fell off before re-evaluation the following morning, it was replaced. The following morning, the gauze wound dressing was removed for evaluation of the incision by the surgeon and surgical intern and remained off thereafter.
All dogs were discharged the day after surgery with written instructions for postoperative care and an E-collar. Each dog was sent home with carprofen (Rimadyl; Zoetis), 2.2 mg/kg, PO, q12h for 7 d and tramadol (Tramadol; Amneal Pharmacy, Glasgow, Kentucky, USA), 3 to 5 mg/kg, PO, q8h for 10 d. No antibiotics were prescribed immediately after surgery. Each client was given detailed discharge instructions about activity restrictions. For the first 2 wk after surgery, the dog was permitted to be outside while on a leash for elimination purposes only, and was otherwise confined to a small area or kennel and not allowed to jump. On wk 2 to 4, the dog could start going on short, 10-minute walks 2 to 3 × daily, but otherwise had to remain under strict restriction: confined to a small area or kennel and not allowed to jump. For wk 4 to 6, the dog could start going on 15- to 20-minute walks, with continued confinement when indoors. For wk 6 to 8, the dog was allowed 20- to 30-minute walks, with continued confinement when indoors.
Using standard recheck protocols for TPLOs in this facility, the incision was evaluated by the surgeon and surgical intern within 24 to 48 h after surgery, at 10 to 14 d, and finally at 8 to 12 wk. At each recheck, the incision was evaluated by the surgeon and surgical intern for clinical signs of infection. Previously documented criteria for SSI include purulent discharge (with or without positive bacterial culture); isolation of clinically relevant bacteria from an aseptically collected sample using either swab or needle and syringe to collect fluid; or when ≥ 3 of the following signs are present simultaneously: redness, swelling, pain, excessive heat, serous wound drainage, or wound dehiscence (6,22,23). All dogs that had clinical signs consistent with SSI were started on the antibiotic Clavamox (Clavamox; Zoetis), 13.75 to 22 mg/kg, PO, for 10 d while awaiting culture results. When culture results were received, the dogs were placed on antibiotics based on the sensitivity patterns.
At the 8- to 12-week recheck examination, radiography was performed to visualize osteotomy healing. If the dog did not return for the 8- to 12-week recheck, a phone interview was conducted by the same surgical intern for all clients, using a questionnaire, to determine if there were clinical signs of infection. The questionnaire included questions such as these: How is the dog doing clinically? Has the dog returned to normal activity? Is the dog limping? Is there any drainage, swelling, or excessive heat along the incision site? Has your primary care veterinarian provided any additional care pertaining to the surgery, such as prescribing antibiotics or additional pain medications, performing radiographs, or submitting cultures?
During this study, if a dog underwent a 2nd surgery to remove the implant, then a site below the skin surgical site was swabbed and a screw was submitted for bacterial culture and sensitivity testing. The culture swab and the screw were submitted together.
Statistical analysis
The sample size was determined using the following priority information: alpha of 0.05, power of 0.8, null hypothesis of > 10% in the regular suture group, and expected proportion of infection in the triclosan treatment group of < 3%. All analyses were done using statistical software (MedCalc; MedCalc Software, Ostend, Belgium). The effects of the categorical or numeric variables (surgery and anesthesia times, sex, weight, age, incision length, stifle side, and breed) on the outcome variable “infection” were evaluated using binary logistic regression. For all analyses, values of P < 0.05 were considered statistically significant. The effect of the suture material on the outcome variable was evaluated using binary logistic regression. For all analyses, P < 0.05 was considered significant, and odds ratio > 1 was also considered significant.
