Polihexanide for prevention of Wound Infection in Surgery. Is the contact time essential? POLIS-trial: A historic controlled, clinical pilot trial

Intraoperative Wound Irrigation for the Prevention of Surgical Site Infection After Laparotomy: A Randomized Clinical Trial by CHIR-Net

Importance

Surgical site infections frequently occur after open abdominal surgery. Intraoperative wound irrigation as a preventive measure is a common practice worldwide, although evidence supporting this practice is lacking.

Objective

To evaluate the preventive effect of intraoperative wound irrigation with polyhexanide solution.

Design, Setting, and Participants

The Intraoperative Wound Irrigation to Prevent Surgical Site Infection After Laparotomy (IOWISI) trial was a multicenter, 3-armed, randomized clinical trial. Patients and outcome assessors were blinded to the intervention. The clinical trial was conducted in 12 university and general hospitals in Germany from September 2017 to December 2021 with 30-day follow-up. Adult patients undergoing laparotomy were eligible for inclusion. The main exclusion criteria were clean laparoscopic procedures and the inability to provide consent. Of 11 700 screened, 689 were included and 557 completed the trial; 689 were included in the intention-to-treat and safety analysis.

Interventions

Randomization was performed online (3:3:1 allocation) to polyhexanide 0.04%, saline, or no irrigation (control) of the operative wound before closure.

Main Outcome and Measures

The primary end point was surgical site infection within 30 postoperative days according to the US Centers for Disease Control and Prevention definition.

Results

Among the 689 patients included, 402 were male and 287 were female. The median (range) age was 65.9 (18.5-94.9) years. Participants were randomized to either wound irrigation with polyhexanide (n = 292), saline (n = 295), or no irrigation (n = 102). The procedures were classified as clean contaminated in 92 cases (8%). The surgical site infection incidence was 11.8% overall (81 of 689), 10.6% in the polyhexanide arm (31 of 292), 12.5% in the saline arm (37 of 295), and 12.8% in the no irrigation arm (13 of 102). Irrigation with polyhexanide was not statistically superior to no irrigation or saline irrigation (hazard ratio [HR], 1.23; 95% CI, 0.64-2.36 vs HR, 1.19; 95% CI, 0.74-1.94; P = .47). The incidence of serious adverse events did not differ among the 3 groups.

Conclusions and Relevance

In this study, intraoperative wound irrigation with polyhexanide solution did not reduce surgical site infection incidence in clean-contaminated open abdominal surgical procedures compared to saline or no irrigation. More clinical trials are warranted to evaluate the potential benefit in contaminated and septic procedures, including the emergency setting.

Trial Registration

drks.de Identifier: DRKS00012251.

Identification of population of bacteria from culture negative surgical site infection patients using molecular tool

BACKGROUND

Managing surgical site infections, with negative culture report in routine diagnosis is a common dilemma in microbiology accounting more than 30% worldwide. The present study attempted to identify the presence of bacterial spp. if any in wound aspirates/swabs of culture negative surgical site infections of hospitalised patients using molecular tools.

METHODS

Ninety-seven patients with post-operative SSI whose wound swabs/aspirate were negative in the conventional aerobic culture after 72 h of incubation were analysed by 16S rRNA gene specific broad range PCR. The amplified DNA fragments were sequenced by Sanger DNA sequencing method and homology of the sequence were matched using NCBI BLAST (NCBI, USA) RESULTS: Of the 97 patients, 16S rRNA based broad range PCR assay could identify the presence of bacterial pathogen in 53(54.63%) cases, of which 29 isolates were supposed to be of viable but non-culturable bacteria (VBNC), 07 were of obligatory anaerobes and 13 were of unculturable bacteria, 04 were with poly bacterial infections.

CONCLUSIONS

Our study highlights the usefulness of PCR assay in detecting the presence of any VBNC, anaerobes and unculturable bacteria in SSI patients regardless of how well the bacteria may or may not grow in culture. Measures should be taken to use anaerobic culture system and PCR diagnosis along with conventional culture to detect the VBNC and unculturable bacteria where Gram stain is positive for better patient care.

Reduction of Postoperative Wound Infections by Antiseptica (RECIPE)?: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether intraoperative subcutaneous wound irrigation with 0.04% polyhexanide can reduce surgical site infection (SSI) in elective laparotomies compared to saline.

BACKGROUND

SSI is a common complication after gastrointestinal surgery. To date, there is a lack of evidence whether subcutaneous wound irrigation is beneficial in terms of reduction of SSI.

METHODS

The RECIPE trial was an investigator initiated single-center, single-blind prospective, randomized controlled trial with 2 parallel treatment groups, comparing wound irrigation with 0.9% saline to antiseptic 0.04% polyhexanide solution in elective laparotomies. Primary endpoint was the rate of SSI within 30 days postoperatively according to Centers for Disease Control and Prevention criteria.

RESULTS

Between February 02, 2015, and May 23, 2018, 456 patients were randomly assigned to saline (n = 228) or polyhexanide (n = 228). Final cohort for analysis comprised 393 patients (202 in the saline and 191 in the polyhexanide group). Overall rate of SSI was 28.2%, n = 111. Simple analysis with cross tabulation revealed that significantly fewer SSIs occurred in the polyhexanide group: n = 70 (34.7%) versus n = 41 (21.5%); P = 0.004. In a multiple logistic regression model the factor wound irrigation with polyhexanide [odds ratio (OR) 0.44; 95% confidence interval (CI) 0.27-0.72; P = 0.001) was associated with risk reduction of SSI. Preoperative anemia (OR 2.08; 95% CI 1.27-3.40; P = 0.004) and more than 5 prior abdominal operations compared to none (OR 8.51; 95% CI 2.57-28.21; P < 0.001) were associated with SSI.

