Intracavity lavage and wound irrigation for prevention of surgical site infection

Gill Norman; Ross A Atkinson; Tanya A Smith; Ceri Rowlands; Amber D Rithalia; Emma J Crosbie; Jo C Dumville

doi:10.1002/14651858.CD012234.pub2

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Figure 1

Study flow diagram

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Figure 4

Funnel plot of comparison 1: all irrigation versus no irrigation, outcome: 1.1 surgical site infection

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Figure 5

Funnel plot of comparison 2: antibacterial versus non‐antibacterial irrigation, outcome: 2.1 surgical site infection

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Analysis 1.1

Comparison 1 All irrigation versus no irrigation, Outcome 1 SSI.

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Analysis 1.2

Comparison 1 All irrigation versus no irrigation, Outcome 2 Adverse events.

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Analysis 1.3

Comparison 1 All irrigation versus no irrigation, Outcome 3 Abscess.

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Analysis 1.4

Comparison 1 All irrigation versus no irrigation, Outcome 4 Mortality.

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Analysis 1.5

Comparison 1 All irrigation versus no irrigation, Outcome 5 Hospital stay.

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Analysis 1.6

Comparison 1 All irrigation versus no irrigation, Outcome 6 Return to theatre (reoperation).

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Analysis 1.7

Comparison 1 All irrigation versus no irrigation, Outcome 7 Readmission to hospital.

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Analysis 2.1

Comparison 2 Antibacterial irrigation versus non‐antibacterial irrigation, Outcome 1 SSI.

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Analysis 2.2

Comparison 2 Antibacterial irrigation versus non‐antibacterial irrigation, Outcome 2 Wound dehiscence.

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Analysis 2.3

Comparison 2 Antibacterial irrigation versus non‐antibacterial irrigation, Outcome 3 Adverse events.

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Analysis 2.4

Comparison 2 Antibacterial irrigation versus non‐antibacterial irrigation, Outcome 4 Abscess.

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Analysis 2.5

Comparison 2 Antibacterial irrigation versus non‐antibacterial irrigation, Outcome 5 Mortality.

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Analysis 2.6

Comparison 2 Antibacterial irrigation versus non‐antibacterial irrigation, Outcome 6 Hospital stay.

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Analysis 2.7

Comparison 2 Antibacterial irrigation versus non‐antibacterial irrigation, Outcome 7 Return to theatre (reoperation).

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Analysis 3.1

Comparison 3 Icodextrin versus lactated Ringer's solution, Outcome 1 Mortality.

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Analysis 3.2

Comparison 3 Icodextrin versus lactated Ringer's solution, Outcome 2 Adverse events.

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Analysis 3.3

Comparison 3 Icodextrin versus lactated Ringer's solution, Outcome 3 Treatment‐related adverse events.

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Analysis 4.1

Comparison 4 Standard irrigation versus pulsatile irrigation, Outcome 1 SSI.

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Summary of findings for the main comparison. All irrigation compared with no irrigation for prevention of surgical site infection

All irrigation compared with no irrigation for prevention of surgical site infection
Patient or population: participants undergoing clean, clean‐contaminated, contaminated or dirty surgical procedures Setting: hospitals Intervention: irrigation of any type Comparison: no irrigation
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
	Risk with no irrigation	Risk with irrigation
SSI	Study population: participants undergoing clean‐contaminated, contaminated or dirty surgical procedures		RR 0.87 (0.68 to 1.11)	6106 (14 RCTs)	⊕⊕⊝⊝ Low¹	On the basis of the included studies there is no clear difference between the intervention and comparison groups in the incidence of SSI.
	98 per 1000	85 per 1000 (67 to 108)
	Risk difference: 13 fewer SSI occur per 1000 with irrigation than with no irrigation (31 fewer to 10 more)
Wound dehiscence	Study population: participants undergoing clean procedures (split‐body design)		RR 1.17 (0.44 to 3.06)	30 (1 RCT)	⊕⊕⊝⊝ Low²	There is no clear difference between surgical sites treated with irrigation and those in the control condition. This is based on a single split‐body design with small numbers of participants.
	200 per 1000	234 per 1000 (88 to 612)
	Risk difference: 34 more wound dehiscences occur per 1000 with irrigation than with no irrigation (112 fewer to 412 more)
Adverse events	Study population: participants undergoing clean‐contaminated or dirty surgical procedures		RR 1.05 (0.76 to 1.44)	403 (3 RCTs)	⊕⊕⊝⊝ Low³	There is no clear difference in the number of adverse events between participants treated with irrigation and those in the control condition.
	247 per 1000	259 per 1000 (187 to 355)
	Risk difference: 12 more per 1000 (from 59 fewer to 108 more)
Adverse events: abscess formation	Study population: participants undergoing dirty or contaminated surgical procedures		RR 0.91 (0.54 to 1.54)	331 (3 RCTs)	⊕⊕⊕⊝ Moderate⁴	There is no clear difference in the number of adverse events between participants treated with irrigation and those in the control condition.
	149 per 1000	136 per 1000
	Risk difference: 13 fewer per 1000 (from 69 fewer to 80 more)
*The risk in the intervention group (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; SSI: surgical site infection
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹Downgraded once for risk of bias in one or more domains other than performance bias in studies that account for more than 50% of the analysis weight; downgraded once for imprecision because confidence intervals include both benefit and harm. Publication bias could not be clearly ruled out but was not additionally downgraded for as the evidence was unclear. ²Downgraded twice for imprecision because confidence intervals are wide and fragile and include the possibility of both benefit and harm. There is also uncertainty as to whether the analysis was correctly adjusted for a split‐body design. ³Downgraded once for imprecision and once for high risk of detection bias in the study with 77% of the analysis weight. ⁴Downgraded once for imprecision.

