Current epidemiological data indicate that the overall prevalence of healthcare-associated infections (HCAIs) in England is 6.4% [confidence interval (CI) 4.7–8.7%], with surgical site infections (SSIs) being the third most common category (15.7%) [1,2]. SSIs could be considered as the most preventable HCAI, particularly when a care bundle approach is used, as there are many associated risk factors to target. A high impact intervention (HII) care bundle  issued by the Department of Health (UK) is based on a guideline for the prevention and treatment of SSIs published by the National Institute for Heath and Clinical Excellence (NICE): a combination of systematic review, other published guidance and expert advice . The HII care bundle incorporates core interventions of rational antibiotic prophylaxis, appropriate preoperative hair removal, avoidance of perioperative hypothermia and perioperative glycaemic control in patients who have diabetes, together with other recommendations which are not of a level IA evidence base. An evidence update from NICE has since made no substantial changes to the recommendations published in the original guideline . Despite the introduction of this directive, and its recommendations, having been circulated for over 5 years no evaluation of compliance with it or its effectiveness has been published [6▪].
The national SSI surveillance system, established and administered by Public Health England to enable hospitals to compare their SSI rates against a national benchmark, aims to use SSI data to improve the quality of patient care . Participating hospitals undertake surveillance in at least one of 17 categories of surgical procedures. In addition, the Department of Health has mandated that acute NHS hospital trusts which perform orthopaedic surgery should undertake a minimum of 3 months of surveillance each year in at least one specified category . It has been suggested that the true prevalence of SSI is underestimated, depending on surgical specialty, accepted and validated definitions and the comprehensiveness of postoperative surveillance [8▪,9▪]. When close postdischarge surveillance is included, particularly with the involvement of unbiased, trained and validated observers, SSIs have been reported to complicate 10–20% of surgical operations indicating that there is widespread underestimation of SSI rates across all classes of surgery [10–18].
SSIs are associated with over a third of postoperative deaths; they can range from a relatively trivial, short-lived, wound discharge (e.g., after open hernia surgery) to being life threatening (e.g., mediastinitis and sternal wound dehiscence) . In between there are the cosmetically unacceptable scars which may cause pain, prolonged duration and expense of hospitalization, and poor emotional wellbeing . Apart from the unrecorded indirect costs related to loss of productivity, reduced quality of life and expensive litigation the actual cost of an SSI can involve many days of inpatient treatment and added procedures, which can run into many thousands of pounds [21,22]. An example of this is the morbidity and mortality which may follow sternal infection after cardiac surgery . There is a paucity of prospective cost–benefit analysis of SSIs, but retrospective analyses clearly identify that the economic costs of SSI are substantial .
There has been further research published since the NICE guideline recommendations were introduced: some presents new data or promising new technology which could be considered for guideline inclusion and the HII for SSIs; some has been shown to be clearly unhelpful in the prevention of SSIs and the rest has not added to the evidence already in place. Much of this is reflected in a NICE evidence update . Review of the most relevant aspects of this new information is the topic of this article.
PREOPERATIVE BATHING AND SKIN PREPARATION
Ensuring personal hygiene of the operative team and surgical patient on the day of surgery is not controversial but the role of preoperative bathing and skin preparation with antiseptics to prevent SSIs is unproven. A Cochrane review of seven randomized controlled trials (RCTs; n = 10 157 patients)  found that preoperative showering or bathing with chlorhexidine was found to be no more effective than placebo, soap or no washing. Most of the studies included were over 20 years old. A further systematic review of 10 studies (n = 7351)  examined the effects of the number of antiseptic showers and type of antiseptics. No definitive conclusions could be made about the optimal number of preoperative showers, but in eight of the studies, chlorhexidine led to a reduction in skin surface bioburden. There were many methodological flaws in the trials, many being underpowered. In addition, skin bacteria did not seem to necessarily correlate with SSI risk. Another systematic review of 20 randomized and nonrandomized studies (n = 9520)  evaluated three types of skin antiseptic (povidone–iodine, alcohol or chlorhexidine) for patient skin preparation, operative team hand scrub procedure, preoperative showering or the use of antiseptic-impregnated incise drapes, prior to thoracic, cardiac, plastic, orthopaedic, neurological, abdominal or pelvic surgery. Significant heterogeneity precluded meta-analysis but preoperative showering appeared to reduce skin surface bioburden; however, the effect on SSIs was inconclusive. Again there were multiple flaws in the studies including inconsistencies in the formulation, strength and application of antiseptics, with mixed quality and randomization and the inclusion of a wide range of procedures.
