TY - JOUR
T1 - Alcoholic chlorhexidine skin preparation or triclosan-coated sutures to reduce surgical site infection
T2 - a systematic review and meta-analysis of high-quality randomised controlled trials
AU - National Institute of Health Research Unit on Global Surgery
AU - Ademuyiwa, Adesoji O.
AU - Adisa, Adewale O.
AU - Bach, Simon
AU - Bhangu, Aneel
AU - Harrison, Ewen
AU - Ingabire, JC Allen
AU - Haque, Parvez D.
AU - Ismail, Lawani
AU - Glasbey, James
AU - Ghosh, Dhruva
AU - Kadir, Bryar
AU - Kamarajah, Sivesh K.
AU - Li, Elizabeth
AU - Lillywhite, Rachel
AU - Mann, Harvinder
AU - Martin, Janet
AU - Ramos de la Madina, Antonio
AU - Moore, Rachel
AU - Morton, Dion
AU - Nepogodiev, Dmitri
AU - Ntirenganya, Faustin
AU - Pinkney, Thomas
AU - Pockney, Peter
AU - Omar, Omar
AU - Simoes, Joana
AU - Smart, Neil
AU - Smith, Donna
AU - Tabiri, Stephen
AU - Taylor, Elliot
AU - Wilkin, Richard
N1 - Publisher Copyright:
© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license
PY - 2022/8
Y1 - 2022/8
N2 - Background: WHO and the UK's National Institute for Health and Care Excellence recommend alcoholic chlorhexidine skin preparation and triclosan-coated sutures to prevent surgical site infections (SSIs). Existing meta-analyses that include studies at high risk of bias, combined with the recent publication of large, randomised trials, justify an updated meta-analysis of high-quality randomised controlled trials (RCTs). We aimed to test the rates of SSI according to skin preparation solutions (ie, alcoholic chlorhexidine vs aqueous povidone-iodine) and types of sutures (ie, coated vs uncoated). Methods: In this systematic review and meta-analysis, we searched MEDLINE, Embase, Pubmed, and Cochrane Library databases, with no language restrictions, to identify high-quality RCTs testing either alcoholic chlorhexidine skin preparation (vs aqueous povidone-iodine) or triclosan-coated sutures (vs uncoated sutures), or both, published from database inception to Sept 1, 2021. Patients who received clean-contaminated, contaminated, or dirty surgery were included. We predefined the characteristics of a high-quality trial through an expert consensus process to develop an enhanced Cochrane risk of bias-2 tool specifically for RCTs with a primary outcome of SSI. Data were extracted from published reports. Meta-analysis was performed using a random-effects model and heterogeneity was assessed using the I2 statistic. This systematic review and meta-analysis was prospectively registered in PROSPERO, CRD42021267220. Findings: Of 942 studies identified, 933 were excluded. Four high-quality RCTs (n=7467 patients) were included that tested alcoholic chlorhexidine. No significant difference in SSI rates was noted between alcoholic chlorhexidine and aqueous povidone-iodine (17·9% [667 of 3723 patients] vs 19·8% [740 of 3744 patients]; odds ratio 0·84 [95% CI 0·65–1·06]; p=0·21, I2=53·1%). Five high-quality RCTs were included that tested triclosan-coated sutures (n=8619 patients), with no significant difference noted between triclosan-coated and uncoated sutures (16·8% [733 of 4360 patients] vs 18·4% [784 of 4259 patients]; OR 0·90 [95% CI 0·74–1·09]; p=0·29, I2=36·4%). Interpretation: Contrary to previous meta-analyses, this study did not show a benefit from either alcoholic chlorhexidine skin preparation or triclosan-coated sutures, both of which are more expensive than other readily available alternatives. Global and national guidance should be reconsidered to remove recommendations for their routine use. Funding: National Institute for Health Research (NIHR) Global Health Research Unit.
AB - Background: WHO and the UK's National Institute for Health and Care Excellence recommend alcoholic chlorhexidine skin preparation and triclosan-coated sutures to prevent surgical site infections (SSIs). Existing meta-analyses that include studies at high risk of bias, combined with the recent publication of large, randomised trials, justify an updated meta-analysis of high-quality randomised controlled trials (RCTs). We aimed to test the rates of SSI according to skin preparation solutions (ie, alcoholic chlorhexidine vs aqueous povidone-iodine) and types of sutures (ie, coated vs uncoated). Methods: In this systematic review and meta-analysis, we searched MEDLINE, Embase, Pubmed, and Cochrane Library databases, with no language restrictions, to identify high-quality RCTs testing either alcoholic chlorhexidine skin preparation (vs aqueous povidone-iodine) or triclosan-coated sutures (vs uncoated sutures), or both, published from database inception to Sept 1, 2021. Patients who received clean-contaminated, contaminated, or dirty surgery were included. We predefined the characteristics of a high-quality trial through an expert consensus process to develop an enhanced Cochrane risk of bias-2 tool specifically for RCTs with a primary outcome of SSI. Data were extracted from published reports. Meta-analysis was performed using a random-effects model and heterogeneity was assessed using the I2 statistic. This systematic review and meta-analysis was prospectively registered in PROSPERO, CRD42021267220. Findings: Of 942 studies identified, 933 were excluded. Four high-quality RCTs (n=7467 patients) were included that tested alcoholic chlorhexidine. No significant difference in SSI rates was noted between alcoholic chlorhexidine and aqueous povidone-iodine (17·9% [667 of 3723 patients] vs 19·8% [740 of 3744 patients]; odds ratio 0·84 [95% CI 0·65–1·06]; p=0·21, I2=53·1%). Five high-quality RCTs were included that tested triclosan-coated sutures (n=8619 patients), with no significant difference noted between triclosan-coated and uncoated sutures (16·8% [733 of 4360 patients] vs 18·4% [784 of 4259 patients]; OR 0·90 [95% CI 0·74–1·09]; p=0·29, I2=36·4%). Interpretation: Contrary to previous meta-analyses, this study did not show a benefit from either alcoholic chlorhexidine skin preparation or triclosan-coated sutures, both of which are more expensive than other readily available alternatives. Global and national guidance should be reconsidered to remove recommendations for their routine use. Funding: National Institute for Health Research (NIHR) Global Health Research Unit.
UR - http://www.scopus.com/inward/record.url?scp=85134782485&partnerID=8YFLogxK
U2 - 10.1016/S1473-3099(22)00133-5
DO - 10.1016/S1473-3099(22)00133-5
M3 - Article
C2 - 35644158
AN - SCOPUS:85134782485
SN - 1473-3099
VL - 22
SP - 1242
EP - 1251
JO - The Lancet Infectious Diseases
JF - The Lancet Infectious Diseases
IS - 8
ER -