Bacterial Adherence to Surgical Sutures
A Possible Factor in Suture Induced Infection
SHMUEL KATZ, M.D.,* MORDECHAI IZHAR, M.Sc.,t DAVID MIRELMAN,PH.D.t
Surgical sutures are known to potentiate the development of
wound infection. The purpose of this study was to investigate
whether the capability of bacteria to adhere to various types of
sutures has a significant effect on their ability to cause in-
fections. Bacterial adherence to sutures was quantitatively
measured using radiolabeled bacteria. In vitro adherence
assays revealed remarkable variations in the affinity of bacteria
to the various sutures: nylon bound the least bacteria while
bacterial adherence to braided sutures (silk, Ti-cron, Dexon)
was five to eight folds higher. The degree of infection obtained
in mice in the presence of different sutures nicely correlated
with their adherence properties. The different removal rate of
adherent bacteria (glutaraldehyde-fixed) from various sutures
by the tissue factors in mice supports the hypothesis that
bacterial adherence to suture materials plays a significant
role in the induction of surgical infection. Our observation
points out at the need for careful suture selection in con-
taminated wounds. The adherence properties of sutures should
be considered in any future surgical suture design.
T HE PRESENCE OF SUTURE MATERIAL in a surgical
wound is known to cause an adverse effect on the
local tissue condition, and increases the susceptibility
to infection.'-3 Surgical sutures potentiate infection
when necrotic or devascularized tissue, hematoma or
dead space caused by tissue damage or poor surgical
technique are present.4 The ability of the sutured tissue
to resist infection varies depending on the kind of ma-
terial implanted.5 The degree of infection elicited by
different sutures depends on their physical and chemi-
cal configuration.6 The variations in the sutures'
capillarity and fluid absorption properties determine
bacterial transport along the suture filaments and
correlate with the in vivo study of experimental wound
infection.7
The purpose of this study was to investigate whether
a difference in bacterial adherence to various surgi-
*
Department of Pediatrics, Hadassah University Hospital.
t Department of Biophysics and the Unit for Molecular Biology
of Parasitic Diseases, Weizmann Institute of Science.
Reprint requests: S. Katz, M.D., Department of Pediatric Surgery,
Hadassah University Hospital, P.O. Box 12000 Jerusalem, Israel.
Submitted for publication: November 21, 1980.
0003-4932/81/0700/0035 $00.85 0 J. B. Lippincott Company
35
From the Department of Pediatric Surgery,
Hadassah University Hospital, Kiryat Hadassah,
Jerusalem, and the Department of Biophysics and Unit
for Molecular Biology of Parasitic Diseases,
Weizmann Institute of Science, Rehovoth, Israel
cal sutures could have an additional significant ef-
fect on tissue susceptibility to infection in the presence
of different types of sutures.
Materials and Methods
Bacterial adherence to surgical sutures was quan-
titatively determined by the use of radiolabeled bac-
teria.
Preparation of Radiolabeled Bacteria
The bacterial strains tested (all clinical isolates)
were: Staphylococcus aureus -coagulase positive,
Escherichia coli (type 7343), Bacteroides fragilis,
Serratia marcescens and Shigella dysenteriae. Eight-
een hours prior to each experiment, bacteria were
transferred, by a sterile wire loop, from stock agar
slants (Bacteroides were stored at -40 C) to freshly
prepared broth (10 ml) containing 10 41 of D-[u-'4C]-
glucose (239 mCi/mmol, 1 mCi/ml) (The Radiochemical
Centre-Amersham England). The broth consisted of
Peptone (0.5%) (Difco Ltd.). Staphylococci cultures
were grown with aeration at 37 C, while the other bac-
teria were allowed to grow statically at 37 C. B. fragilis
was grown in Tryptic Soy broth (Difco) in an anerobic
jar (Gaspak system-BBL) containing a gas generating
kit (Oxoid Ltd.) at 37 C. The bacteria were harvested
and washed in saline three times, at 8000 rpm for ten
minutes. The sedimented bacteria were resuspended
in isotonic saline and their concentration was adjusted
photometrically to give a stock solution of 109 bacteria
per milliliter. From this stock solution, a series of 1:10
dilutions were prepared for the various experiments.
The incorporation of the radioactive labeled precursor
 36 KATZ, IZHAR AND MIRELMAN
into the different bacterial strains was determined in a
Tricarb liquid scintillation spectrometer (model no 3255 was defined as the ratio
Packard Instrument Co. USA) with a Triton X-100-
Toluene scintillation fluid. The usual specific radio-
activity obtained was 1 cpm per 103- 104 bacteria.
Preparation of Glutaraldehyde-Fixed Radiolabeled
Bacteria
The washed bacterial sediment was resuspended and
incubated for 20 minutes in an isotonic saline solu-
tion containing glutaraldehyde 0.2% (Fluka AG Buchs,
SG, Switzerland). The bacteria were sedimented and
washed three times with 0.1 M glycine in sterile
isotonic saline (BDH Chemical Ltd. Poole, England),
and finally resuspended in saline to the original con-
centration. No growth was observed upon culturing