The benefits of preoperative bathing or showering with antiseptics to prevent SSIs are uncertain and only further large trials can improve this evidence base.
PATIENT ANTISEPTIC SKIN PREPARATION
It is conventional practice to prepare patients’ skin at the surgical site immediately before incision using an antiseptic (such as povidone–iodine or chlorhexidine; aqueous or alcohol based). A Cochrane review  compared different preoperative skin preparations for preventing SSI after caesarean section in five randomized, quasi-randomized and cluster-randomized trials (n = 1462). In women who received skin preparation preoperatively the use of incisional drapes made no significant difference to SSI rates [relative risk (RR) = 1.29, 95% CI 0.97–1.71, P = 0.084]. One trial (n = 79) comparing alcohol scrub along with a povidone–iodine incise drape vs. povidone–iodine scrub without drape reported no infections in either group. No conclusions can be confidently drawn because of heterogeneity and low numbers of patients studied, which reflects the conclusions of the systematic review mentioned earlier . This latter review included an RCT (n = 849)  which compared alcoholic 2% chlorhexidine, administered from a disposable device, with a conventional aqueous povidone–iodine skin preparation. The chlorhexidine group significantly reduced SSIs but the comparison with an aqueous-based antiseptic was flawed; nevertheless, this device has had a wide uptake in surgery in general. The most effective antiseptic for skin preparation before surgical incision is uncertain, but alcohol-based antiseptics are likely to be more effective than aqueous solutions.
ANTIBIOTIC PROPHYLAXIS IN BREAST AND HERNIA SURGERY
Antibiotic prophylaxis for breast or hernia surgery remains controversial. A Cochrane review assessed 17 RCTs (n = 7843) for the effect of antibiotic prophylaxis on SSIs in adult patients undergoing elective open inguinal or femoral hernia repair. SSIs were significantly lower with antibiotic prophylaxis (3.1 vs. 4.5%, respectively; odds ratio (OR) = 0.64, 95% CI 0.50–0.82, P = 0.00042), although infections after herniorrhaphy (no mesh) were not significantly different .
Two studies have assessed antibiotic prophylaxis to prevent SSI after breast cancer surgery. A Cochrane review  examined seven RCTs (n = 1945) which compared preoperative or perioperative antibiotic prophylaxis with none or placebo. A significantly reduced incidence of SSI was found after prophylactic antibiotics (RR = 0.72, 95% CI 0.53–0.97, P = 0.031). However, a double-blind RCT (n = 254)  found no difference in SSIs between placebo and antibiotic (17/127; 13.4%; P = 0.719). There were flaws in the studies; some were old and various antibiotics were used. The risk of antimicrobial resistance and its cost have to be considered and prophylactic use in clean surgery is still not clear-cut.
NEGATIVE PRESSURE WOUND THERAPY
Negative pressure wound therapy (NPWT) is widely used in the treatment of chronic wounds to promote wound healing, wound debridement, alleviate exudate and odour and improve quality of life [33,34]. It delivers intermittent or continuous negative pressure (ranging from <50 to >125 mmHg) to the wound site which is covered with a foam or gauze dressing and sealed with an occlusive drape. Success has been reported in complex wounds  with emerging evidence to show that its use in high-risk, postoperative incisions prevents SSIs [36–40]. The likely modes of action are through holding wound edges together (thereby reducing the likelihood of surgical dehiscence), stimulation of perfusion, reduction of lateral tension, haematoma and oedema, and protection of the surgical site from exogenous sources of microorganisms.