Results
We prospectively recruited 116 dogs for this study: 58 in each suture group. Forty dogs did not return for the 8- to 12-week recheck examination (34.48%), so phone interviews were conducted for these dogs. Of these, 22 received the triclosan suture and 18 received the regular suture. There were no significant differences in infection rates based on the dog’s age (P = 0.633), weight (P = 0.108), surgery time (P = 0.341), total anesthesia time (P = 0.582), incision length (P = 0.512), left or right stifle (P = 0.115), or breed (P = 0.128) (Table 1). However, there were significant differences in infection rates based on sex (P = 0.032) and type of suture used (P = 0.016). The odds ratio for infection for regular sutures versus triclosan was 3.37.
Table 1.
A binary logistic regression was used to evaluate the associations between infection status and suture type, age, weight, stifle, sex, anesthesia time, surgery time, and incision length in dogs undergoing tibial plateau leveling osteotomy.
| B | SE | Wald | df | P-value | Exp (B) | 95% confidence interval | ||
|---|---|---|---|---|---|---|---|---|
|
| ||||||||
| Lower | Upper | |||||||
| Suture | 1.774 | 0.736 | 5.808 | 1 | 0.016 | 5.895 | 1.383 | 24.949 |
| Age (y) | −0.048 | 0.102 | 0.227 | 1 | 0.633 | 0.953 | 0.781 | 1.163 |
| Body weight (kg) | −0.067 | 0.042 | 2.584 | 1 | 0.108 | 0.935 | 0.862 | 1.015 |
| Stifle | 1.063 | 0.675 | 2.480 | 1 | 0.115 | 2.894 | 0.771 | 10.861 |
| Sex | 1.607 | 0.749 | 4.609 | 1 | 0.032 | 4.990 | 1.150 | 21.651 |
| Anesthesia time (min) | 0.013 | 0.024 | 0.303 | 1 | 0.582 | 1.013 | 0.966 | 1.063 |
| Incision length (mm) | 0.025 | 0.038 | 0.431 | 1 | 0.512 | 1.025 | 0.951 | 1.105 |
| Surgery time (min) | 0.130 | 0.137 | 0.906 | 1 | 0.341 | 1.139 | 0.871 | 1.490 |
Table 1 shows a binary logistic regression used to evaluate the association between infection status and suture type for age, weight, stifle, sex, anesthesia time, incision length, and surgery time.
Twenty-four castrated males received the triclosan-impregnated suture. Of these dogs, 3 had an infection. Thirty-two castrated males received the regular suture, and 9 dogs in this group had an SSI. Thirty-three spayed females received triclosan-impregnated suture, and no dogs in this group had an SSI. However, 24 spayed females received regular suture, and 3 dogs from this group had a, SSI. Finally, 1 intact female received triclosan-impregnated suture and 2 intact males received regular suture. No intact dog had an SSI. The dog’s sex had a significant (P = 0.032) effect on the infection rate.
There were 25 breeds in this study, including mixed-breed (n = 33), Labrador retriever (n = 17), pitbull (n = 15), boxer (n = 8), golden retriever (n = 8), German shepherd (n = 6), husky (n = 4), Rottweiler (n = 3), American heeler (n = 2), chow chow (n = 2), Great Dane (n = 2), Dogue De Bordeaux (n = 2), Australian shepherd (n = 2), border collie (n = 1), Great Pyrenees (n = 1), Belgian sheepdog (n = 1), English springer spaniel (n = 1), Brittany spaniel (n = 1), black mouth cur (n = 1), mastiff (n = 1), dalmatian (n = 1), Weimaraner (n = 1), and English bulldog (n = 1). Breed did not have a significant effect on infection rate (P = 0.128).
Fifty-four dogs (47%) underwent a right-sided TPLO procedure, and 62 dogs (53%) had a left-sided TPLO procedure. The stifle side had no significant effect on the infection rate (P = 0.115).
