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Meta-Analysis
. 2017 Oct 30;10(10):CD012234.
doi: 10.1002/14651858.CD012234.pub2.

Intracavity lavage and wound irrigation for prevention of surgical site infection

Gill Norman  1 , Ross A Atkinson, Tanya A Smith, Ceri Rowlands, Amber D Rithalia, Emma J Crosbie, Jo C Dumville
Affiliations
Meta-Analysis

Intracavity lavage and wound irrigation for prevention of surgical site infection

Gill Norman et al. Cochrane Database Syst Rev. .

Abstract

Background: Surgical site infections (SSIs) are wound infections that occur after an operative procedure. A preventable complication, they are costly and associated with poorer patient outcomes, increased mortality, morbidity and reoperation rates. Surgical wound irrigation is an intraoperative technique, which may reduce the rate of SSIs through removal of dead or damaged tissue, metabolic waste, and wound exudate. Irrigation can be undertaken prior to wound closure or postoperatively. Intracavity lavage is a similar technique used in operations that expose a bodily cavity; such as procedures on the abdominal cavity and during joint replacement surgery.

Objectives: To assess the effects of wound irrigation and intracavity lavage on the prevention of surgical site infection (SSI).

Search methods: In February 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase and EBSCO CINAHL Plus. We also searched three clinical trials registries and references of included studies and relevant systematic reviews. There were no restrictions on language, date of publication or study setting.

Selection criteria: We included all randomised controlled trials (RCTs) of participants undergoing surgical procedures in which the use of a particular type of intraoperative washout (irrigation or lavage) was the only systematic difference between groups, and in which wounds underwent primary closure. The primary outcomes were SSI and wound dehiscence. Secondary outcomes were mortality, use of systemic antibiotics, antibiotic resistance, adverse events, re-intervention, length of hospital stay, and readmissions.

Data collection and analysis: Two review authors independently assessed studies for inclusion at each stage. Two review authors also undertook data extraction, assessment of risk of bias and GRADE assessment. We calculated risk ratios or differences in means with 95% confidence intervals where possible.

Main results: We included 59 RCTs with 14,738 participants. Studies assessed comparisons between irrigation and no irrigation, between antibacterial and non-antibacterial irrigation, between different antibiotics, different antiseptics or different non-antibacterial agents, or between different methods of irrigation delivery. No studies compared antiseptic with antibiotic irrigation. Surgical site infectionIrrigation compared with no irrigation (20 studies; 7192 participants): there is no clear difference in risk of SSI between irrigation and no irrigation (RR 0.87, 95% CI 0.68 to 1.11; I2 = 28%; 14 studies, 6106 participants). This would represent an absolute difference of 13 fewer SSIs per 1000 people treated with irrigation compared with no irrigation; the 95% CI spanned from 31 fewer to 10 more SSIs. This was low-certainty evidence downgraded for risk of bias and imprecision.Antibacterial irrigation compared with non-antibacterial irrigation (36 studies, 6163 participants): there may be a lower incidence of SSI in participants treated with antibacterial irrigation compared with non-antibacterial irrigation (RR 0.57, 95% CI 0.44 to 0.75; I2 = 53%; 30 studies, 5141 participants). This would represent an absolute difference of 60 fewer SSIs per 1000 people treated with antibacterial irrigation than with non-antibacterial (95% CI 35 fewer to 78 fewer). This was low-certainty evidence downgraded for risk of bias and suspected publication bias.Comparison of irrigation of two agents of the same class (10 studies; 2118 participants): there may be a higher incidence of SSI in participants treated with povidone iodine compared with superoxidised water (Dermacyn) (RR 2.80, 95% CI 1.05 to 7.47; low-certainty evidence from one study, 190 participants). This would represent an absolute difference of 95 more SSIs per 1000 people treated with povidone iodine than with superoxidised water (95% CI 3 more to 341 more). All other comparisons found low- or very low-certainty evidence of no clear difference between groups.Comparison of two irrigation techniques: two studies compared standard (non-pulsed) methods with pulsatile methods. There may, on average, be fewer SSIs in participants treated with pulsatile methods compared with standard methods (RR 0.34, 95% CI 0.19 to 0.62; I2 = 0%; two studies, 484 participants). This would represent an absolute difference of 109 fewer SSIs occurring per 1000 with pulsatile irrigation compared with standard (95% CI 62 fewer to 134 fewer). This was low-certainty evidence downgraded twice for risks of bias across multiple domains. Wound dehiscenceFew studies reported wound dehiscence. No comparison had evidence for a difference between intervention groups. This included comparisons between irrigation and no irrigation (one study, low-certainty evidence); antibacterial and non-antibacterial irrigation (three studies, very low-certainty evidence) and pulsatile and standard irrigation (one study, low-certainty evidence). Secondary outcomesFew studies reported outcomes such as use of systemic antibiotics and antibiotic resistance and they were poorly and incompletely reported. There was limited reporting of mortality; this may have been partially due to failure to specify zero events in participants at low risk of death. Adverse event reporting was variable and often limited to individual event types. The evidence for the impact of interventions on length of hospital stay was low or moderate certainty; where differences were seen they were too small to be clinically important.

