Triclosan Coated Sutures

Health Technology Assessment Committee Recommendations

1. There is no consistent evidence to support the broad use of Triclosan Coated Sutures (TCS); however, more recent evidence suggests a benefit in abdominal surgery.  
2. Given the insufficient evidence to draw conclusions about other clinical indications, HTAC recommends that the purchase of TCS be limited to use in abdominal surgery, or where it is determined to be medically necessary based on the clinical evidence.   
3. There is no proven link between products containing triclosan and antibacterial resistance; however, the possibility of a link and the environmental concerns suggests taking a cautious approach and limiting use of the product to where there is proven clinical benefit.
4. The Committee recommends that the existing policy communiqué be updated.

Health Technology Assessment Committee Findings

An evidence review by CADTH in November 2014 formed the basis of recommendations by the Health Technology Assessment Committee (HTAC) in February 2015 to discontinue the purchase and use of Triclosan Coated Sutures (TCS) in BC.

In April 2016, HTAC received an updated evidence review from CADTH and re-evaluated the public provision of TCS.  The review included eight new reports: one systematic review with subgroup analysis, five new randomized control trials, a non-randomized study, and one economic analysis.  The above recommendations are based on the updated evidence review:

1. The updated evidence review concluded that the totality of evidence suggests that triclosan coated sutures likely reduce the risk of surgical site infection (SSI).
2. Further interpretation of the clinical evidence was possible with this update, primarily on the strength of the included Systematic Review, which found that TCS may be more beneficial in some clinical populations and contexts, but not others. 
   1. Subgroup analysis identified an overall benefit in abdominal surgery.  The Relative Risk was .56, suggesting that use of sutures reduced surgical site infection by 44%.  Even at the tail end of the confidence interval, there is a reduction of at least 23%.  The observed heterogeneity of 64.6% is substantial, but may reflect ambiguity around what is categorized as ‘abdominal’.
   2. The Systematic Review reported no conflicts of interest, but one author is a consultant of Johnson & Johnson medical, one of the manufacturers of TCS.  CADTH concludes that influence on design, analysis and reporting of the research is unclear.  There did not appear to be any obvious signs of publication bias in the review.
3. The economic evaluation identified suggested the use of TCS may be cost saving in abdominal surgeries; however, generalizability to the Canadian context is limited.
4. Following the change in policy regarding TCS usage, Johnson & Johnson reduced the price of TCS under the current contract and pricing is now very similar, or slightly less in some instances, than the price of the non-antibacterial equivalent.
5. No conclusive benefit was shown for either colorectal or vein harvesting surgery, and there is insufficient evidence to draw conclusions about other clinical indications.
6. Triclosan is highly toxic to a variety of aquatic organisms when released into the environment.
7. Similar to previous reviews, no evidence was identified regarding the risks of triclosan coated sutures leading to drug-resistant bacteria or adverse events in patients.
8. Studies underway and the development of evidence-based guidelines such as those currently underway by the Centers for Disease Control and Prevention (CDC) may help to further clarify the most appropriate clinical indications and methods of application.