THE IDEAL SURGICAL SUTURE

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  • Note: The Centers for Disease Control and Prevention, or CDC, classifies surgical wounds into 4 categories: Class I/Clean Class II/Clean-contaminated Class III/Contaminated Class IV/Dirty-infected
  • Note: There are a number of factors that contribute to bacterial colonization that can lead to surgical site infections
  • Note: These SSI risk factors are patient related
  • Note: These are surgical factors that contribute to SSI risk
  • Note: During surgery, these factors can contribute to SSI risk
  • Note: Because SSIs can occur days after surgery, certain postoperative issues are important to consider Discuss targeting the ICU or PA/Residents to determine who changes dressings. A lot of times the resident changes the dressings in the ICU and do not change gloves, which can lead to cross-examination
  • Note: One factor increasing this trend is the prevalence of patients with comorbidities These patient populations include patients who are immunocompromised (HIV, organ transplants), elderly, in renal failure, or have diabetes, as well as other patient populations
  • Note: When microorganisms like bacteria attach themselves to the surface of an implanted medical device like a suture, they form biofilms that make themselves highly resistant to antimicrobial treatment and extremely difficult to remove from the surface of the device
  • Note: Direct and indirect costs of SSIs include decreased patient satisfaction and increased litigation
  • Note: Sum up the serious and growing problem
  • Note: Many factors play a role in the wound closure environment: the operating room, tools used to close the wound, personnel using aseptic technique, and patient factors (eg, other disease states, the extent of the surgical procedure, and level of immune system function)
  • Note: Q & A for class
  • Note: The answer: ETHICON Plus SUTURES. This will lead into the next section of the presentation
  • Note: Section 2 will cover Plus SUTURES, IRGACARE ® MP (triclosan), and some important studies
  • Note: Today, many wound closure options are available to surgeons Desirable properties of an antibacterial suture include: biocompatibility, effectiveness against common organisms that cause SSIs, and cost-effectiveness Antibacterial sutures should also be able to withstand manufacturing processes and have excellent suture handling properties
  • Note: IRGACARE ® MP (triclosan) is a biocidal agent used in all Plus SUTURES products IRGACARE MP is a high-purity material that meets United States Pharmacopeia specifications for triclosan and contributes minimally to the background exposure to toxic residues It has demonstrated antibacterial efficacy and a long history of safety. IRGACARE MP is active against the most common pathogens implicated in SSIs, including S aureus , S epidermidis , and others IRGACARE MP is also a great candidate for incorporation into sutures because of its compatibility with suture processing
  • Note: IRGACARE ® MP (triclosan) withstands manufacturing processes, is cost-effective, and has excellent physical and functional properties Coated polyglactin 910 sutures with triclosan appeared to exhibit no difference from traditional polyglactin 910 sutures with respect to tactile smoothness, dry tie-down, and wet tie-down
  • Note: IRGACARE ® MP (triclosan) has favorable pharmacokinetic properties. It is well absorbed (50% – 100%) by the gastrointestinal tract and well distributed in the body It binds to serum albumin and is present as the sulfate and/or glucuronide conjugate, depending on exposure There is no indication that triclosan accumulates in plasma over time, nor is it stored after single or repeated exposure
  • Note: IRGACARE ® MP (triclosan) has favorable pharmacokinetic properties. It is well absorbed (50% – 100%) by the gastrointestinal tract and well distributed in the body It binds to serum albumin and is present as the sulfate and/or glucuronide conjugate, depending on exposure There is no indication that triclosan accumulates in plasma over time, nor is it stored after single or repeated exposure
  • Note: An in vivo study showed that MONOCRYL Plus Sutures deliver reliable breaking strength over a 2-week period The absorption of MONOCRYL Plus Suture is consistent, and its decrease in tensile strength is predictable It performs as well as or better than gut suture throughout the critical wound healing period
  • Note: Coated VICRYL Plus Sutures deliver wound support for approximately 4 weeks
  • Note: The primary endpoint of overall intraoperative handling is shown in the first set of bars on the left For primary and secondary endpoints, both sutures performed very well. The majority (94%) of responses rated the handling as “very good” or “excellent” for both sutures Both sutures performed very well in all intraoperative handling scores
  • THE IDEAL SURGICAL SUTURE

    1. 1. Superior Protection DR SREEJOY PATNAIK
    2. 2. Understanding Surgical Site Infection ( SSIs) •Classification •Causes •Risk Factor •Cost & Consequences
    3. 3. What Are SSIs? • SSIs are infections associated with surgical procedures and are a major source of postoperative illness • These infections are responsible for approximately one quarter of all nosocomial infections and affect 1.4 million people worldwide at any time • SSIs result in longer hospitalization, increased patient mortality and higher costs for healthcare providers and payers Nichols RL. Emerg Infect Dis. 2001;7:220-224. World Health Organization. 2002;1-50.