Summary of findings for the main comparison. All irrigation compared with no irrigation for prevention of surgical site infection

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Summary of findings 2. Irrigation with antibacterial solution compared with irrigation with non‐antibacterial solution for prevention of surgical site infection

Irrigation with antibacterial compared with non‐antibacterial solution for prevention of surgical site infection
Patient or population: participants undergoing clean, clean‐contaminated, contaminated or dirty surgical procedures Setting: hospitals Intervention: irrigation with antibacterial solution (antiseptic or antibiotic) Comparison: irrigation with solution without antibacterial properties
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
	Risk with non‐antibacterial	Risk with antibacterial
SSI	Study population: participants undergoing clean‐contaminated, contaminated or dirty surgical procedures		RR 0.57 (0.44 to 0.75)	5141 (30 RCTs)	⊕⊕⊝⊝ Low¹	The included studies found that there may be fewer SSIs in participants treated with antibacterial irrigation compared with those treated with non‐antibacterial irrigation.
	140 per 1000	80 per 1000 (62 to 105)
	Risk difference: 60 fewer SSI occur per 1000 with antibacterial irrigation than with non‐antibacterial (78 to 35 fewer)
Wound dehiscence	Study population: participants undergoing clean or clean‐contaminated surgical procedures		RR 1.26 (0.65 to 2.45)	660 (3 RCTs)	⊕⊝⊝⊝ Very low²	The effect of antibacterial compared with non‐antibacterial irrigation on wound dehiscence is very uncertain.
	45 per 1000	56 per 1000 (29 to 109)
	Risk difference: 11 more wound dehiscences occur per 1000 with antibacterial irrigation than with non‐antibacterial (16 fewer to 64 more)
Adverse events	Study population: participants undergoing clean, clean‐contaminated or dirty surgical procedures		RR 0.55 (0.22 to 1.34)	178 (3 RCTs)	⊕⊕⊝⊝ Low³	It is unclear whether there is a difference in the incidence of all adverse events between participants treated with antibacterial irrigation compared with those treated with non‐antibacterial irrigation.
	67 per 1000	37 per 1000 (15 to 90)
	Risk difference: 30 fewer adverse events occur per 1000 with antibacterial irrigation than with non‐antibacterial (53 fewer to 23 more)
Adverse events: abscess formation	Study population: participants undergoing clean‐contaminated, contaminated or dirty surgical procedures		RR 0.82 (0.42 to 1.62)	1309 (9 RCTs)	⊕⊝⊝⊝ Very low⁴	The effect of antibacterial compared with non‐antibacterial irrigation on abscess formation is very uncertain
	31 per 1000	25 per 1000 (13 to 50)
	Risk difference: 6 fewer abscesses form per 1000 with antibacterial irrigation than with non‐antibacterial (18 fewer to 19 more)
*The risk in the intervention group (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; SSI: surgical site infection
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹Downgraded once for risk of bias due to high risk of bias for at least one domain in studies contributing over 50% of the weight and once for probable publication bias. We did not further downgrade for inconsistency because the inconsistency present appeared due to the difference between larger and smaller studies and hence was accounted for by the downgrade for potential publication bias. ²Downgraded once for inconsistency due to study with highest weight showing effect in opposite direction to other included studies, once for high risk of bias and twice for imprecision, due to confidence intervals being wide and fragile, and including both benefit and harm. ³Downgraded twice for imprecision due to wide and fragile confidence intervals, which included both benefit and harm, as well as no difference between interventions. ⁴Downgraded once for risk of bias in studies with the majority of the weight and twice for imprecision due to wide and fragile confidence intervals, which included both benefit and harm, as well as no difference between interventions.