of these glutaraldehyde-fixed bacteria.
Suture Materials
Suture materials studied were all size 3-0 (u.s.p.) cut
to 3 cm length, if not otherwise specified. The fol-
lowing suture materials were tested: a) absorbable;
plain gut, chromic (cat gut), (Ethicon Inc. Somerville
N.Y. USA) and Dexon (polyglycolic acid) (Davis &
Geck American Cyanamid Co., New York, N.Y.);
b) nonabsorbable; silk (black braided) linen, Ethilon
(black monofilament nylon) Nurolon (braided poly-
amide 6.6) (Ethicon Inc. U.S.A.) Surgilon (silicone
treated braided nylon) Ti-cron (silicone treated braided
blue polyester) (Davis & Geck American Cyanamid
Co. U.S.A.).
In Vitro Assay -Bacterial Adherence to Sutures
Sutures, 3 cm in length were preincubated in 37 C
sterile isotonic saline (4 ml) in 1007 Petri dishes 60 x 15
mm style (Falcon Plastics B-D U.S.A.), and agitated
in a New Brunswick (U.S.A.) controlled environment
incubation shaker at 100 rpm for one hour. Radio-
labeled bacteria (106_ 109/ml, depending on the ex-
periment) were added and duplicates of the various
sutures were incubated and shaked for 20 minutes,
as described. The sutures were picked up with fine
forceps and the nonadherent bacteria were washed by
triple immersions of the sutures in an isotonic saline
solution (100 ml). This washing procedure was found to
be satisfactory, since no further release of radio-
active bacteria was observed by longer or additional
immersion periods. The number of adherent bacteria
was determined by suspending the sutures in Triton
X-100 based scintillation fluid and counting the radio-
activity in a Tricarb liquid scintillation spectrometer
(Packard U.S.A.).
Ann. Surg * July 1981
The adherence index of the various suture materials
A.I. = cpm of examined suture
cpm of Ethilon (nylon)
This calculated index expressed the affinity of bacteria
to the different suture materials.
The adherence of glutaraldehyde-fixed bacteria to
sutures was determined by the above described method.
The adherence of such fixed bacteria was almost
exactly the same (+ 10%) as with the same number of
viable bacteria.
Standardized Experimental Animal Model
The experimental model of wound infection in mice
described by Edlich et al.6 was slightly modified by us,
and has proven to be reliable and reproducible in day-
to-day assessment of suture infectivity and of bacterial
adherence to various suture materials. Female mice
(strains CB6FI, or CKB) weighing 20-25 g were
anesthetized with ether, the dorsal hair was removed
and the skin swabbed with ethyl alcohol (70%). The
dorsal skin was incised in midline, and two identical
pockets, between the panniculus carnosus and both
sides of paravertebral muscles were created by a fine
mosquito clamp. The sutures were directly implanted
into the pocket together with bacteria rather than in-
sertion of the suture by a straight needle and topical
injection of bacteria.6 The skin incision was then
closed by a 9 mm auto clipper (Clay-Adams U.S.A.).
On the fifth day after operation, the animal was killed
and the skin incision was widely opened to expose
the paravertebral fascia and the suture implantation
site. The local inflammatory response was assessed
and classified. 0-no infection, 1-mild inflammatory
reaction, 2-gross purulent discharge.
This model was used in three different ways: In the
first 50 mice, five different sutures; Chromic, Dexon,
Ethilon, Silk and Ti-cron were implanted in the right
dorsal subcutaneous pocket, and 0.1 ml of isotonic
saline containing a predetermined number of pyogenic
staphylococci (106 108) was applicated to both dorsal
pockets, thus leaving the left one as a control. All the
experiments were performed in duplicate, and the in-
flammatory response was assessed on the fifth day after
operation.
The second way to produce suture infection in mice
was achieved by dipping the different sutures in bac-
terial suspension 107 to 109 bacteria per milliliter and
then implanting them in the subcutaneous pockets as
described, without insertion of additional bacteria.
The wound infection produced by this method repre-
VOl. 194.o NO. I BACTERIAL ADHERENCE TO SUTURES 37
TABLE 1. Adherence of Bacteria to Surgical Sutures
Adhered Bacteria
Nature of S. aureus* E. colit S. marcescenst S. dvsenteriaet B. fragilist
Suture Type Material cells/3 cm cells/3 cm cells/3 cm cells cm cells/3 cm
Chromic (mono- Natural cat gut (1.5 0.2) X 107 (3.6 + 0.4) x 106 (6.8 1.0) x 106 (1.7 0.2) x 106 (1.3 0.2) x 107
filament) (absorbable)
Dexon (braided) Polyglycolic acid (5.1 0.5) x 107 (1.2 0.2) x 107 (2.7 + 0.4) x 107 (3.9 0.5) x 106 (2.6 0.5) x 107
(absorbable)
Nurolon Polyamide (6.6) (7.5 1.0) x 106 (1.6 0.3) x 106 (6.1 1.0) x 106 (1.9 0.2) x 106 (1.1 + 0.2) x 107
(braided) (nonabsorb-
able)
Nylon (mono- Polyamide (6.6) (7.1 0.8) x 106 (1.2 0.3) x 106 (3.4 0.5) x 106 (5.4 + 0.7) x 105 (4.3 0.4) x 106
filament) (nonabsorb-
able)
Silk (braided) Natural fiber (2.5 0.4) x 107 (5.2 0.6) x 106 (1.6 0.2) x 107 (2.0 0.2) x 106 (1.5 0.2) x 107
(nonabsorb-
able)
Tri-Cron Silicone treated (2.4 + 0.5) x 107 (5.0 0.6) x 106 (1.4 0.2) x 107 (1.8 0.2) x 106 (1.4 + 0.2) x 107
(braided)
* n = 20. t n = 4.
t n = 6.