    4. 4. Classification of SSI - Definitions Skin Hypodermis Superficial incisional wound Infection occurs within 30 days of operation and infection involves only skin or subcutaneous tissue of the incision Deep soft tissues (fascias & muscle) Organ space Source: CDC Guidelines for Prevention of SSIs1999
    5. 5. Superficial Incisional SSI Characteristics of Superficial Incisional SSI Purulent drainage, with or without laboratory confirmation, from the superficial incision. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision. At least one of the following signs or symptoms of infection Pain or tenderness, heat, Localized swelling, redness Diagnosis of superficial incisional SSI by the surgeon or attending physician
    6. 6. Classification of SSI - Definitions Skin Hypodermis Deep soft tissues (fascias & muscle) Deep incisional wound Infection occurs within 30 days after the operation if no ‘implant’ is left in place or within 1 year if implant is left In place And the infection appears to be related to the operation Organ space Source: CDC Guidelines for Prevention of SSIs1999
    7. 7. Deep Incisional SSI Characteristics of Deep Incisional SSI
    8. 8. Classification of SSI - Definitions Skin Hypodermis Deep soft tissues (fascias & muscle) Organ Organ space space Infection occurs within 30 days after the operation if no implant is left in place or within 1 year if implant is in place, and the infection appears to be related to the operation and infection involves any part of the anatomy which was opened or manipulated during the operation Source: CDC Guidelines for Prevention of SSIs1999
    9. 9. Organ/Space SSI Characteristics of Organ/Space SSI
    10. 10. Pathogens associated with SSIs http://www.wvdhhr.org/IDEP/pdfs/idep/staphylococcus/resistant_staph_aureus_protocol_07.pdf, Infection Control and Hospital Epidemiology: SURVEILLANCE PROTOCOL Staphylococcus aureus Infections of Public Health Significance
    11. 11. Pathogens associated with SSIs – An Indian Perspective Abbreviations: MRSA, methicillin-resistant Staphalycoccus aureus; MRSE, methicillin-sensitive Staphalycoccus aureus; NS, not stated. a Includes surgery of the hydrocele, hernia, appendix, hepatobiliary, breast lungs, thoracic cavity, thyroid, urinary and genital, oesophageal, gastric and bowels. b Includes caesarean, tubectomy, appendisectomy, prostatectomy, hysterectomy, orthoreduction, herniorrphy and fasciotomy.
    12. 12. Understanding Surgical Site Infection ( SSIs) •Classification •Causes •Risk Factor •Cost & Consequences
    13. 13. CDC Surgical Wound Categories CDC=Centers for Disease Control and Prevention. Mangram AJ et al. Am J Infect Control. 1999;27:97-134.
