Neither alcoholic chlorhexidine skin preparation nor triclosan-coated sutures help prevent SSI: Study

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).

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. 

• Of 942 studies identified, 933 were excluded. Four high-quality RCTs were included that tested alcoholic chlorhexidine.
• No significant difference in SSI rates was noted between alcoholic chlorhexidine and aqueous povidone-iodine
• Five high-quality RCTs were included that tested triclosan-coated sutures, with no significant difference, noted between triclosan-coated and uncoated sutures

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.

Reference:

Alcoholic chlorhexidine skin preparation or triclosan-coated sutures to reduce surgical site infection: a systematic review and meta-analysis of high-quality randomised controlled trials by National Institute of Health Research Unit on Global Surgery published in The Lancet Infectious Diseases.

DOI: https://doi.org/10.1016/S1473-3099(22)00133-5

Keywords:

The Lancet Infectious Diseases, Alcoholic, chlorhexidine, skin, preparation, triclosan-coated, sutures, reduce, surgical, site, infection, systematic, review, meta-analysis, high-quality, randomised controlled trials, National Institute of Health Research Unit on Global Surgery