Intracavity lavage and wound irrigation for prevention of surgical site infection

Abstract

BackgroundSurgical 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.ObjectivesTo assess the effects of wound irrigation and intracavity lavage on the prevention of surgical site infection (SSI).Search methodsIn 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 criteriaWe 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 analysisTwo 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 resultsWe 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 ir...

Intraoperative surgical site infection control and prevention: a position paper and future addendum to WSES intra-abdominal infections guidelines

“…A 2017 Cochrane review included 36 studies (6163 participants) comparing the use of antibacterial irrigation with non-antibacterial irrigation [48]; authors reported a lower incidence of SSI in patients 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 was low-certainty evidence downgraded once because 54% of the analysis weight was contributed by studies at high risk of bias in one or more domains, and once because publication bias was considered likely to have affected the result.…”

“…The 2017 Cochrane review comparing antibacterial irrigation with non-antibacterial irrigation (36 studies, 6163 participants), the largest meta-analysis published, reported a lower incidence of SSI in participants treated with antibacterial irrigation compared with nonantibacterial irrigation (RR 0.57, 95% CI 0.44 to 0.75; I2 = 53%; 30 studies, 5141 participants) but evidence are of low certainty [48]. Therefore, where a possible difference in the incidence of SSI was identified (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.…”

A cross‐sectional survey of patients with open surgical wounds in Slovenia

“…In the past two decades, wound care has received a lot of attention from researchers. Many studies have aimed to investigate which interventions might be effective in promoting wound healing or preventing wounds (Atkinson & Cullum, ; Dumville, Owens, Crosbie, Peinemann, & Liu, ; Lavallée, Gray, Dumville, Russell, & Cullum, ; Norman et al., ; Westby, Norman, Dumville, Stubbs, & Cullum, ). However, less has been written about the basic nature of wounds and their prevalence (Cullum et al., ).…”

A Randomized Controlled Trial on Intra-Abdominal Irrigation during Emergency Trauma Laparotomy; Time for Yet Another Paradigm Shift

“…During the last decade of the twentieth century (and in some more recent literature [25][26][27][28][29][30][31][32]) animal and other experimental studies began addressing the question of which fluid and how much [8,[25][26][27][33][34][35][36][37][38][39][40]. It was during this period that the potential adverse effects of the use of abdominal washouts were described: upregulation of pro-inflammatory mediators, damage to peritoneal mesothelial cells and polymorphonuclear neutrophil membranes, promotion of postoperative adhesions, documented instances of bacterial translocation, failure to effectively decrease peritoneal bacterial counts, and potential adverse effects on final hemostasis (through technical or chemical issues) [7,33].…”

“…A few systematic reviews have recently tried to provide some answers to this issue; but the evidence-base used has clear problems, i.e. the studies pooled are greater than 14 years old in more than 60% of the cases (in fact only 4 studies were more recent than the year 2010, only 2 of which are focused on the peritoneal cavity) [28][29][30][31]. Our interpretation of these meta-analyses and systematic reviews is in line with the conclusions reached by our own study; in that there is no benefit to large volume intra-peritoneal lavage with normal saline and, in fact, larger volumes can potentially increase complications rates.…”