sents an infection due solely to bacteria adhered to and B. fragilis. It was found that bacteria adhere dif-
the suture. ferently to the various suture materials under the same
In the third type of study this model was used to experimental conditions. Ethilon (nylon) -This mono-
determine the rate of removal of adhered bacteria from filament suture was the material that bound the least
the different materials. Sutures were incubated with bacteria, whereas the affinity of bacteria to other suture
suspension of inert glutaraldehyde-fixed radiolabeled materials was found to increase in the following order:
bacteria and then implanted in the dorsal pockets. Nurolon, Surgilon, Chromic catgut, Ti-cron, Linen,
The mice were killed one, two and three days fol- Silk, Plain and Dexon (Table 1).
lowing the operation, the sutures were taken out and The amount of bacteria that adhered to surgical
the remaining, radioactively labeled bacteria were
counted as described. The removal rate of bacteria
from different suture materials by the tissue was
compared. Staphylococcus aureus
ror
I--
0
Electr-on Microscopy
Sutures were incubated in staphylococci suspen- 0
0
sion, washed and then agitated in a solution of glutaral- U
L-
n
dehyde (1.5%) for 1 hour at room temperature. After
washing in 0.1 M buffered sodium Cacodylate (pH 7.2)
and incubation in 1% osmium tetraoxide for 30 minutes, a)
the sutures were washed again and dehydrated with -oL-
.0
increasing concentrations of alcohol and subjected
to critical point drying. The sutures were then fixed
to metal planchets, coated with gold and examined 0 5
e 10
using a Jeol JSM-35C Scanning electron microscope.
Results C0
108 109 Bacteria/ml
In Vitro Adherence Assay
Incubation suspension
The in vitro adherence assay was performed a total
FIG. 1. Adherence of radiolabeled Staphylococcus aureus to 3-0
of 20 times with S. (lureus, six times with E. coli and sutures (3 cm) incubated with bacterial suspension in different con-
four times using each: S. marcescens, S. dysenteria centrations. 0 * Silk. A A Ethilon.
 38 KATZ, IZHAR AND MIRELMAN Ann. Surg * July 1981