    14. 14. Incidence of SSI in India – by wound type Source: Lizioli et al.7
    15. 15. Understanding Surgical Site Infection ( SSIs) •Classification •Causes •Risk Factor •Cost & Consequences
    16. 16. Factors in Bacterial Colonization Leading to SSIs • • • • Patient-related Procedure/Techniques Postoperative Implants Hebert CK et al. Clin Orthop. 1996;331:140-145. Fletcher N et al. J Bone Joint Surg Am. 2007;89:1605-1618. Mangram AJ et al. Am J Infect Control. 1999;27:97-134. Fry DE. Medscape Surgery. 2003.
    17. 17. SSI Risk Factors – Patient Related • • • • • • • Advanced age Malnutrition Obesity Diabetes mellitus History of smoking Distant infection Steroid therapy Sumnicht RW. Med Bull US Army Eur. 1958;15:51-56. Mangram AJ et al. Am J Infect Control. 1999;27:97-134. Fry DE. Medscape Surgery. 2003. • • • • • Chronic inflammation Open wounds Radiation Immunosuppressed Length of preoperative stay
    18. 18. SSI Risk Factors – Procedures/Techniques • Duration of operation • Duration of surgical scrub • Preoperative shaving, skin preparation • Inadequate OR ventilation • Inadequate sterilization of instruments • Surgical technique Mangram AJ et al. Am J Infect Control. 1999;27:97-134. • Poor hemostasis • Failure to obliterate dead space • Tissue trauma • Skin antisepsis • Antimicrobial prophylaxis • Surgical drains
    19. 19. SSI Risk Factors – Procedures/Techniques Cont’d • • • • • • • Length of preoperative hospital stay Insufficient preoperative preparation Personal hygiene, hair removal, skin disinfection Insufficient antibiotic therapy Intra-operative hypothermia Intra-operative hypoxemia Intra-operative hypotension Nguyen D et al. Infect Cont Hosp Epidemiol. 2001;22:485-492. Mangram AJ et al. Am J Infect Control. 1999;27:97-134. Fry DE. Medscape Surgery. 2003.
    20. 20. SSI Postoperative Issues • Incision care – Sterile dressing – Dressing changes (use of sterile technique, aseptic precautions) • Discharge planning – Home incision care Mangram AJ et al. Am J Infect Control. 1999;27:97-134.
    21. 21. Additional Factors Affecting SSI Rates • Growing problems -Emergence of resistant organisms -More debilitated, elderly, immunocompromised patients; comorbid disease -Organ transplants -Prosthetic implants • The risk of SSI can be generally defined as the amount of bacterial contamination at the site of the infection combined with the virulence, or degree of pathogenicity, of the bacteria in relation to the immune system resistance of the patient Dose of Bacterial Contamination × Virulence Resistance of the Host Patient Mangram AJ et al. Am J Infect Control. 1999;27:97-134. = Risk of SSI
    22. 22. The Risks of Biofilm • Biofilm is created when microorganisms like bacteria attach themselves to living or nonliving surfaces in internal or external environments • Postoperative bacteria may contaminate the tissue in a surgical wound as well as the suture material itself • Furthermore, the bacteria develop extracellular polymers that promote greater adhesion and resistance to antimicrobial treatment Donlan RM. Emerg Infect Dis. 2001;7:277-281. Edmiston CE et al. J Am Coll Surg. 2006;203:481-489. Mangram AJ et al. Am J Infect Control. 1999;27:97-134.