Authors' conclusions: The evidence base for intracavity lavage and wound irrigation is generally of low certainty. Therefore where we identified a possible difference in the incidence of SSI (in comparisons of antibacterial and non-antibacterial interventions, and pulsatile versus standard methods) these should be considered in the context of uncertainty, particularly given the possibility of publication bias for the comparison of antibacterial and non-antibacterial interventions. Clinicians should also consider whether the evidence is relevant to the surgical populations under consideration, the varying reporting of other prophylactic antibiotics, and concerns about antibiotic resistance.We did not identify any trials that compared an antibiotic with an antiseptic. This gap in the direct evidence base may merit further investigation, potentially using network meta-analysis; to inform the direction of new primary research. Any new trial should be adequately powered to detect a difference in SSIs in eligible participants, should use robust research methodology to reduce the risks of bias and internationally recognised criteria for diagnosis of SSI, and should have adequate duration and follow-up.

PubMed Disclaimer

Conflict of interest statement

Gill Norman: my employment at the University of Manchester is supported by a grant from National Institute for Health Research (NIHR), UK (NIHR Cochrane Programme Grant 13/89/08‐High Priority Cochrane Reviews in Wound Prevention and Treatment).

Ross Atkinson: none known.

Tanya Smith: none known.

Ceri Rowlands: none known.

Amber Rithalia: none known.

Emma Crosbie: I have received funding from an NIHR Clinician Scientist Award, the HTA, Wellbeing of Women/the Wellcome Trust and Central Manchester University Hospitals NHS Foundation Trust. I am an employee of the University of Manchester.

Jo Dumville: I receive research funding from the NIHR for the production of systematic reviews focusing on high priority Cochrane Reviews in the prevention and treatment of wounds. Work on this review was also partly funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester and the NIHR Manchester Biomedical Research Centre (BRC).

Figures

1
1
Study flow diagram
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
4
4
Funnel plot of comparison 1: all irrigation versus no irrigation, outcome: 1.1 surgical site infection
5
5
Funnel plot of comparison 2: antibacterial versus non‐antibacterial irrigation, outcome: 2.1 surgical site infection
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD012234

References

References to studies included in this review

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References to studies excluded from this review

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Iqbal 2015 {published data only}
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Keblawi 2006 {published data only}
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Kellum 1985 {published data only}
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Martins 2012 {published data only}
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References to studies awaiting assessment

De Cicco 2015 {published data only}
    1. Cicco C, Schonman R, Ussia A, Koninckx PR. Extensive peritoneal lavage decreases postoperative C‐reactive protein concentrations: A RCT. Gynecological Surgery 2015;12(4):271‐4.
De Kok 1998 {published data only}
    1. Kok EH, Rhijn LW, Rietra PJ. The effect of wound irrigation on bacterial contamination of suction instrumentation during joint prosthesis surgery. Nederlands Tijdschrift voor Orthopaedie 1998;5(1):22.
    1. Kok EH, Rhijn LW, Rietra PJ, Plasmans CM, Veraart BE. The effect of wound irrigation on bacterial contamination of suction instruments in prosthetic surgery. Acta Orthopaedica Scandinavica 1998;69(Suppl 282):14.
Kosuş 2010 {published data only}
    1. Kosuş A, Kosuş N, Guler A, Capar M. Rifamycin SV application to subcutaneous tissue for prevention of post‐cesarean surgical site infection [Sezaryen sonrasi kesi yeri enfeksiyonunu onlemek icin ciltalti rifamisin SV uygulanmasi]. European Journal of General Medicine 2010;7(3):269‐76.
Munoz‐Mahamud 2011 {published data only}
    1. Munoz‐Mahamud E, Garcia S, Bori G, Martinez‐Pastor JC, Zumbado JA, Riba J, et al. Comparison of a low‐pressure and a high‐pressure pulsatile lavage during debridement for orthopaedic implant infection. Archives of Orthopaedic and Trauma Surgery 2011;131(9):1233‐8. - PubMed
Taylor 1999 {published data only}
    1. Taylor GJ, Calder S, Vickers M. Surgical wound decontamination with chlorhexidine jet lavage. Journal of Bone and Joint Surgery 1999;81(Suppl 1):48.

References to ongoing studies

ACTRN12610000423011 {published data only}
    1. ACTRN12610000423011. Does peritoneal lavage influence the rate of complications in paediatric laparoscopic appendicectomy? A prospective randomised clinical trial. apps.who.int/trialsearch/Trial2.aspx?TrialID=ACTRN12610000423011 (first received 26 May 2010).
NCT01175044 {published data only}
    1. NCT01175044. Dilute Betadine lavage in the prevention of postoperative infection. clinicaltrials.gov/ct2/show/NCT01175044 (first received 2 August 2010).
NCT02186457 {published data only}
    1. NCT02186457. Antibiotic irrigation for pancreatoduodenectomy. clinicaltrials.gov/ct2/show/NCT02186457 (first received 1 July 2014).
NCT02395614 {published data only}
    1. NCT02395614. Surgical site infection with 0.05% chlorhexidine (CHG) compared with triple antibiotic irrigation. clinicaltrials.gov/ct2/show/study/NCT02395614 (first received 17 March 2015).
NCT02527512 {published data only}
    1. NCT02527512. Bacterial contamination: iodine vs saline irrigation in pediatric spine surgery. clinicaltrials.gov/ct2/show/NCT02527512 (first received 7 August 2015).
NCT02714023 {published data only}
    1. NCT02714023. Water and saline head‐to‐head in the blinded evaluation study trial (WASHITBEST). clinicaltrials.gov/ct2/show/NCT02714023 (first received 8 March 2016).

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