Preoperative bathing or showering with skin antiseptics to prevent surgical site infection

Joan Webster; Sonya Osborne

doi:10.1002/14651858.CD004985.pub5

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Figure 1

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

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Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Analysis 1.1

Comparison 1 Chlorhexidine 4% versus placebo, Outcome 1 Surgical site infection.

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Analysis 1.2

Comparison 1 Chlorhexidine 4% versus placebo, Outcome 2 Surgical site infection (high quality studies).

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Analysis 1.3

Comparison 1 Chlorhexidine 4% versus placebo, Outcome 3 Allergic reaction.

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Analysis 2.1

Comparison 2 Chlorhexidine 4% versus bar soap, Outcome 1 Surgical site infection.

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Analysis 3.1

Comparison 3 Chlorhexadine 4% versus no wash, Outcome 1 Surgical site infection.

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Analysis 4.1

Comparison 4 Chlorhexidine full wash versus partial wash, Outcome 1 Surgical site infection.

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Summary of findings for the main comparison. Preoperative showering with chlorhexidine 4% compared to placebo

pre‐operative showering with Chlorhexidine 4% compared to placebo for surgical patients
Patient or population: surgical patients Settings: Hospitals Intervention: pre‐operative showering with Chlorhexidine 4% Comparison: placebo
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	placebo	pre‐operative showering with Chlorhexidine 4%
Surgical site infection Follow‐up: 1 ‐ 6 weeks¹	Low risk population		RR 0.91 (0.8 to 1.04)	7791 (4 studies)	⊕⊕⊕⊕ high²
	30 per 1000	27 per 1000 (24 to 31)
	High risk population
	100 per 1000	91 per 1000 (80 to 104)
Allergic reaction Follow‐up: 1 ‐ 6 weeks¹	Study population		RR 0.89 (0.36 to 2.19)	3589 (2 studies)	⊕⊕⊕⊝ moderate³
	6 per 1000	5 per 1000 (2 to 13)
	Medium risk population
	3 per 1000	3 per 1000 (1 to 7)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Some studies followed patients only until hospital discharge; however, as these studies are over 20 years old, we have assumed 7 days. ² In one trial, five months into the study, the placebo solution was found to contain a microbiological agent. The solution was changed for the remaining 17 months of the trial. There was a total of over 7,000 participants included in this outcome, so we do not believe that the overall effect estimate would have been substantially altered. ³ Only 19 events were reported. All of these were from one trial.

Summary of findings for the main comparison. Preoperative showering with chlorhexidine 4% compared to placebo

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Summary of findings 2. Chlorhexidine 4% compared with bar soap

Chlorhexidine 4% compared to bar soap for Surgical patients
Patient or population: Surgical patients Settings: Intervention: Chlorhexidine 4% Comparison: bar soap
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	bar soap	Chlorhexidine 4%
Surgical site infection	Study population		RR 1.02 (0.57 to 1.84)	1443 (3 studies)	⊕⊝⊝⊝ very low^1,2,3
	136 per 1000	139 per 1000 (78 to 250)
	Medium risk population
	128 per 1000	131 per 1000 (73 to 236)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ The method of allocation was unclear in some studies and outcome assessment was not blinded. ² Heterogeneity between trials was evident; this was most probably due to the different types of surgeries and different definitions used for infection. ³ 95% confidence interval around the pooled estimate of effect includes both 1) no effect and 2) appreciable benefit or appreciable harm.

Summary of findings 2. Chlorhexidine 4% compared with bar soap

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Summary of findings 3. Chlorhexadine 4% compared with no wash

Chlorhexadine 4% compared to no wash for surgical patients
Patient or population: surgical patients Settings: Hospital Intervention: Chlorhexadine 4% Comparison: no wash
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	no wash	Chlorhexadine 4%
Surgical site infection Follow‐up: 1 ‐ 3 weeks¹	Study population		RR 0.82 (0.26 to 2.62)	1142 (3 studies)	⊕⊝⊝⊝ very low^2,3,4
	56 per 1000	46 per 1000 (15 to 147)
	Medium risk population
	46 per 1000	38 per 1000 (12 to 121)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Some studies followed patients only until hospital discharge; as the studies were over 20 years old, we have assumed this to be one week. ² A number of potential biases existed including inadequate allocation concealment and blinding. ³ Hetrogeneity between studies was evident; this was most likely due to different types of surgeries, differences in length of follow‐up, varying sample sizes and ways of defining infection. ⁴ Wide confidence intervals, low event rate.

Summary of findings 3. Chlorhexadine 4% compared with no wash

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Comparison 1. Chlorhexidine 4% versus placebo

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Surgical site infection Show forest plot	4	7791	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.80, 1.04]

2 Surgical site infection (high quality studies) Show forest plot	2	6302	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.82, 1.10]

3 Allergic reaction Show forest plot	2	3589	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.36, 2.19]

Comparison 1. Chlorhexidine 4% versus placebo

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Comparison 2. Chlorhexidine 4% versus bar soap

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Surgical site infection Show forest plot	3	1443	Risk Ratio (M‐H, Random, 95% CI)	1.02 [0.57, 1.84]

Comparison 2. Chlorhexidine 4% versus bar soap

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Comparison 3. Chlorhexadine 4% versus no wash

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Surgical site infection Show forest plot	3	1142	Risk Ratio (M‐H, Random, 95% CI)	0.82 [0.26, 2.62]

Comparison 3. Chlorhexadine 4% versus no wash

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Comparison 4. Chlorhexidine full wash versus partial wash

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Surgical site infection Show forest plot	1	1093	Risk Ratio (M‐H, Fixed, 95% CI)	0.40 [0.19, 0.85]

Comparison 4. Chlorhexidine full wash versus partial wash

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