    23. 23. Implants and SSI Contamination Colonization Biofilm formation Implant The result of an implant becoming contaminated: • fewer bacteria are required for infection to develop • implants provide nidus for attachment of the organisms • the infection is harder to treat because of biofilm formation Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol, 1999, 27:97-134 Ward KH et al. Mechanism of persistent infection associated with peritoneaI implants. J. Med. Microbiol., vol. 36 (1992), p. 406-413 Nucci C et al. A microbiological and confocal microscopy study documenting a slime-producing Staphylococcus epidermidis isolated from a nylon corneal suture of a patient with antibiotic-resistant endophthalmitis. Graefe’s Arch Clin Exp Ophthalmol, 2005, 243:951–954
    24. 24. Understanding Surgical Site Infection ( SSIs) •Classification •Causes •Risk Factor •Cost & Consequences
    25. 25. Consequences & Costs Associated With SSIs Economic Burden of SSIs Increased hospital stay and costs Source Surgery type Length of post-operative hospital stay Bhatia 2003 CABG 10 days SSI Difference 15 days (mild) 3 No SSI 5 days 19 days (moderate) 9 days 25 days (severe) Lilani 2005 5 Elective surgery a 6.19 days 15 days 24.82 days 18.63 days In India, it is estimated that SSIs increase post-operative hospital stay by 5–18 days and an increase in healthcare costs by upto 30%
    26. 26. Additional Costs Associated With SSIs • Direct costs – Prolonged hospitalization, re-admission – Outpatient and emergency care visits – Additional surgical procedures • Incision and drainage • Staged reimplantation – Prolonged antibiotic therapy – Increased use of ancillary services • Home health visits • Radiology, laboratory – Drug costs – Durable medical equipment Urban JA. Surg Infect (Larchmt). 2006;7(suppl 1):S19-S22. • Indirect costs – Lost productivity (patient, family) – Temporary or permanent impairment of physical/mental function – Decreased patient satisfaction – Decreased referrals – Increased litigation
    27. 27. Summary • The major pathogens that lead to SSIs are: – Staphylococcus aureus – Staphylococcus epidermidis – Methicillin-resistant Staphylococcus aureus (MRSA) – Methicillin-resistant Staphylococcus epidermidis (MRSE) • Staphylococcus aureus is a major pathogen that leads to surgical site infection • SSIs are costly in terms of longer hospitalization and increased mortality for patients, and higher costs for hospitals Nichols RL. Emerg Infect Dis. 2001;7:220-224.
    28. 28. Objective: Control Microbiologic Risk Tools Operating Room Personnel
    29. 29. • Comprehensive infection-control protocols include dozens of pre-operative, intra-operative, and post-operative components such as:  Disinfection of OT  Skin prep  Hair removal  Patient scrubbing  Antibiotic prophylaxis  Sterile instruments  Drapes, gowns, gloves  Dressing of wound
    30. 30. Question: If all of these measures are employed before, during, and after the procedure… what one measure would help control bacterial wound contamination of the suture during the procedure and inside the patient? what one measure would actively provide protection to the patient after they leave the OR?
    31. 31. Answer : ETHICON Plus SUTURES with Antibacterial Technology
    32. 32. ETHICON Plus SUTURES Deliver More • Pharmacology • IRGACARE® MP (triclosan) • Plus SUTURES product overview • Plus SUTURES clinical studies ® Ciba Corporation Inc
    33. 33. • Biocompatibility • Effectiveness against S aureus and S epidermidis (most common for device infections) • Ability to withstand manufacturing process – Heat, humidity, solvent, sterilization, etc – Ability to mass produce • Will not negatively alter suture properties • Maintains antibacterial activity for a clinically relevant duration • Cost-effectiveness Ming X et al. Surg Infect (Larchmt). 2007;8:209-213.