Summary of findings 2. Irrigation with antibacterial solution compared with irrigation with non‐antibacterial solution for prevention of surgical site infection

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Summary of findings 3. Standard irrigation compared with pulsatile irrigation for prevention of surgical site infection

Standard irrigation compared with pulsatile irrigation for prevention of surgical site infection
Patient or population: participants undergoing clean, clean‐contaminated, contaminated or dirty surgical procedures Setting: hospital Intervention: standard irrigation with saline Comparison: pulsatile irrigation with saline
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
	Risk with standard irrigation	Risk with pulsatile irrigation
SSI	Study population: participants undergoing clean or clean‐contaminated surgical procedures		RR 0.34 (0.19 to 0.62)	484 (2 RCTs)	⊕⊕⊝⊝ Low¹	Included studies show that there may be fewer SSIs in participants treated with pulsatile saline irrigation compared with standard techniques; the evidence is low certainty due to high risk of biases in the study contributing the majority of participants and weight to the analysis.
	165 per 1000	56 per 1000 (31 to 103)
	Risk difference: 109 fewer SSI occur per 1000 with pulsatile irrigation than with standard (134 fewer to 62 fewer)
Wound dehiscence	Study population: participants undergoing clean‐contaminated surgical procedures		RR 0.31 (0.01 to 7.55)	128 (1 RCT)	⊕⊕⊝⊝ Low²	There is no clear difference in the incidence of wound dehiscence between groups treated with standard or pulsatile techniques of saline irrigation. Confidence intervals include both benefit and harm and are wide and fragile.
	16 per 1000	5 per 1000 (0 to 122)
	Risk difference: 11 fewer wound dehiscences occur per 1000 with pulsatile irrigation than with standard (16 fewer to 106 more)
Adverse events	Study population: participants undergoing clean‐contaminated surgical procedures		RR 1.31 (0.87 to 1.97)	128 (1 RCT)	⊕⊕⊝⊝ Low²	There is no clear difference in the incidence of adverse events between groups treated with standard or pulsatile techniques of saline irrigation. Confidence intervals include both benefit and harm and are wide and fragile.
	486 per 1000	371 per 1000
	Risk difference: 115 fewer adverse events occur per 1000 with pulsatile irrigation (360 fewer to 48 more)
Adverse events: abscess formation	There were no reported data on abscess formation
*The risk in the intervention group (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; SSI: surgical site infection
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
¹Downgraded twice for high risk of bias in multiple domains for study contributing most of the weight. ²Downgraded twice for imprecision due to wide and fragile confidence intervals, which include both benefit and harm.

Summary of findings 3. Standard irrigation compared with pulsatile irrigation for prevention of surgical site infection

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Table 1. Summary of GRADE assessments for comparisons with limited data

Comparison	Surgery	Participants (studies)	SSI RR (95% CI)	GRADE judgement: certainty of the evidence	Reason for downgrading
Icodextrin vs Ringer's solution	Clean‐contaminated (uterine)	426 (1 RCT) Trew 2011	2.89 (0.30 to 27.56)	Low	Downgraded twice for very serious imprecision
Povidone iodine vs Dermacyn	Clean (cardiac)	190 (1 RCT) Mohd 2010	2.80 (1.05 to 7.47)	Low	Downgraded once for high risk of bias and once for imprecision
Povidone iodine vs chlorhexidine	Dirty (peritonitis)	53 (1 RCT)¹ Vallance 1985	1.13 (0.78 to 1.63)	Very low	Downgraded twice for high risk of bias in multiple domains and once for imprecision
Cepharin vs cefoxitin	Clean‐contaminated (caesarean section)	132 (1 RCT)¹ Levin 1983	Not estimable (no events in either group)	No assessment possible	‐
Epicillin vs lincomycin	Contaminated (appendicitis)	162 (1 RCT)¹ Marti 1979	Not estimable (data not reported for groups)	No assessment possible	‐
Gentamicin vs clindamycin	Clean (breast)	51 (1 RCT)¹ Oller 2015	Not estimable (no events in either group)	No assessment possible	‐
Cephapirin versus moxalactam	Clean‐contaminated (caesarean section)	149 (total 360) (1 RCT)² Dashow 1986	1.69 (0.29 to 9.84)	Low	Downgraded twice for very serious imprecision
Cephapirin versus cefamandole	Clean‐contaminated (caesarean section)	134 (total 360) (1 RCT)² Dashow 1986	1.37 (0.24 to 7.95)	Low	Downgraded twice for very serious imprecision
Cephapirin versus ampicillin	Clean‐contaminated (caesarean section)	140 (total 360) (1 RCT)² Dashow 1986	7.00 (0.37 to 133.06)	Low	Downgraded twice for very serious imprecision
Cefamandole versus moxalactam	Clean‐contaminated (caesarean section)	143 (total 360) (1 RCT)² Dashow 1986	1.23 (0.18 to 8.52)	Low	Downgraded twice for very serious imprecision
Cefamandole versus ampicillin	Clean‐contaminated (caesarean section)	134 (total 360) (1 RCT)² Dashow 1986	5.46 (0.27 to 111.65)	Low	Downgraded twice for very serious imprecision
Moxalactam versus ampicillin	Clean‐contaminated (caesarean section)	149 (total 360) (1 RCT)² Dashow 1986	4.44 (0.22 to 90.88)	Low	Downgraded twice for very serious imprecision
Cefazolin versus cefamandole	Clean‐contaminated (caesarean section)	207 (1 RCT) Peterson 1990	4.58 (0.22 to 93.38)	Low	Downgraded twice for very serious imprecision
¹Three‐armed trial; not all participants relevant to this comparison. ²Five‐armed trial; not all participants relevant to this comparison. CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio; SSI: surgical site infection

