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Three Part Question

In [adults with uncomplicated non-bite traumatic lacerations] what is the [optimal time interval from injury to primary closure] to avoid [subsequent wound infection].

Clinical Scenario

A 34-year-old male presents to the emergency department with a laceration to his left hand inflicted by a clean knife approximately 12 hours prior to arrival. The patient washed the wound thoroughly after the injury and then wrapped it in a pressure bandage. He comes to the ED this morning because he is concerned it needs stitches. You remember hearing of the “golden window” for wound closure and wonder if closing this patient’s wound would significantly increase his risk of developing an infection.

Search Strategy

Medline 1966-07/20 using PubMed, Cochrane Library (2020), and Embase
[(exp lacerations OR exp wounds) AND (emergency service OR emergency treatment OR emergency department) AND (exp infection and exp wound healing]. Limit to English language.

Search Outcome

410 studies were identified; one systematic review addressed the clinical question. This review, published in 2012, analyzed four studies with a combined total of 3724 patients. Three studies have since been published that were not included in the meta-analysis.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Zehtabchi et al. November 2012 USA	3,724 patients with lacerations across 4 studies	Meta-analysis	Infection rate in early versus delayed wound (older than 12 hours) presentations	Despite the higher rates of infection in delayed wounds in three trials, only one study reached statistical significance, with a relative risk of infection of 4.8.	The overall quality of evidence was low. One study with the smallest sample size showed higher rate of infection in patients with delayed wounds. Observational studies were included providing lower quality of evidence as some patients were lost to follow-up. Providers prescribed prophylactic antibiotics in a non-randomized fashion, further confounding data.
Quinn et al. February 2014 USA	2663 consecutive patients with traumatic lacerations from 3 emergency departments	Prospective multicenter cohort study	Patients were followed for 30 days to determine the development of a wound infection rates	No significant differences were found in infection rates for wounds closed before of after 12 hours. Variables associated with infection were: diabetes (RR 2.7), lower extremity lacerations (RR 4.1), contaminated lacerations (RR 2.0), and lacerations greater than 5 cm (RR 2.9).	Only 85 patients presented with wounds 12 hours or more after injury and 15% of these were treated without initial closure. Comparatively, only 3.6% of wounds were treated without initial closure in the less than12 hour group. Infection rates were determined by phone interview.
Waseem et al. July 2012 USA	297 ED participants with lacerations	Prospective observational study	Time interval of laceration repair in relation to wound infections	Median wound closure time in the infection group was 867 min and in the non-infection group 330 min (p = 0.03). After controlling for multiple factors, there was a tendency for a small increase in infection rate after 1,000 min.	Small sample size, and practice variations among ED physicians. Development of infection was a rare event so lack of significance could be related to low power. Confounding factors, primarily wound location, seemingly accounted for higher infectious rates than time alone.
Brudvik et al. May 2015 Norway	97 ED participants with lacerations	Prospective cohort study	Wound infections at the time of suture removal were assessed	There were no serious infections, but mild clinical wound infections occurred in 15% of patients. No statistically significant correlation was found between the incidence of wound infections and the length of the wound, the time elapsed before suturing, the wound’s location on the body, contamination or underlying chronic diseases.	Small sample size; majority of reported infections were mild; 15 persons were not re-evaluated in person and had phone interviews instead; and the study excluded lacerations older than 12 hours on the head/face and older than 8 hours anywhere else.

Comment(s)

While many sources reference a “golden window” for primary wound closure without increased risk of wound infection, evidence does not support a strict time cut-off. Instead, the reviewed studies consistently demonstrated that other factors should be considered when deciding to close a wound primarily, versus delayed closure or allowing a wound to heal by secondary intention. These factors include wound location, contamination of the wound, co-morbidities such as vascular diseases and diabetes, and length of the wound.

Clinical Bottom Line

In adults with uncomplicated non-bite traumatic lacerations there is not an optimal time interval from injury to primary closure that has been shown to avoid subsequent wound infection. Instead, time to closure should be considered ain the context of other risk factors for wound infection, including patient co-morbidities, contamination, wound length, and wound location.

References

1. Zehtabchi S, Tan A, Yadav K, Badawy A, Lucchesi M. The impact of wound age on the infection rate of simple lacerations repaired in the emergency department. Injury 2012 Nov;43(11):1793-1798
2. Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? Emerg Med J 2014 Feb;31(2):96-100
3. Waseem M, Lakdawala V, Patel R, Kapoor R, Leber M, Sun X. Is there a relationship between wound infections and laceration closure times? Int J Emerg Med 2012 Jul 26;5(1):32.
4. Brudvik C, Tariq H, Bernardshaw SV, Steen K. Infections in traumatic wounds sutured at a Norwegian Accident and Emergency Department. Tidsskr Nor Laegeforen 2015 May 5;135(8):759-62