    34. 34. ETHICON Plus SUTURES Deliver More • Pharmacology • IRGACARE® MP (triclosan) • Plus SUTURES product overview • Plus SUTURES clinical studies ® Ciba Corporation Inc
    35. 35. IRGACARE® MP (triclosan) Properties • IRGACARE MP – 2,4,4′ -tri-chloro-2′ hydroxydiphenyl ether – High-purity material that meets USP specifications for triclosan, with minimal residue content • IRGACARE MP is safe – Biocompatible, nontoxic – Consumer products • IRGACARE MP is effective – Active against methicillinsensitive and methicillin-resistant S aureus and S epidermidis (most common for device infections) – Active against Escherichia coli and Klebsiella pneumoniae • IRGACARE MP is compatible with suture processing – Maintains excellent suture properties USP=United States Pharmacopeia. Zurita R et al. Macromol Biosci. 2006;6:58-69. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457. Barbolt TA. Surg Infect (Larchmt). 2002;3(suppl 1):S45-S53. ® Ciba Corporation Inc
    36. 36. Why IRGACARE® MP (triclosan)? • • • • Able to withstand the manufacturing process Cost-effective Effective, safe, and compatible Performance/function properties – Handling – Absorption profile, breaking-strength retention Storch M et al. Surg Infect (Larchmt). 2002;3(suppl 1):S65-S77. ® Ciba Corporation Inc
    37. 37. IRGACARE® MP (triclosan): Pharmacokinetics • Well absorbed after oral administration • Well distributed in the body • Rapidly metabolized in liver to the glucuronide/sulfate conjugate – T½=10 to 13 hours • Excreted through kidneys Barbolt TA. Surg Infect (Larchmt). 2002;3(suppl 1):S45-S53. ® Ciba Corporation Inc
    38. 38. IRGACARE® MP (triclosan) and Microbial Resistance • • • IRGACARE MP is very effective against S aureus, S epidermidis, and E coli, which are the 3 most important bacteria related to SSIs There is no connection between the use of IRGACARE MP and significant antibiotic resistance The use of IRGACARE MP may lead to the overall reduction of the antibiotic burden – Decreases the risk of SSIs and the resulting application of stronger antibiotics against SSIs – The use of IRGACARE MP is not associated with increased bacterial virulence that raises the antibiotic burden Ming X et al. Surg Infect (Larchmt). 2007;8:209-213. Barbolt TA. Surg Infect (Larchmt). 2002;3(suppl 1):S45-S53. Ford HR et al. Surg Infect (Larchmt). 2005;6:313-321. ® Ciba Corporation Inc
    39. 39. ETHICON Plus SUTURES Deliver More • Pharmacology • IRGACARE® MP (triclosan) • Plus SUTURES product overview • Plus SUTURES clinical studies ® Ciba Corporation Inc
    40. 40. ETHICON Plus SUTURES: Proven Antibacterial Efficacy Produces a Zone of Inhibition • In vitro testing (petri dish) has shown Plus Antibacterial Sutures create a zone of inhibition around the suture in which certain bacteria are unable to grow • Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture: Testing has demonstrated the zone of inhibition lasts in vitro for a minimum of 7 days for S aureus • MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture: Testing has demonstrated the zone of inhibition lasts in vitro for 31 days for S aureus and 21 days for E coli Rothenburger S et al. Surg Infect (Larchmt). 2002;3:S79-S87. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457.