Table 1. Summary of GRADE assessments for comparisons with limited data

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Table 2. Summary of primary outcome data: surgical site infection (SSI) and wound dehiscence

Study	Surgical category/type	Participants	Interventions	Definition of SSI	Follow‐up	SSI events	Risk ratio (95% CI)	Wound dehiscence risk ratio (95% CI)
Comparison of irrigation compared with no irrigation
Bourgeois 1985	Clean‐contaminated Caeasarean section	223	Antibiotic irrigation/saline irrigation No irrigation	NR
Buanes 1991	Dirty Perforated appendicitis	35	Saline postoperative irrigation No postoperative irrigation	Temperature > 38.5C for > 24 h plus localised, drainage‐confirmed accumulation of fluid	6 weeks	9/39 2/44	5.08 (1.17 to 22.09) Not included in pooled analysis ‐ intervention too different	NR
Cervantes‐Sanchez 2000	Contaminated Appendicitis	283	Saline irrigation No irrigation	Collection of pus or positive bacteriologic culture from wound discharge	4 weeks	11/127 39/156	0.25 (0.19 to 0.65)	NR
Cho 2004	Clean‐contaminated Gastrectomy	34	Saline irrigation No irrigation	Centers for Disease Control and Prevention criteria	2 weeks	1/17 3/17	0.33 (0.04 to 2.89)	NR
De Jong 1982	Mixed Abdominal/inguinal hernia	592	Antiseptic irrigation No irrigation	Purulent discharge seen within 4 weeks or culturing of fluid from the wound was positive	4 weeks	36/279 39/279	0.92 (0.61 to 1.41)	NR
Elliott 1986¹	Clean‐contaminated Caeasarean section	158	Antibiotic irrigation No irrigation	NR	6 weeks	0/80 1/78	0.33 (0.01 to 7.86)	NR
Gungorduk 2010	Clean‐contaminated Caeasarean section	520	Saline irrigation No irrigation	Wound drained purulent material/serosanguineous fluid plus induration, warmth and tenderness	6 weeks	17/260 19/260	0.89 (0.48 to 1.68)	NR
Harrigill 2003	Clean‐contaminated Caeasarean section	196	Saline irrigation No irrigation	Undue tenderness, erythema, discharge, or separation of the incision accompanying fever	NR	1/97 2/99	0.51 (0.05 to 5.54)	NR
Mahomed 2016	Clean‐contaminated Caeasarean section	3270	Antiseptic irrigation No irrigation	Abscess or wound draining pus or sero‐sanguinous fluid, or redness, induration, warmth and tenderness or general practitioner prescribed antibiotics	4 weeks	144/1520 147/1507	0.97 (0.78 to 1.21)	NR
Oleson 1980	Dirty Perforated appendicitis	33	Antibiotic irrigation/saline irrigation No irrigation	NR	Mean 8 d (5‐16)	5/20 4/10	0.63 (0.21 to 1.83)	NR
Ozlem 2015	Dirty Perforated appendicitis	14	Saline irrigation No irrigation	NR	NR	2/7 0/7	5.00 (0.28 to 88.53)	NR
Platt 2003	Clean Breast	30	Saline irrigation No irrigation	Wound discharge, invasive infection	8 weeks	0/30 0/30	Not estimable Not included in pooled analysis ‐ split‐body design	1.15 (0.44 to 3.06)
Schein 1990	Dirty Abdominal infection	87	Saline irrigation/ Antibiotic irrigation No irrigation	Discharge of pus	2 weeks	10/58 6/29	0.83 (0.34 to 2.07)	NR
Snow 2016	Mixed Appendix	83	Saline irrigation No irrigation	NR	6 weeks	0/40 0/41	Not estimable	NR
St Peter 2012	Dirty Appendix	220	Saline irrigation No irrigation	NR				NR
Tanaka 2015	Clean‐contaminated Liver resection	193	Saline irrigation No irrigation	Incisional or organ/space infection Incisional infection: clinically apparent cellulitis, induration, or purulent discharge. Organ/space infection: radiologic evidence of fluid collection necessitating drainage or antibiotic therapy	4 weeks	21/96 13/97	1.63 (0.87 to 3.07)	NR
Tanphiphat 1978	Contaminated Appendix	374	Antiseptic irrigation No irrigation	Collection of pus that emptied itself spontaneously or after incision	2 weeks	13/128 12/124	1.05 (0.50 to 2.21)	NR
Temizkan 2016	Clean‐contaminated Caeasarean section	430	Saline irrigation No irrigation	Partial or total separation of incision, plus purulent or serous wound discharge with induration, warmth, and tenderness	NR	1/215 2/215	0.50 (0.05 to 5.47)	NR
Tighe 1982	Contaminated Appendix	131	Antiseptic irrigation No irrigation Non‐antibacterial irrigation	Prescence of pus either spontaneously or on probing. All infections confirmed bacteriologically	NR	17/131 Results are not given by intervention group; no effect estimate calculable		NR
Viney 2012	Clean‐contaminated Caeasarean section	236	Saline irrigation No irrigation	NR				NR
Comparison of antibacterial irrigationwith non‐antibacterial irrigation