A retrospective analysis of surgery for colorectal, pancreatic and peritoneal surface malignancies  found that patients treated with postoperative NPWT developed fewer superficial incisional SSIs compared with those who had a standard dressing (6.7 vs. 19.5%, P < 0.015). After clean-contaminated surgery, NPWT was associated with fewer superficial incisional SSIs (6.0 vs. 27.4%, P < 0 0.001), total SSIs (16.0 vs. 5.5%, P < 0.011) and need for postoperative wound interventions (16.0 vs. 35.5%, P < 0.011). The authors concluded there was a benefit but their results require validation by prospective randomised studies. In a prospective study of obese patients (BMI ≥ 30) having cardiac surgery through median sternotomy  it was found that NPWT reduced the incidence of SSI (4%) when compared to standard wound dressings (16%; P = 0.027; OR = 4.57; 95% CI 1.23–16.94). SSIs caused by Gram-positive skin flora were found in one patient having NPWT compared with 10 in the standard group (P = 0.009; OR = 11.39; 95% CI 1.42–91.36). Portable NPWT devices have been successfully used to decrease incidence of groin wound infection in patients after vascular surgery . In patients treated conventionally, with a skin adhesive or absorbent dressing, 19/63 (30%) groin incisions developed an SSI; whereas 3/52 (6%) groin incisions treated with the NPWT device did so (P = 0.0011). A further retrospective review of patients undergoing open colectomy  showed that 69/254 (27.2%) developed an SSI; 4 (12.5%) occurred in patients who had wounds treated with NPWT and 65 (29.3%) in patients having conventional wound care. In an orthopaedic study, patients with blunt, high-energy fractures of the lower limb were randomized in a multicentre RCT (n = 249) to standard dressings or NPWT . Significantly more infections were seen in the standard dressing group (23/122; 19%) than the NPWT group.
However, a study of ventral hernia repair  suggested that NPWT conferred no effect on the development of an SSI in patients after repair of potentially contaminated and infected hernias (25.8% SSIs with standard incisional wound care; 20.4% after NPWT; P = 0.50). A 12-month follow-up showed no differences between the groups in late wound complications (31.4% standard care; 28.6% after NPWT; P = 0.74). As these early studies are relatively small, with some controversial findings, further well powered and designed RCTs and systematic reviews are needed before the use of NPWT can be routinely recommended to reduce the risk of SSI.
PERIOPERATIVE OXYGEN SUPPLEMENTATION
Optimal oxygenation during surgery is part of best practice to ensure a haemoglobin saturation of more than 95%. A systematic review and meta-analysis of seven RCTs (n = 2728) examined the role of perioperative oxygen supplementation (fraction of inspired oxygen, FiO2 = 0.8) for 2 h postoperatively in the recovery room to reduce SSIs . No significant difference was seen in the rate of SSIs between supplemented oxygen and control groups (15.5 vs. 17.5%, respectively; OR = 0.85, 95% CI 0.52–1.38, P = 0.51). However, two subgroup analyses did show a significant benefit, when studies of neuraxial anaesthesia were excluded and in colorectal surgery, which justifies further research.
Flaws in the trials included heterogeneity of antibiotic use, definition of SSI, patient population and duration of perioperative oxygen supplementation.
ANTISEPTIC SURGICAL DRESSINGS
It is conventional to cover incisions with a dressing at the end of an operation. Whether a dressing is necessary at all, or whether it should be a transparent polyurethane or absorptive island dressing, is unclear. A Cochrane review of 16 RCTs (n = 2578)  investigated the value of wound dressings for the prevention of SSIs and found that there was no evidence that covering wounds reduced SSIs. There were many methodological flaws in these trials, including heterogeneity, small size and poor scientific quality; many were old studies.
There are many studies of antiseptic dressing use in chronic wound management, although many are of poor quality, but few have been used to prevent SSI. However, silver nylon dressings have been investigated in a small RCT (n = 110) involving patients undergoing colorectal surgery  for the prevention of SSI. Infections were lower when silver nylon dressings had been used (7/55; 13%) compared with gauze (18/54; 33%; P = 0.011). Again there were many flaws and further evidence is needed to advocate the use of antiseptic dressings.
The concept of a wound barrier, used during surgery to protect the wound edges from contamination, is attractive, but wound guards, based on semirigid plastic rings inserted into the incision with drapes attached to the circumference, have not been part of routine surgical practice. A systematic review and meta-analysis  found 10 RCTs and two controlled trials (n = 1933) of the use of wound guards to prevent SSIs after open abdominal, mostly colorectal, surgery. Most studies were old and of poor quality, with variable definitions and risk of bias, but an exploratory meta-analysis using a random effects model suggested a potentially significant benefit (RR = 0.60, 95% CI 0.41–0.86, P = 0.005). The same group has since published an acceptable RCT, the ROSSINI trial, which showed definitively that there was no benefit conferred by wound edge protection devices in the prevention of SSI [46▪].