Noxon

0) I 5-
7, FIG. 2. Comparative adherence of S. aureus to
different sutures. Adherence to nylon = 1 unit.
Ti-Cro n CL j0 i

I I-NaturdiH
- Synthetic - I Natural-I kSynthetic-1
k-Non- Absorbable - HAbsorbable - I

sutures was related to their concentration in the in- marized in Figure 3. The pattern of adherence of the
cubation suspension (Fig. 1). However, even at high various types of bacteria to the different suture ma-
concentrations only 0.5 to 4% of the bacteria adhere terials was almost identical.
to the incubated sutures in this assay. The possible effect of serum or fresh frozen plasma
The number of bacteria that adhered to an examined on bacterial adherence was studied in two ways: pre-
material divided by the number of those adhered to the incubation of staphylococci in human serum or plasma
standard nylon-monofilament suture in the same (20 minutes at 37 C) resulted in formation of bacterial
experimental conditions was defined as the adherence macroaggregates which caused a decrease of approxi-
index (Al). The Al was found to be a better parameter mately 40% in the ability of bacteria to adhere to
in assessment of the suture-bacteria affinity or ad- sutures. On the other hand, when sutures were pre-
herence potency of bacteria to the various types of incubated with serum or plasma prior to the exposure
sutures. The Al of the different suture materials tested to radiolabeled bacteria, adherence was markedly en-
by radiolabeled S. aureus is shown in Figure 2. The hanced (40-100%) most likely due to an increase in
comparative adherence assay of E. coli, S. marcescens the absorption of bacteria to the suture surface.
and S. dysenteria, and B. fragilis to suture is sum-
In Vivo Model of Wound Infection
I0 Suture materials potentiated bacterial growth and
E. coli Serrati caused infection in mice. A suspension of staphylo-
8 cocci (several concentrations were tested) injected into
the empty subcutaneous pockets failed to promote
6
and develop local infection probably due to self elimina-
tion of the bacteria by the animal. A minimal number of
4 contaminating bacteria (109) was necessary to elicit
significant wound infection in the absence of suture.
NyNbuLi C S D NyNuLiCS
C While the minimal infective dose of staphylococci in
the presence of suture material was only 105 bacteria.
Shigelln BNnteroides The infectivity properties of the different suture
D 8D-
materials were studied by dipping sutures in bacterial
6- suspension of S. aureus (109 bacteria/ml) and then
4- implanting the sutures with the adherent bacteria into
dorsal subcutaneous pockets in mice. The amount of
2- bacteria adhered to the sutures after dipping is given
NLNuI C IS ID I___ NNu,Li,CSSD_ in Table 1. The inflammatory response and the in-
Suture rmaterial fectivity score obtained are summarized in Table 2.
It is clearly shown that the different sutures elicit
FIG. 3. The comparative adherence assays of 4 bacterial strains
to different sutures in units (adherence to nylon = 1 unit). Ny different degrees of inflammatory reaction. Interest-
= Ethilon, Nu = Nurolon, Li = Linen, C = Chromic, S = Silk, ingly, this phenomenon correlates nicely with the ad-
D = Dexon. herence index obtained in the in vitro adherence assay.
Vol. 194 * No. BACTERIAL ADHERENCE TO SUTURES 39
TABLE 2. Infectivity Score of Sutures* from Chromic and Silk, and poorly detached from
Suture Degree of Inflammatory Response Infectivity
Dexon. The absolute number of bacteria remaining on
Type (Number of Mice) Scoret the sutures and the relative percentage of bacterial
clearance of each suture material is demonstrated in
0 1 2 Figure 4.
Chromic - 5/10 5/10 15
Dexon 1/10 9/10 19 Scanning Electron Microscopy
Nylon 3/10 7/10 7
Silk 3/10 7/10 17 Scanning electron photomicrographs demonstrated
Ti-Cron 2/10 8/10 18 bacterial adherence to various sutures. The gross
* Wound infection in mice, 5 days following dipping of sutures appearance of the sutures (Fig. 5) and the adhered
in bacterial suspension and then implanting into subcutaneous pock- bacteria attached to them (magnification x 10000) are
ets in mice. For experimental conditions see text. shown in Figure 6. It seems that the suture con-
t Infectivity score is the summation of the degree of inflammatory
response found in animals. figuration-its filament composition and surface
smoothness-contribute to the different affinity of
It is concluded that bacterial adherence to suture bacteria to the various materials. The ability of bacteria
materials probably plays an important role in the degree (approximately 1 ,t in diameter) to adhere to discrete
of infection induced around the suture. sites in between the interlacing filaments of braided
Sutures to which glutaraldehyde-fixed radiolabeled sutures increased the adherence to these types of
bacteria were adhered did not cause any infection at sutures. The penetration of the bacteria to the inter-
the suture site. This enabled the exclusive deter- stices of a multifilament suture may obstruct them
mination of bacterial removal rate from the various from tissue phagocytic factors such as polymorpho-
sutures by the surrounding tissue. As shown in Figure nuclears and macrophages (approximately 10 ,. in di-
4, bacteria were removed at different rates, from the ameter) and this can perhaps explain the slower re-
various sutures. The fastest removal of bacteria was moval rate of bacteria from such sutures (e.g. Silk,
from Ethilon (monofilament-nylon) and its adherent Ti-cron and Dexon) as compared to nylon.
radiolabeled bacteria were almost completely removed
on the day of implantation, and very few were detect- Discussion
able on the following day. It is well established that the presence of suture
On the other hand, bacteria were slowly removed materials increases the incidence of surgical infection.