Al‐Shehri 1994	Mixed Appendicits	254	Antibiotic Saline	Purulent discharge in wound, regardless of culture results, or occurrence of serous discharge with positive culture	1 month	1/120 7/134	0.16 (0.02 to 1.28)	NR
Baker 1994	Clean‐contaminated Colorectal	330	Antiseptic Saline	Spontaneous or incisional discharge from wound, pus or serous fluid, with infective organism identified on culture	6 weeks	17/150 17/150	1.00 (0.53 to 1.88)	NR
Bourgeois 1985	Clean‐contaminated Caeasarean section	223	Antibiotic irrigation Saline irrigation (No irrigation)	NR				NR
Browne 1978	Dirty Peritonitis	35	Antiseptic irrigation Saline irrigation	NR				NR
Carl 2000	Clean‐contaminated	40	Antibiotic Saline	NR	4‐6 weeks	1/20 1/20	1.00 (0.07 to 14.90)	NR
Case 1987	Clean Breast	54	Antibiotic Saline	NR	6 weeks	0/23 1/30	0.43 (0.02 to 10.11)	0.43 (0.02 to 10.11)
Chang 2006	Clean Spinal	244	Antiseptic Saline	Superficial (above lumbosacral fascia) or deep (below lumbosacral fascia), early onset (within 2 weeks) or late onset (otherwise). Deep infections confirmed by laboratory parameters: erythrocyte sedimentation rate, level of C‐reactive protein, and positive biopsy culture	2 weeks, long‐term follow‐up to 19 months	0/120 6/124	0.08 (0.00 to 1.40) Only included in sensitivity analysis due to suspected data overlap with Cheng 2005	0.52 (0.05 to 5.62)
Cheng 2005	Clean Spinal	417	Antiseptic Saline	Unusual pain, tenderness, erythema, induration, fever, or wound drainage; investigated with erythrocyte sedimentation rate, C‐reactive protein, and bacteriological cultures from operative site or blood	2 weeks', long‐term follow‐up to mean 15.5 months	0/208 7/206	0.07 (0.00 to 1.015)	NR
Dashow 1986	Clean‐contaminated Caesarean	360	4 antibiotics Saline	Wound breakdown with positive culture or presence of cellulitis	NR	7/283 3/77	0.63 (0.17 to 2.40)	NR
Greig 1987	Mixed Colorectal	129	Antibiotic Saline	Discharge of pus from the wound "wound sepsis"	1 month	15/64 18/65	0.85 (0.47 to 1.53)	NR
Halsall 1981	Mixed Appendicitis	192	Antiseptic Saline	Wound discharging pus	4 weeks	18/99 29/93	0.58 (0.35 to 0.98)	NR
Kokavec 2008	Clean Orthopaedic	162	Antiseptic Saline	Positive bacteriological examination	6 weeks then mean 7.8 (2‐4) months	0/89 2/73	0.16 (0.01 to 3.37)	NR
Kubota 1999	Dirty Perforated appendicitis	16	Antiseptic Saline	NR	NR	1/8 4/8	0.25 (0.04 to 1.77)	NR
Kubota 2015	Dirty Perforated appendicitis	44	Antiseptic Saline	Infection at operation site, up to 30 d after surgery; confirmed causative pathogen(s) identical to those of appendicitis	30 d	0/24 4/20	0.09 (0.01 to 1.64)	NR
Levin 1983	Clean‐contaminated Caeasarean section	128	2 Antibiotics Saline	Purulent wound discharge with or without wound separation	8 weeks	0/85 3/43	0.07 (0.00 to 1.38)	NR
Lord 1983	Mixed Gastrointestinal/colorectal	200	Antibiotic Saline	NR	NR	3/100 9/100	0.33 (0.09 to 1.20)	NR
Magann 1993	Clean‐contaminated Caeasarean section	100	Antibiotic Saline	Hyperemic skin incision and fluctuant mass which when opened contained purulent material	NR	2/50 4/50	0.50 (0.10 to 0.50)	NR
Marti 1979	Contaminated Appendicitis	162	2 Antibiotics Saline	Septic complications with spontaneous or induced purulent discharge	4 d; longer follow‐up unclear	Results are not given by intervention group; no effect estimate calculable		NR
Mirsharifi 2008	Clean‐contaminated Cholecystectomy	102	Antibiotic Saline	Erythema, induration, tenderness, warmth, suppurative discharge	6 weeks	6/51 6/51	1.00 (0.35 to 2.89)	NR
Moylan 1968	Clean‐contaminated Abdominal	260	Antibiotic Saline	NR, wounds were monitored with daily photographs	Until discharge	12/124 23/116	0.49 (0.25 to 0.94)	NR
Neeff 2016	Clean‐contaminated Colorectal	197	Antiseptic Non‐antibacterial	NR	NR	19/101 22/96	0.82 (0.48 to 1.42)	NR
Oestreicher 1989	Mixed General surgery	540	Antiseptic Saline	NR	NR	16/267 15/273	1.09 (0.55 to 2.16)	NR
Oleson 1980	Dirty Perforated appendicitis	33	Antibiotic irrigation Saline irrigation No irrigation	NR	mean 8 d (5‐16)	3/10 2/10	1.50 (0.32 to 3.09)	NR
Oller 2015	Clean Breast	51	2 Antibiotics Saline	NR	NR	0/34 0/17	Not estimable	NR
Rambo 1972	Dirty Peritonitis	94	Antibiotic Saline	NR	NR	11/44 13/50	0.96 (0.48 to 1.92)	NR
Ruiz‐Tovar 2011	Clean‐contaminated Colorectal	128	Antibiotic Saline	NR	NR	6/64 27/64	0.22 (0.10 to 0.50)	NR
Ruiz‐Tovar 2012	Clean‐contaminated Colorectal	108	Antibiotic Saline	Presence of purulent discharge, confirmed with microbiologic culture	30 d	2/52 7/51	0.29 (0.06 to 1.31)	NR