The overall prevalence of SSI was 12.9% (15/116). The SSI rate for dogs that received the triclosan suture was 5.17% (3/58), whereas the rate for dogs that received the regular suture was 20.6% (12/58). Based on positive culture results from fluid collected from the incisions, 13 stifles had SSI; the remaining 2 were treated as SSI based on clinical signs alone and were included in the statistical analysis. The time frame for clinical signs of SSI was within 24 to 48 h after surgery [0/15 (0%)], 10 to 14 d postoperatively [12/15 (80%)], and 8 to 12 wk postoperatively [3/15 (20%)]. One dog presented 6 d after surgery with purulent drainage; culture was conducted and this dog was included in the 10- to 14-day recheck group. Four dogs that had infection at 10 to 14 d after surgery also had purulent discharge, redness, and swelling indicative of infection at 8 to 12 wk postoperatively.
Discussion
Most SSIs detected during this study were associated with incisions closed with regular sutures. Incisions closed with triclosanimpregnated sutures had lower rates of infection. Further, the infection rate was higher in neutered male dogs.
In the 116 dogs, the overall SSI rate was 12.9%, which is within the acceptable limits of previously reported infection rates associated with the TPLO procedure (2–10). In this study, dogs without triclosan-impregnated suture had higher SSI rates. The majority of the infections were detected 10 to 14 d after surgery. Four dogs that had SSI at the 10- to 14-day recheck also showed evidence of infection at the 8- to 12-week recheck. The culture results in these dogs at the 10- to 14-day recheck often included different bacterial species from those at the 8- to 12-week recheck (Table 2). This could have been the result of a decreased number of bacteria present at the 10- to 14-day recheck and therefore not detected on the original culture. Perhaps more likely, it could have been due to self-trauma — possibly from a lack of owner compliance, even though each dog was sent home with an E-collar to prevent licking or chewing and the clients were given written discharge instructions to keep the E-collar in place until incision recheck.
Table 2.
Pathogens isolated from cultures with triclosanimpregnated suture for incisional closure in dogs undergoing tibial plateau leveling osteotomy.
| 10 to 14 d post-surgery | 8 to 12 wk post-surgery | |
|---|---|---|
| Patient #25 | Staphylococcus aureus | |
| Patient #95 | Beta-hemolytic streptococci Serratia marcescens Methicillin-resistant Staph. pseudintermedius |
Explant, sample was submitted for culture and sensitivity. Unfortunately, the sample was lost in transit. |
| Patient #46 | Pseudomonas aeruginosa |
As this was a randomized, double-blinded, prospective study, variables and bias were limited. There were other variables evaluated that had no effects on the results. Interestingly, sex and suture type were the only statistically significant variables (Table 1). Further studies are needed to determine if castrated male dogs have a higher infection rate after undergoing TPLO. Previously, at least 1 study reported that intact male dogs had a lower infection rate, but to the authors’ knowledge, no additional studies have specifically examined sex as a cause of higher infection rates (2).
The length of follow-up posed some limitations since this study only included follow-up for the first 12 wk after surgery and SSI can occur up to 2 y after surgery. Other study limitations included issues with assuring owner compliance to prevent self-trauma and having to conduct phone interviews due to clients not returning for recheck examinations. Based on information from the Centers for Disease Control, superficial SSI typically occurs within 30 d of surgery, and deep SSI will occur at 30 to 90 d when an implant is present (24). However, infections can occur up to 2 y after surgery when implants are involved. The standard protocol for rechecks by the surgeon in the present study was at 24 to 48 h, 10 to 14 d, and 8 to 12 wk after surgery. Unfortunately, many dogs did not return for the 8- to 12-week recheck (34.48%), and so detailed phone interviews were conducted for those dogs, by a single surgical intern, to determine if there were any incision complications: None were reported via phone interview. There are some limitations with phone interviews and client-provided information does not replace complete evaluation by a veterinarian. However, given the detailed questionnaire used, we believe that the phone interviews provided a good representation of the infection rates in this group and, if one of these dogs did have a complication or concern, the clients would likely have pursued veterinary care. To the authors’ knowledge, no studies have been done to determine the duration of bacterial inhibition with triclosan-impregnated suture. Therefore, longer-term studies may be needed to determine if there is a significant difference in infection rates when comparing triclosan and regular sutures.