    41. 41. Plus Antibacterial Sutures Proven in vitro to create a zone of inhibition around the suture against the most common surgical site pathogens Suture with IRGACARE* MP Rothenburger S, Spangler D, Bhende S, Burkely D. In vitro antibacterial evaluation of coated VICRYL* Plus antibacterial suture, (coated polyglactin 910 with triclosan) using zone of inhibition assays. Surg Infect (Larchmt), 2002, 3:79-87 Ming X, Nichols M, Rothenburger S. In vivo antibacterial efficacy of MONOCRYL* Plus Antibacterial Suture, (poliglecaprone 25 with triclosan). Surg Infect (Larchmt), 2007, 8:209-213 Ming X, Rothenburger S, Nichols MM. In vivo and in vitro antibacterial efficacy of PDS* Plus (polidioxanone 25 with triclosan) Suture., Surg Infect (Larchmt), 2008, 9:451-457
    42. 42. Breaking Strength: MONOCRYL* Plus Antibacterial (poliglecaprone 25) Sutures † Data from MONOCRYL Plus Suture package insert. Data on file. ETHICON, INC. *Trademark † • Wound support for approximately 14 days • Consistent absorption rate with a predictable decrease in tensile strength over time • Stronger than gut suture initially and through the critical wound healing period
    43. 43. Breaking Strength: Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture † Data from Coated VICRYL Plus Suture package insert. Data on file. ETHICON, INC. *Trademark † • Wound support up to 4 weeks
    44. 44. ETHICON Plus SUTURES Deliver More • Pharmacology • IRGACARE® MP (triclosan) • Plus SUTURES product overview • Plus SUTURES clinical studies ® Ciba Corporation Inc
    45. 45. Bacterial Adherence to Surgical Sutures: Can Antibacterial-coated Sutures Reduce the Risk of Microbial Contamination? Edmiston CE, Seabrook GR, Goheen MP, et al. J Am Coll Surg. 2006;203:481-489. Study Results and Conclusions Adherence of MRSA to noncoated polyglactin 910 braided suture, 5400x magnification • This in vitro model demonstrated a significant reduction in gram-positive and gramnegative bacterial adherence to a triclosan-coated braided suture; this reduction was associated with decreased microbial viability • Antibacterial efficacy was seen against clinical isolates of MRSA, ESBL-producing E coli, and biofilm-coated S epidermidis (organisms commonly cultured from surgical wounds) (A) Mean microbial recovery from noncoated and triclosan-coated polyglactin 910 surgical sutures exposed to bacterial inoculum for 5 seconds, P<0.01. (B) Mean microbial recovery from noncoated and triclosan-coated polyglactin 910 surgical sutures exposed to bacterial inoculum for 2 minutes, P<0.01. NP=noncoated polyglactin 910; TP=triclosan-coated polyglactin 910. Edmiston CE et al. J Am Coll Surg. 2006;203:481-489.
    46. 46. Chemistry and Safety of Triclosan, and Its Use as an Antimicrobial Coating on Coated VICRYL* Plus Antibacterial Suture (Coated Polyglactin 910 Suture With Triclosan) Barbolt TA. Surg Infect (Larchmt). 2002;3(suppl 1):S45-S53. Study Results and Conclusions Test Chronic toxicity and carcinogenicity Genotoxicity Reproductive toxicity Immunotoxicity Cytotoxicity Intracutaneous reactivity Material-mediated pyrogenicity • • • Experimental System Rat Hamster Ames bacterial assay Mouse lymphoma test Mouse micronucleus test Rat Rabbit Guinea pig Human L-929 fibroblast Rabbit Rabbit Result Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Extensive toxicology database supports the safety of triclosan Amount of triclosan absorbed from the suture is considerably lower than from consumer products, making triclosan-coated sutures well suited for their intended indications In most reasonable estimates for triclosan absorption from consumer products, the potential total body burden of triclosan is 29 times greater from consumer products than for sutures (0.088 mg/kg for a 58-kg patient) Barbolt TA. Surg Infect (Larchmt). 2002;3(suppl 1):S45-S53.