Ruiz‐Tovar 2013	Clean Breast	40	Antibiotic Saline	NR	2 weeks	0/20 0/20	Not estimable	NR
Ruiz‐Tovar 2016a	Clean‐contaminated Colorectal	106	Antibiotic Saline	NR	30 d	2/52 7/52	0.20 (0.05 to 1.87)	NR
Ruiz‐Tovar 2016b	Clean‐contaminated Bariatric surgery	80	Antibiotic Saline	NR	30 d after discharge	NR		NR
Schein 1990	Dirty Abdominal infection	87	Antibiotic Saline (No irrigation)	Discharge of pus	2 weeks	5/29 5/29 (6/29)	1.00 (0.32 to 3.09)	NR
Silverman 1986	Mixed Gastrointestinal/colorectal	159	Antibiotic Saline	Discharge of pus	6 weeks	10/85 24/74	0.36 (0.19 to 0.71)	NR
Sindelar 1979	Mixed General Surgery	500	Antiseptic Saline	Pus discharged within 12 weeks or serous drainage from questionable wounds plus positive culture	12 weeks	7/242 39/258	0.19 (0.09 to 0.42)	NR
Takesue 2011	Clean‐contaminated Colorectal	400	Antiseptic Saline	National Nosocomial Infections Surveillance system	30 d (total 3 months)	19/180 29/183	0.67 (0.39 to 1.14)	1.44 (0.71 to 2.93)
Tighe 1982	Contaminated Appendix	131	Antiseptic irrigation Non‐antibacterial irrigation (No irrigation)	Prescence of pus either spontaneously or on probing. All infections confirmed bacteriologically	NR	7/131 Results are not given by intervention group; No effect estimate calculable		NR
Vallance 1985	Dirty Peritonitis	53	2 Antiseptics Saline	Pus in wound, sero‐sanguinous discharge, Inflammation or induration	1 month	23/29 10/16	0.61 (0.40 to 0.92)	NR
Comparisons of two different agents in the same class
Brown 2007	Clean‐contaminated Uterine	449	2 non‐antibacterials Icodextrin Ringer's solution	NR clearly; data on infection ambiguous				NR
Dashow 1986	Clean‐contaminated Caesarean	360	4 antibiotics (Saline) Cephapirin Cefamandole Moxalactam Ampicillin	Wound breakdown with positive culture or presence of cellulitis	NR	3/70 2/64 2/79 0/70	Cephapirin: cefamandole 1.37 (0.24 to 7.95) Cephapirin: moxalactam 1.69 (0.29 to 9.84) Cephapirin: ampicillin 7.00 (0.37 to 133.06) Cefamandole: moxalactam 1.23 (0.18 to 8.52) Cefamandole: ampicillin 5.46 (0.27 to 111.65) Moxalactam: ampicillin 4.44 (0.22 to 90.88)	NR
Levin 1983;	Clean‐contaminated Caesarean	128	2 antibiotics (Saline) Cephapirin cefoxitin	Purulent wound discharge with or without wound separation	8 weeks	0/44 0/41	Not estimable; zero events	NR
Marti 1979	Contaminated Appendicitis	162	2 antibiotics (Saline) Epicillin Lincomycin	Septic complications with spontaneous or induced purulent discharge	4 d; longer follow‐up unclear	Not estimable; number of participants and events per group not reported		NR
Mohd 2010;	Clean Cardiac	190	2 antiseptics Povidone iodine Dermacyn	Centers for Disease Control and Prevention criteria	6 weeks	14/90 5/88	2.80 (1.05 to 7.47)	NR
Oller 2015	Clean Breast	51	2 antibiotics Clindamycin Gentamicin	NR	NR	0/17 0/17	Not estimable; zero events	NR
Peterson 1990	Clean‐contaminated Caesarean	207 113 in relevant groups	2 antibiotics Cefazolin Cefamandole	Presence of cellulitis and/or purulent exudate	> 2 weeks	2/59 0/54	4.58 (0.22 to 93.38)	NR
Shimizu 2011	Clean Brain	20	2 non‐antibacterials Saline Artificial CSF	NR				NR
Trew 2011	Clean‐contaminated Uterine	498	2 non‐antibacterials Icodextrin Ringer's solution	NR	4‐16 weeks	3/217 1/209	2.89 (0.30 to 27.56)	NR
Vallance 1985	Dirty Peritonitis	53	2 antiseptics (Saline) Povidone iodine Chlorhexidine	Pus in wound, sero‐sanguinous discharge, Inflammation or induration	1 month	4/16 4/13	1.13 (95% CI 0.78 to 1.63)	NR
Comparison of pulsatile versus standard irrigation delivery
Hargrove 2006	Clean Orthopaedic	356	Pulsatile saline Standard saline	Nosocomial Infection National Surveillance Survey	30 days or discharge	9/164 30/192	0.35 (0.17 to 0.72)	NR
Nikfarjam 2014	Clean‐contaminated Abdominal	137	Pulsatile saline Standard saline	Purulent drainage, with or without laboratory confirmation; organisms isolated from aseptically obtained culture of fluid or tissue; at least 1 of the following: pain or tenderness, localised swelling, redness, or heat and incision is deliberately opened by surgeon, unless incision is culture‐negative; diagnosis of superficial incisional SSI by surgeon or attending physician	1 month	4/66 12/62	0.31 (0.11 to 0.92)	0.31 (0.01 to 7.55)
¹Elliott is a 4‐armed trial with a factorial design, arms with and without intravenous antibiotics are combined CI: confidence interval; CSF: cerebrospinal fluid; NR: not reported; RR: risk ratio