co T
0
x

E
u
4
rL)
.- e-

c
30-
U) Q1)
0
m CL
C7
Ncn ._c
U-
co E 20H
2 _ .a
1-
Z
.I-
E 0
D

1oH
II
0
m
I II
1 2 3 2 3
Days Days
FIG. 4. Removal of fixed staphylococci adhered to sutures following implantation in a subcutaneous pocket in mice. (a, left) Absolute number
of remaining bacteria. (b, right) Percentage of remaining adhered bacteria to different sutures. 0 0 Dexon, 0 0 Silk, A A
Chromic.
 40 KATZ, IZHAR AND MIRELMAN Ann. Surg * July 1981

OF

FIG. 5. Composite scanning electron micrograph (x 100) showing the gross appearance of four surgical sutures;
left), Chromic catgut (b, upper right), Silk (c, lower left), Dexon (d, lower right). Monofilament nylon (a, upper

This is atributed to the inflammatory reaction caused
by the sutures. Different physical properties and con-
figuration of the suture materials have been found to be
a factor affecting the degree of wound infection.6 In this
investigation, we have tested the ability of bacteria
to adhere to different suture materials and tried to
correlate this with the occurrence of surgical in-
fections. Our results show that bacteria adhere with
different affinity to various types of suture materials.
The nylon monofilament was the suture to which the
least amount of bacteria adhered, whereas braided
Dexon was the thread which attached the most. Im-
plantation of sutures with attached bacteria into mice
readily induced infection. The degree of infection
caused by the bacteria-associated sutures that were
subcutaneously implanted into mice correlated well
with the adherence properties of the different types
of sutures. The removal of adhered bacteria by tissue
defense factors from braided sutures was slower than
monofilaments.
These studies show that the physical properties and
chemical composition of the suture material play an
important role in the interaction between bacteria and
suture and may be a major contributor to the in-
duction, severity and persistence of wound infection.2
It must be emphasized that these experiments dealt
only with the early postoperative infection, and the
effect of degradation products of the absorbable
sutures were not taken into consideration. Further-
more, the role of bacterial adherence to sutures in
the development of delayed infection or sinus forma-
tion was not investigated in this study.
Our present observations on the adherence of bac-
teria to various suture materials point to the need
of careful suture selection whenever wound infection
is expected. In addition, our above described assay
Vol. 194 . No. 1 BACTERIAL ADHERENCE TO SUTURES 41

FIG. 6. Composite scanning electron micrograph showing staphylococci adhered to surgical sutures; Monofilament nylon (x 10000) (a, upper
left), Chromic catgut (x 10000) (b, upper right), Silk (x 10000) (c, lower left), Dexon (x 2700) (d, lower right).

for the in vitro adherence of bacteria to sutures
can serve as an appropriate test that should be included
when physical properties specifications of sutures are
determined. Its inclusion in routine and experimental
use will undoubtedly contribute to the development of
better designed sutures and minimize their role in the
induction of surgical wound infection.
References
1. Elek SD, Conen PE. The virulence of Staphylococcus pyogenes
for man. A study of the problems of wound infection. Br J
Exp Pathol 1957; 38:573-586.
2. James RC, Macleod CM. Induction of Staphylococcal in-
fections in mice with small inocula introduced on sutures.
Br J Exp Pathol 1961; 42:266-277.
3. Everett WG. Suture materials in general surgery. Prog Surg
1970; 8:14-37.
4. Edlich RF, Tsung MS, Rogers W, et al. Studies in the manage-
ment of the contaminated wound. I. Technique of closure of
such wounds together with a note on reproducible model.
J Surg Res 1968; 8:585-592.
5. Alexander JW, Kaplan JZ, Altemeir WA. Role of suture
materials in the development of wound infection. Ann Surg
1967; 165:192- 199.
6. Edlich RF, Panek PH, Rodeheaver GT, et al. Physical and
chemical configuration of sutures in the development of
surgical infection. Am Surg 1973; 177:679-687.
7. Blomstedt B, Osterberg B, Bergstrand A. Suture material and
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