Both in vitro and in vivo studies have demonstrated the antimicrobial effects of triclosan-impregnated suture for a minimum 7 d to prevent colonization by Staph. aureus, multi-resistant Staph. aureus, methicillin-resistant Staph. pseudintermedius, methicillin-susceptible Staph. pseudintermedius, Staph. epidermis, multi-resistant Staph. epidermis, and E. coli (14,25). In one in vitro study conducted in rats, the deep zone of an SSI was contaminated with Staph. epidermis and the incision was closed with antibacterial-coated suture material. The antibacterial suture material reduced the number of positive cultures by 66.6% (20). These studies support the findings in the present study, as we observed a significant reduction in SSI with the triclosan-impregnated suture. In the 3 dogs that had SSI with the triclosan-impregnated suture, the infection presented during the 10- to 14-day recheck and the 8- to 12-week recheck. In 2 of the 3 dogs with SSI after receiving triclosan-impregnated suture, pathogens were present that have not been proven sensitive to triclosan (Table 3). In both groups, there was overlap in the bacteria cultured from both the regular suture and the triclosan-impregnated suture that have previously been proven to be not susceptible to triclosan. Beta-hemolytic streptococci and Pseudomonas aeruginosa were present in both groups. P. aeruginosa and beta-hemolytic streptococci encode a triclosanresistant enoyl-acyl-carrier protein reductase, FabV and FabK respectively, which is resistant to the activity of triclosan (26,27). Therefore, the triclosan suture would not be effective in preventing these infections.
Table 3.
Pathogens isolated from cultures with regular suture for incisional closure in dogs undergoing tibial plateau leveling osteotomy.
| 10 to 14 d post-surgery | 8 to 12 wk post-surgery | |
|---|---|---|
| Patient #5 | Beta-hemolytic streptococci Staphylococcus pseudintermedius |
|
| Patient #26 |
Serratia marcescens
Enterococcus |
Staph. pseudintermedius
P. aeruginosa |
| Patient #53 | Beta-hemolytic streptococci | Beta-hemolytic streptococci Staph. pseudintermedius P. aeruginosa |
| Patient #54 | Beta-hemolytic streptococci Staph. pseudintermedius Pseudomonas |
|
| Patient #77 | Staph. aureus | |
| Patient #102 | Staph. aureus | |
| Patient #108 |
Staph. pseudintermedius
S. marcescens |
|
| Patient #116 | Staph. pseudintermedius | |
| Patient #38 |
Staph. pseudintermedius Non-pathogenic coryneform |
|
| Patient #65 |
P. aeruginosa Explant Staph. pseudintermedius |
In conclusion, dogs that received triclosan-impregnated suture for incisional closure after TPLO had significantly decreased rates of SSI. The dog’s sex also affected the prevalence of SSI. Future studies are needed to determine if sex is a significant factor in infection rates with triclosan-impregnated suture or if this was a statistical error. Further studies are indicated to evaluate the effect of incisional closure with triclosan-impregnated suture following other orthopedic procedures in dogs and cats. CVJ
Footnotes
Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office (hbroughton@cvma-acmv.org) for additional copies or permission to use this material elsewhere.