Table 2. Summary of primary outcome data: surgical site infection (SSI) and wound dehiscence

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Table 3. Summary of subgroup analyses

Comparison	Subgroup basis	Pre‐specified or exploratory	Subgroups used	Subgroup results RR (95% CI)	I² & Chi² subgroup differences	I² & Chi² overall
Irrigation vs no irrigation	Surgical classification	Pre‐specified	Clean‐contaminated Contaminated/Dirty/Mixed	1.00 (0.82, 1.21) 0.74 (0.47 to 1.16)	I² = 29.1%. Chi² = 1.41	I² = 28% Chi² = 16.58
Irrigation vs no irrigation	Type of irrigation	Exploratory	Non‐antibacterial Antiseptic Antibiotic	0.80 (0.46 to 1.41) 0.97 (0.81 to 1.17) 0.92 (0.42 to 1.99)	I² = 0% Chi² = 0.39	I² = 28% Chi² = 16.58
Antibacterial vs non‐antibacterial	Surgical classification	Pre‐specified	Clean Clean‐contaminated Contaminated/Dirty/Mixed	0.17 (0.03 to 0.89) 0.57 (0.40 to 0.79) 0.61 (0.40 to 0.92)	I²= 9.7% Chi² = 2.21	I² = 53% Chi² = 56.94
Antibacterial vs non‐antibacterial	Type of irrigation	Exploratory	Antiseptic Antibiotic	0.63 (0.40 to 0.95) 0.57 (0.44 to 0.75)	I²= 0% Chi² = 0.38	I² = 53% Chi² = 56.94
CI: confidence interval; RR: risk ratio