SCALPEL OR DIATHERMY FOR SKIN INCISION
The use of diathermy for surgical incision may allow quicker surgical access and less bleeding than the use of a scalpel, but the effect on wound complications and SSIs has been investigated in a Cochrane review  of nine RCTs (n = 1901). No difference was seen between patients whose abdominal incisions were made with diathermy or with a scalpel (RR = 0.90, 95% CI 0.68–1.18, P = 0.44; seven RCTs, n = 1559). The trials were flawed by being underpowered, with heterogeneity, and definitions were not consistent. The use of diathermy to reduce the risk of SSI needs further evaluation in good-quality studies.
There is laboratory-based evidence that antimicrobial sutures (impregnated or coated with the broad-spectrum antiseptic triclosan) can effectively and safely deliver an antimicrobial into tissues. Several flawed and underpowered early studies showed some promise but now there are three independently undertaken systematic reviews and meta-analyses which found level 1A evidence for their use. The first  identified 17 RCTs (n = 3720). In a fixed effects model, antimicrobial sutures significantly reduced SSIs by 30% (RR = 0.70, 95% CI 0.57–0.85, P < 0.001). Subanalyses suggested that the effect was only significant after abdominal surgery but not after breast or cardiac surgery. Some studies were flawed by being underpowered with varying definitions of SSI and use of unconventional comparators. The second  identified 13 RCTs (n = 3568) of better quality and one additional trial of colorectal surgery. In a fixed effects model, there was a significant reduction of SSIs associated with the use of antimicrobial sutures (RR = 0.73, 95% CI 0.59–0.91, P = 0.005). The third meta-analysis [50▪] identified 15 RCTs (n = 4800) using Preferred Reporting Items for Systematic Reviewes and Meta-analyses (PRISMA) guidelines. In a fixed effects model the use of antimicrobial sutures significantly reduced SSIs by 33% (RR = 0.67, 95 CI 0.53–0.84, P < 0.0005) with no evidence of publication bias, a sensitivity analysis robust up to removal of three trials and the effect being significant in subsets of clean, clean-contaminated and contaminated surgery. This evidence presents a strong case for the use of antimicrobial-coated sutures to reduce SSIs.
Evidence-based medicine, derived from systematic reviews and meta-analysis, provides the strongest data for the compilation of guidelines. Wherever there are gaps in knowledge recommendations have to be based on operator experience, patient preferences and data from less convincing cohort and noncomparative studies. However, many of the RCTs included in meta-analysis are also of less than perfect scientific quality and guidelines should reflect that.
It is interesting that many aspects of current research to prevent SSIs involve a return to the use of antiseptics which has commented on before [51,52] and is timely bearing in mind the worldwide concern of rising antibiotic resistance and the lack of new antibiotic groups entering the research train .
There is an attractive logic to having several evidence-based interventions in a care bundle because when enacted together they might act with a summation effect and reduce the risk of an SSI to a very low level. However, unless there is near-complete to complete compliance with a bundle there seems little point introducing innovations which may have large resource implications to implement.
Financial support and sponsorship
Conflicts of interest
In the last 5 years D.L. has acted in an advisory capacity or been supported financially in sponsored symposia for Ethicon (Johnson and Johnson), Smith and Nephew and Carefusion. K.O. has no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
1. Health Protection Agency. English national point prevalence survey on healthcare-associated infections and antimicrobial use, 2011. London: Health Protection Agency; 2012.
2. Health Protection Agency. Surveillance of surgical site infections in NHS hospitals in England, 2010/2011. London: Health Protection Agency; 2011.
3. HCAI. Reducing healthcare associated infections. High impact intervention. Care bundle to prevent surgical site infection
for prevention of SSI. London: Department of Health; 2010.
4. National Institute for Health and Clinical Excellence. Surgical site infection
: prevention and treatment of surgical site infection
. Clinical guideline 74. London: National Institute for Health and Clinical Excellence; 2008.
5. National Institute for Health and Clinical Excellence. Surgical site infection
. Evidence update 43. London: National Institute for Health and Clinical Excellence; 2013.
6▪. Leaper DJ, Tanner J, Kiernan M, et al. Surgical site infection
: compliance with guidelines and care bundles. Int Wound J 2014; [Epub ahead of print].
Explored the poor compliance with guidelines as an explanation for the lack of decline in SSI.
7. Health Protection Agency. Fifth report of the mandatory surveillance of surgical site infection
in orthopaedic surgery, April 2004 to March 2009. London: Health Protection Agency; 2011.
8▪. Leaper D, Tanner J, Kiernan K. Surveillance of surgical site infection
: more accurate definitions and intensive recording needed. J Hosp Infect 2013; 83:83–86.