References
- 1.Berrios-Torres SI, Umschmeid CA, Bratzler DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152:784–791. doi: 10.1001/jamasurg.2017.0904. [DOI] [PubMed] [Google Scholar]
- 2.Fitzpatrick N, Solano MA. Predictive variables for complications after TPLO with stifle inspection by arthrotomy in 1000 consecutive dogs. Vet Surg. 2010;39:460–474. doi: 10.1111/j.1532-950X.2010.00663.x. [DOI] [PubMed] [Google Scholar]
- 3.Gatineau M, Dupuis J, Planté J, et al. Retrospective study of 476 tibial plateau levelling osteotomy procedures. Rate of subsequent ‘pivot shift’, meniscal tear and other complications. Vet Comp Orthop Traumatol. 2011;24:333–341. doi: 10.3415/VCOT-10-07-0109. [DOI] [PubMed] [Google Scholar]
- 4.Pacchiana PD, Morris E, Gillings SL, et al. Surgical and postoperative complications associated with tibial plateau leveling osteotomy in dogs with cranial cruciate ligament rupture: 397 cases (1998–2001) J Am Vet Med Assoc. 2003;222:184–193. doi: 10.2460/javma.2003.222.184. [DOI] [PubMed] [Google Scholar]
- 5.Etter SW, Ragetly GR, Bennett RA, et al. Effect of using triclosan-impregnated suture for incisional closure on surgical site infection and inflammation following tibial plateau leveling osteotomy in dogs. J Am Vet Med Assoc. 2013;242:355–358. doi: 10.2460/javma.242.3.355. [DOI] [PubMed] [Google Scholar]
- 6.Frey TN, Hoelzler MG, Scavelli TD, et al. Risk factors for surgical site infection-inflammation in dogs undergoing surgery for rupture of the cranial cruciate ligament: 902 cases (2005–2006) J Am Vet Med Assoc. 2010;236:88–94. doi: 10.2460/javma.236.1.88. [DOI] [PubMed] [Google Scholar]
- 7.Gallagher AD, Mertens WD. Implant removal rate from infection after tibial plateau leveling osteotomy in dogs. Vet Surg. 2012;41:705–711. doi: 10.1111/j.1532-950X.2012.00971.x. [DOI] [PubMed] [Google Scholar]
- 8.Savicky R, Beale B, Murtaugh R, et al. Outcome following removal of TPLO implants with surgical site infection. Vet Comp Orthop Traumatol. 2013;26:260–265. doi: 10.3415/VCOT-11-12-0177. [DOI] [PubMed] [Google Scholar]
- 9.Thompson AM, Bergh MS, Wang C, et al. Tibial plateau levelling osteotomy implant removal: A retrospective analysis of 129 cases. Vet Comp Orthop Traumatol. 2011;24:450–456. doi: 10.3415/VCOT-10-12-0172. [DOI] [PubMed] [Google Scholar]
- 10.Giannetto JJ, Atkay SA. Prospective evaluation of surgical wound dressing and the incidence of surgical site infections in dogs undergoing a tibial plateau levelling osteotomy. Vet Comp Orthop Traumatol. 2019;32:18–25. doi: 10.1055/s-0038-1676352. [DOI] [PubMed] [Google Scholar]
- 11.Nazarali A, Singh A, Moens NMM, et al. Association between methicillin-resistant Staphylococcus pseudintermedius carriage and the development of surgical site infections flowing tibial plateau leveling osteotomy in dogs. J Am Vet Med Assoc. 2015;247:909–916. doi: 10.2460/javma.247.8.909. [DOI] [PubMed] [Google Scholar]
- 12.de Jonge SW, Atema JJ, Solomkin JS, Boermeester MA. Meta-analysis and trial sequential analysis of triclosan-coated sutures for the prevention of surgical-site infection. Br J Surg. 2017;104:e118–e133. doi: 10.1002/bjs.10445. [DOI] [PubMed] [Google Scholar]
- 13.Rothenburger S, Spangler D, Bhende S, Burkley D. In vitro antimicrobial evaluation of coated VICRYL plus antibacterial suture (coated polyglactin 910 with triclosan) using zone of inhibition assays. Surg Infect. 2002;3:S79–S87. doi: 10.1089/sur.2002.3.s1-79. [DOI] [PubMed] [Google Scholar]