    47. 47. In Vitro Antimicrobial Evaluation of Coated VICRYL* Plus Antibacterial Suture (Coated Polyglactin 910 With Triclosan) Using Zone of Inhibition Assays Rothenburger S, Spangler D, Bhende S, et al. Surg Infect (Larchmt). 2002;3(suppl):S79-S87. • • • Coated polyglactin 910 sutures with triclosan exhibit antibacterial activity in vitro against methicillin-sensitive and -resistant S aureus and S epidermidis compared with untreated controls Antibacterial activity endures despite extended exposure to aqueous environment Suture diameter, knotting, or passage through tissues did not diminish antibacterial activity of triclosan-coated sutures Rothenburger S et al. Surg Infect (Larchmt). 2002;3(suppl):S79-S87. Suture without triclosan Suture with triclosan
    48. 48. In Vitro Antibacterial Efficacy of MONOCRYL* Plus Antibacterial Suture (Poliglecaprone 25 With Triclosan) Ming X, Rothenburger S, Yang D. Surg Infect (Larchmt). 2007;8:201-207. Study Results and Conclusions • Compared to controls, poliglecaprone 25 suture with triclosan [MONOCRYL* Plus Antibacterial (poliglecaprone 25) Sutures] provided sustained and stable in vitro antibacterial efficacy sufficient to inhibit or reduce in vitro colonization of the suture by: – S aureus – MRSA – S epidermidis – MRSE – E coli – K pneumoniae • MONOCRYL Plus Sutures and PDS* Plus Antibacterial (polydioxanone) Sutures provide protection against E coli and K pneumoniae bacteria in addition to the S aureus, S epidermidis, MRSA, and MRSE strains that are inhibited by Coated VICRYL* Plus Antibacterial (polyglactin 910) Sutures Ming X et al. Surg Infect (Larchmt). 2007;8:201-207. *Trademark
    49. 49. Intraoperative Handling and Wound Healing: Controlled Clinical Trial Comparing Coated VICRYL* Plus Antibacterial Suture (Coated Polyglactin 910 Suture With Triclosan) With Coated VICRYL* Suture (Coated Polyglactin 910 Suture) Ford HR, Jones P, Gaines B, et al. Surg Infect (Larchmt). 2005;6:313-321. Results While both sutures performed well—≥94% of responses rated the handling as “very good” or “excellent”—significantly fewer patients in the triclosan-coated polyglactin 910 group reported pain on day 1 vs the control group (68% vs 89%; P=0.01) Intraoperative Handling 100 Percent Response 90 80 Good, Fair, Poor 70 Very Good 60 50 Excellent 40 30 20 10 0 VP V Overall Handling VP V Ease of Passage VP V First Throw Ford HR et al. Surg Infect (Larchmt). 2005;6:313-321. VP V Tie Down VP V Security VP V Hand VP V Memory VP V Nonfraying
    50. 50. Study Conclusions • In this pediatric cohort of 147 patients, scores for intraoperative handling were favorable and not significantly different for Coated VICRYL* Plus Antibacterial (polyglactin 910) and Coated VICRYL* (polyglactin 910) Sutures • Wound healing characteristics comparable between groups • Incidence of postoperative pain significantly less in patients treated with Coated VICRYL Plus Sutures compared with Coated VICRYL Sutures Ford HR et al. Surg Infect (Larchmt). 2005;6:313-321.
    51. 51. References 1. 2. 3. 4. 5. 6. 7. Agarwal M, Thomas P. Prevalence of post-op. nosocomial infection in neurosurgical patients and associated risk factors--a prospective study of 2441 patients. The Nursing Journal of India 2003;94(9):197-198, 212. Ashraf M, Biswas J, Gupta S, et al. Determinants of wound infections for breast procedures: assessment of the risk of wound infection posed by an invasive procedure for subsequent operation. Int J Surg 2009 Dec;7(6):543-546. Bhatia JY, Pandey K, Rodrigues C, et al. Postoperative wound infection in patients undergoing coronary artery bypass graft surgery: A prospective study with evaluation of risk factors. J Med Microbiol 2003;21(4):246-251. Kownhar H, Shankar EM, Vignesh R, et al. High isolation rate of Staphylococcus aureus from surgical site infections in an Indian hospital [9]. J Antimicrob Chemother 2008;61(3):758-760. Lilani SP, Jangale N, Chowdhary A, et al. Surgical site infection in clean and cleancontaminated cases. J Med Microbiol 2005;23(4):249-252. Suchitra JB, Lakshmidevi N. Hospital-acquired infections: Are prevention strategies matching incidence rates? Healthc Infect 2009;14(1):21-25. Lizioli A, Privitera G, Alliata E, et al. Prevalence of nosocomial infections in Italy: result from the Lombardy survey in 2000. J Hosp Infect 2003 Jun;54(2):141-148.

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