Explored the need for consistent definitions of SSI.
9▪. Tanner J, Padley W, Kiernan MA, et al. A benchmark too far: findings from a national survey of surgical site infection
surveillance. J Hosp Infect 2013; 83:87–91.
Explored the need for consistent surveillance methods for SSI.
10. Taylor EW, Byrne DJ, Leaper DJ, et al. Antibiotic prophylaxis
and open groin hernia repair. World J Surg 1997; 21:811–814.
11. Melling AG, Ali B, Scott EM, Leaper DJ. The effects of preoperative warming on the incidence of wound infection after clean surgery. Lancet 2001; 358:876–880.
12. Tanner J, Khan D, Aplin C, et al. Post discharge surveillance to identify colorectal surgical site infection
rates and related costs. J Hosp Infect 2009; 72:243–250.
13. Williams N, Sweetland H, Goyal S, et al. Randomised trial of antimicrobial-coated sutures to prevent surgical site infection
after breast cancer surgery. Surg Infect 2011; 12:469–474.
14. Yokoe DS, Khan Y, Olsen MA, et al. Enhanced surgical site infection
surveillance following hysterectomy, vascular, and colorectal surgery. Infect Control Hosp Epidemiol 2012; 33:768–773.
15. Thibon P, Borgey F, Boutreux S, et al. Effect of perioperative oxygen supplementation on 30-day surgical site infection
rate in abdominal, gynecologic, and breast surgery. Anesthesiology 2012; 117:504–511.
16. Lyytikainen O, Kanerva M, Agthe N, et al. Healthcare-associated infections in Finnish acute care hospitals: a national prevalence survey. J Hosp Infect 2008; 69:288–294.
17. Richet HM, Chidiac C, Prat A, et al. Analysis of risk factors for surgical wound infections following vascular surgery. Am J Med 1991; 91:170–172.
18. Turtiainen J, Saimanen E, Partio T, et al. Surgical wound infections after vascular surgery: prospective multicenter observational study. Scand J Surg 2010; 99:167–172.
19. Astagneau P, Rioux C, Golliot F, Brücker G. INCISO Network Study Group. Morbidity and mortality associated with surgical site infections: results from the 1997–1999 INCISO surveillance. J Hosp Infect 2001; 48:267–274.
20. Bayat A, McGrouther DA, Ferguson MW. Skin scarring. Br Med J 2003; 326:88–92.
21. Kent KG, Bartek S, Kuntz KM, et al. Prospective study of wound complications in continuous infrainguinal incisions after lower limb arterial reconstruction: incidence, risk factors, and cost. Surgery 1996; 119:378–383.
22. Leaper D, Nazir J, Roberts C, Searle R. Economic and clinical contributions of an antimicrobial barrier dressing: a strategy for the reduction of surgical site infections. J Med Econ 2010; 13:447–452.
23. Strecker T, Rosch J, Horch RE, et al. Sternal wound infections following cardiac surgery: risk factor analysis and interdisciplinary treatment. Heart Surg Forum 2007; 10:E366–E371.
24. Fry DE. The economic costs of surgical site infection
. Surg Infect 2002; 3:S37–S43.
25. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics
to prevent surgical site infection
. Cochrane Database Syst Rev 2012; 9:CD004985.
26. Jakobsson J, Perlkvist A, Wann-Hansson C. Searching for evidence regarding using preoperative disinfection showers to prevent surgical site infections: a systematic review. Worldviews Evidence-Based Nursing 2011; 8:143–152.
27. Kamel C, McGahan L, Polisena J, et al. Preoperative skin antiseptic preparations for preventing surgical site infections: a systematic review. Infect Control Hosp Epidemiol 2012; 33:608–617.
28. Hadiati DR, Hakimi M, Nurdiati DS, Ota E. Skin preparation for preventing infection following caesarean section. Cochrane Database Syst Rev 2014. CD007462.
29. Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010; 362:18–26.
30. Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic prophylaxis
for hernia repair. Cochrane Database Syst Rev 2007; 3:CD003769.
31. Bunn F, Jones DJ, Bell-Syer S. Prophylactic antibiotics to prevent surgical site infection
after breast cancer surgery. Cochrane Database Syst Rev 2012; 1:CD005360.
32. Cabaluna ND, Uy GB, Galicia RM, et al. A randomized, double-blinded placebo-controlled clinical trial of the routine use of preoperative antibiotic prophylaxis
in modified radical mastectomy. World J Surg 2013; 37:59–66.