- 14.Ming X, Rothenburger S, Nichols MM. In vivo and in vitro antibacterial efficacy of PDS plus (polidioxanone with triclosan) suture. Surg Infect. 2008;9:451–457. doi: 10.1089/sur.2007.061. [DOI] [PubMed] [Google Scholar]
- 15.Ming X, Rothenburger S, Yang D. In vitro antibacterial efficacy of MONOCRYL plus antibacterial suture (poliglecaprone 25 with triclosan) Surg Infect. 2007;8:201–208. doi: 10.1089/sur.2006.005. [DOI] [PubMed] [Google Scholar]
- 16.Rogers SO. Surgical perspective: Centers for Disease Control and Prevention guideline for the prevention of surgical site infection 2017. Surg Infect. 2017;18:383–384. doi: 10.1089/sur.2017.097. [DOI] [PubMed] [Google Scholar]
- 17.World Health Organization. WHO Guidelines for Safe Surgery 2009 Safe Surgery Saves Lives. Geneva, Switzerland: World Health Organization; 2009. [PubMed] [Google Scholar]
- 18.Storch M, Rothenburger S, Jacinto G. Experimental efficacy study of coated vicryl plus antibacterial suture in guinea pigs challenged with Staphylococcus aureus. Surg Infect. 2004;5:281–288. doi: 10.1089/sur.2004.5.281. [DOI] [PubMed] [Google Scholar]
- 19.McCagherty J, Yool D, Paterson G, et al. Investigation of the in vitro antimicrobial activity of triclosan-coated suture material on bacteria commonly isolated from wounds in dogs. Am J Vet Res. 2020;81:84–90. doi: 10.2460/ajvr.81.1.84. [DOI] [PubMed] [Google Scholar]
- 20.Marco F, Vallez R, Gonzalez P, Ortega L, de al Lama J, Lopez-Duran L. Study of the efficacy of coated Vicryl plus antibacterial suture in an animal model of orthopedic surgery. Surg Infect. 2007;8:359–365. doi: 10.1089/sur.2006.013. [DOI] [PubMed] [Google Scholar]
- 21.Ueno M, Saito W, Yamagata M, et al. Triclosan-coated sutures reduce wound infections after spinal surgery: A retrospective, nonrandomized, clinic study. Spine J. 2015;15:933–938. doi: 10.1016/j.spinee.2013.06.046. [DOI] [PubMed] [Google Scholar]
- 22.Nicoll C, Singh A, Weese S, et al. Economic impact of tibial plateau leveling osteotomy surgical site infection in dogs. Vet Surg. 2014;43:899–902. doi: 10.1111/j.1532-950X.2014.12175.x. [DOI] [PubMed] [Google Scholar]
- 23.Eugster S, Schawalder P, Gaschen F, et al. A prospective study of postoperative surgical site infections in dogs and cats. Vet Surg. 2004;33:542–550. doi: 10.1111/j.1532-950X.2004.04076.x. [DOI] [PubMed] [Google Scholar]
- 24.Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical site infection guidelines, 2016 update. J Am Coll Surg. 2017;224:59–74. doi: 10.1016/j.jamcollsurg.2016.10.029. [DOI] [PubMed] [Google Scholar]
- 25.Bischofberger AS, Brauer T, Gugelchuk G, Klohnen A. Difference in incisional complications following exploratory celiotomies using antibacterial-coated suture material for subcutaneous closure: Prospective randomised study in 100 horses. Equine Vet J. 2010;42:304–309. doi: 10.1111/j.2042-3306.2009.00020.x. [DOI] [PubMed] [Google Scholar]
- 26.Marrakchi H, DeWolf WE, Jr, Quinn C, et al. Characterization of Streptococcus pneumoniae enoyl-(acyl-carrier protein) reductase (FabK) Biochem J. 2003;370:1055–1062. doi: 10.1042/BJ20021699. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Huang YH, Lin JS, Ma JC, Wang HH. Functional characterization of triclosan-resistant enoyl-acyl-carrier protein reductase (FabV) in Pseudomonas aeruginosa. Front Microbiol. 2016;7:1903. doi: 10.3389/fmicb.2016.01903. [DOI] [PMC free article] [PubMed] [Google Scholar]