CONCLUSIONS

Intraoperative subcutaneous wound irrigation with antiseptic 0.04% polyhexanide solution is effective in reducing SSI after elective laparotomies.

Colorectal Surgical Site Infections and Their Causative Pathogens: Differences between Left- and Right-Side Resections

BACKGROUND

Surgical site infections (SSIs), after colorectal resection, pose a significant burden. Recognition of the spectrum of potentially involved pathogens is crucial for determining correct antibiotic prophylaxis. This study aimed to determine whether the distribution of SSI-associated pathogens depends on the location of the colorectal resection.

METHODS

We retrospectively categorized 2713 consecutive colon resections as left- or right-side operations, identified patients having concurrent peritonitis or development of postoperative SSIs and peritonitis, and assigned all subcutaneously and intra-abdominally isolated pathogens according to the location of the resection.

RESULTS

Gram-positive cocci (especially enterococci) and gram-negative bacilli (especially Pseudomonas aeruginosa) were isolated more frequently from patients in whom SSIs developed after left-side resections than after right-side resections (52.5% vs. 32.6%, p < 0.01 and 15.9% vs. 6.7%, p < 0.01, respectively); enterococci were the causative organisms in a large percentage of SSIs (46.3%). Moreover, intra-abdominal P. aeruginosa and Candida spp. were isolated more frequently during left-side resections than during right-side operations in patients with peritonitis (15.8% vs. 6.3%, p = 0.02 and 14.3% vs. 5.3%, p = 0.02, respectively).

CONCLUSIONS

Our results indicate that differences exist in the distribution of pathogens after left- or right-side colorectal resections. Our data further suggest that gram-positive cocci play an important role in SSIs occurring after colorectal resections; therefore, antibiotic prophylaxis should emphasize their coverage. Further, enterococcal coverage may be especially advantageous during left-side resections.

[Enterococci and surgical site infections : Causal agent or harmless commensals?]

BACKGROUND

The role of enterococci in the context of peritonitis and surgical site infections (SSI) has not yet been definitively clarified but enterococci are being detected more frequently. Numerous resistances reduce the available antibiotic options.

OBJECTIVE

This article gives an overview of the pathogenic importance of enterococci and of current recommendations for therapy and prophylaxis. On the basis of our own data we discuss the relevance of enterococci for SSI.

MATERIAL AND METHODS

All colorectal resections carried out between January 2008 and September 2016 were retrospectively documented. Revision surgery, SSI and intra-abdominally or subcutaneously detected pathogens were recorded.

RESULTS

A total of 2713 interventions were evaluated with 28.3% having primary peritonitis. In 587 patients (21.6%) SSI followed, and pathogen determination was possible in 431 cases (73.4%). Enterococci were frequently found in re-operations (58.4%) and SSI (46.1%), with E. faecalis and E. faecium in approximately equal proportions. If intra-abdominal enterococci were detectable in patients with primary peritonitis, it was more common to develop SSI and enterococci were more frequently detected subcutaneously. Enterococci in SSI were found to be significantly more frequent in left hemicolectomies as well as in pre-existing renal insufficiency.

CONCLUSION

It can be inferred that enterococci are not adequately covered by commonly used perioperative antibiotic therapy or preoperative prophylaxis, which increases the risk for SSI by enterococci. This could be favored by selection of these pathogens due to the use of antibiotics without enterococcal efficacy (e. g. cephalosporins). The consideration in the choice of perioperative antibiotic prophylaxis by the additional administration of ampicillin or vancomycin could be advantageous.

Intraoperative wound irrigation to prevent surgical site infection after laparotomy (IOWISI): study protocol for a randomized controlled trial

Background

Postoperative surgical site infection (SSI) is one of the most common hospital infections and contributes substantially to postoperative morbidity and mortality. In addition, SSIs dramatically increase the treatment cost and length of hospital stay. Following visceral surgery by laparotomy, SSI rates are especially high (14–25%). Therefore, measures to prevent SSI in this field are urgently needed. Prophylactic intraoperative wound irrigation (IOWI) of the subcutaneous soft tissue before skin closure hypothetically represents an easy and economical option to reduce SSI rates and is already frequently used in clinical practice. However, there are currently no definite recommendations on the use of IOWI since high-level evidence supporting its use is lacking. Consequently, clinical practice varies widely. Antiseptic polyhexanide (PHX)-based solutions are approved for soft-tissue wound irrigation in surgery but have not been specifically evaluated in randomized clinical trials for the prevention of SSI following laparotomy for visceral surgery.

Methods/design

The IOWISI trial is a multicentre, randomized, observer- and patient-blinded clinical trial with three parallel treatment groups, comparing IOWI with a 0.04% PHX solution to no irrigation (test 1) or saline (test 2) before skin closure after laparotomy for visceral surgery (contamination level II–IV). The primary endpoint of the trial is the SSI rate within 30 days postoperatively. Statistical analysis of the primary endpoint measure will be based on the intention-to-treat population. The global level of significance is set at 2.5% for test 1 and 5% for test 2 and the sample size (n = 540) is determined to assure a power of 94% (test 1) and 85% (test 2).

Discussion

The IOWISI trial will provide high-level evidence as a basis for clinical recommendations regarding the use of IOWI with PHX or saline and will potentially impact on future clinical guidelines and practice. The pragmatic trial design guarantees high external validity.

Trial registration

Registered at the German Clinical Trials Register, DRKS00012251. Registered on 3 July 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2154-6) contains supplementary material, which is available to authorized users.