33. Leaper DJ, Schultz G, Carville K, et al. Extending the TIME concept: what have we learned in the past 10 years? Int Wound J 2012; 9:1–19.
34. Ubbink DT, Westerbos SJ, Nelson EA, Vermeulen H. A systematic review of topical negative pressure therapy for acute and chronic wounds. Br J Surg 2008; 95:985–992.
35. Kirby M. Negative pressure wound therapy: using NPWT in practice. Br J Diabetes Vasc Dis 2007; 7:230–234.
36. Blackham AU, Farrah JP, McCoy TP, et al. Prevention of surgical site infections in high-risk patients with laparotomy incisions using negative-pressure therapy. Am J Surg 2013; 205:647–654.
37. Grauhan O, Navasardyan A, Tutkun B, et al. Effect of surgical incision management on wound infections in a poststernotomy patient population. Int Wound J 2014; 11:6–9.
38. Matatov T, Reddy KN, Doucet LD, et al. Experience with a new negative pressure incision management system in prevention of groin wound infection in vascular surgery patients. J Vasc Surg 2013; 57:1–5.
39. Bonds A, Novick T, Dietert J, et al. Incisional negative pressure wound therapy significantly reduces surgical site infection
in open colorectal surgery. Dis Colon Rectum 2013; 56:1403–1408.
40. Stannard JP, Volgas DA, McGwin G, et al. Incisional negative pressure wound therapy after high-risk lower extremity fractures. J Orthop Trauma 2012; 26:37–42.
41. Pauli EM, Krpata DM, Novitsky YW, Rosen MJ. Negative pressure therapy for high-risk abdominal wall reconstruction incisions. Surg Infect 2013; 14:270–274.
42. Togioka B, Galvagno S, Sumida S, et al. The role of perioperative high inspired oxygen therapy in reducing surgical site infection
: a meta-analysis. Anesth Analg 2012; 114:334–342.
43. Dumville JC, Walter CJ, Sharp CA, Page T. Dressings for the prevention of surgical site infection
. Cochrane Database Syst Rev 2011; CD003091.
44. Krieger BR, Davis DM, Sanchez JE, et al. The use of silver nylon in preventing surgical site infections following colon and rectal surgery. Dis Colon Rectum 2011; 54:1014–1019.
45. Gheorghe A, Calvert M, Pinkney TD, et al. West Midlands Research Collaborative; ROSSINI Trial Management Group. Systematic review of the clinical effectiveness of wound-edge protection devices in reducing surgical site infection
in patients undergoing open abdominal surgery. Ann Surg 2012; 255:1017–1029.
46▪. Pinkney TD, Calvert M, Bartlett DC, et al. West Midlands Research Collaborative; ROSSINI Trial Investigators. Impact of wound edge protection devices on surgical site infection
after laparotomy: multicentre randomised controlled trial (ROSSINI Trial). Br Med J 2013; 347:f4305.
Confirmed that wound protector devices do not prevent SSI.
47. Charoenkwan K, Chotirosniramit N, Rerkasem K. Scalpel versus electrosurgery for abdominal incisions. Cochrane Database Syst Rev 2012; CD005987.
48. Wang ZX, Jiang CP, Cao Y, et al. Systematic review and meta-analysis of triclosan-coated sutures for the prevention of surgical-site infection. Br J Surg 2013; 100:465–473.
49. Edmiston CE, Daoud FC, Leaper DJ. Is there an evidence-based argument for embracing an antimicrobial (triclosan)-coated suture technology to reduce the risk for surgical-site infections? A meta-analysis. Surgery 2013; 154:89–100.
50▪. Daoud FC, Edmiston CE, Leaper DJ. Meta-analysis of prevention of surgical site infections following incision closure with triclosan-coated sutures: robustness to new evidence. Surg Infect (Larchment) 2014; 15:165–181.
Showed that antimicrobial sutures reduce SSIs with sensitivity and robustness in most classes of surgery.
51. Leaper D. Topical antiseptics
in wound care: time for reflection. Int Wound J 2011; 8:547–549.
52. Leaper DJ, Fry D, Assadian O. Perspectives in prevention and treatment of surgical site infection
– a narrative review of the literature. Wounds 2013; 25:313–323.
53. Leaper D. Editorial: European Union antibiotic awareness day. Relevance for wound care practitioners. Int Wound J 2010; 7:314–315.