Table 3. Summary of subgroup analyses

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Table 4. Summary of secondary outcomes

Study Surgical category/type	Participants (N) Follow‐up	Interventions	Mortality RR (95% CI)	Systemic antibiotics RR (95% CI)	Antibiotic resistance RR (95% CI)	Adverse events RR (95% CI)	Reoperation RR (95% CI)	Readmission RR (95% CI)	Length of stay (days (95% CI))
Irrigation compared with no irrigation
Bourgeois 1985 Clean‐contaminated Caeasarean section	223 6 weeks	Antibiotic irrigation/Saline irrigation No irrigation	‐	‐	‐	Specific complication only	‐	‐	Difference in means ‐0.46 (‐0.64 to ‐0.29)
Buanes 1991 Dirty Perforated appendicitis	85 6 weeks	Saline postoperative irrigation No postoperative irrigation	‐	‐	‐	‐	‐	‐	Medians 5 (3‐11) vs 5 (4‐12)
Cervantes‐Sanchez 2000 Contaminated Appendicitis	283 4 weeks	Saline irrigation No irrigation	‐	‐	‐	No group data	‐	‐	‐
Cho 2004 Clean‐contaminated Gastrectomy	34 2 weeks (primary outcome)	Saline irrigation No irrigation	No secondary outcomes were reported
De Jong 1982 Mixed Abdominal/inguinal hernia	592 4 weeks (primary outcome)	Antiseptic irrigation No irrigation	No secondary outcomes were reported
Elliott 1986¹ Clean‐contaminated Caeasarean section	158 6 weeks	Antibiotic irrigation No irrigation	‐	‐	‐	Specific complication only	‐	‐	Difference in means ‐0.20 (‐0.57 to 0.17)
Gungorduk 2010 Clean‐contaminated Caeasarean section	520 6 weeks	Saline irrigation No irrigation	‐	‐	‐	‐	‐	‐	Difference in means 0.01 (‐0.03 to 0.05)
Harrigill 2003 Clean‐contaminated Caeasarean section	196 NR	Saline irrigation No irrigation	‐	‐	‐	Overall RR 1.10 (0.55 to 2.22)	‐	‐	Difference in means 0.10 (‐0.17 to 0.37)
Mahomed 2016 Clean‐contaminated Caeasarean section	3270 4 weeks	Antiseptic irrigation No irrigation	‐	‐	‐	‐	RR 0.77 (0.29 to 2.07)	RR 1.29 (0.81 to 2.06)	‐
Oleson 1980 Dirty Perforated appendicitis	33 mean 8 days (5‐16)	Antibiotic irrigation/Saline irrigation No irrigation	‐	‐	‐	Abscess RR 0.17 (0.01 to 3.94)	‐	‐	Medians 14 (8‐22) vs 13 (9‐22)
Ozlem 2015 Dirty Perforated appendicitis	14 NR	Saline irrigation No irrigation	‐	‐	‐	Overall RR 1.00 (0.08 to 13.02) Abscess but no group data	‐	‐	‐
Platt 2003 Clean Breast	30 8 weeks	Saline irrigation No irrigation	‐	‐	‐	‐	‐	‐	‐
Schein 1990 Dirty Abdominal infection	87 2 weeks	Saline irrigation Antibiotic irrigation No irrigation	RR 0.75 (0.30 to 1.90)	‐	‐	‐	‐	‐	Difference in means not estimable 11.5 vs 13
Snow 2016 Mixed Appendix	83 6 weeks	Saline irrigation No irrigation	‐	‐	‐	Abscess RR 1.02 (0.15 to 6.93)	‐	‐	Medians 2.0 (1‐3) vs 2.0 (1‐2.25)
St Peter 2012 Dirty Appendix	220 2‐4 weeks	Saline irrigation No irrigation	‐	‐	‐	Abscess RR 0.95 (0.55 to 1.65)	RR 0.33 (0.01 to 8.09)	RR 0.14 (0.01 to 2.73)	Difference in means ‐0.10 (‐0.85 to 0.65)
Tanaka 2015 Clean‐contaminated Liver resection	193 4 weeks	Saline irrigation No irrigation	RR 2.02 (0.36 to 2.04)	‐	‐	Overall RR 1.04 (0.72 to 1.49)	‐	‐	Difference in means 0.00 (‐3.74 to 3.74)
Tanphiphat 1978 Contaminated Appendix	374 2 weeks	Antiseptic irrigation No irrigation	No secondary outcomes were reported
Temizkan 2016 Clean‐contaminated Caeasarean section	430 NR	Saline irrigation No irrigation	No secondary outcomes were reported
Tighe 1982 Contaminated Appendix	131 NR	Antiseptic irrigation No irrigation Non‐antibacterial irrigation	‐	53/131 participants "distributed evenly across the groups"	‐	‐	‐	‐	No group data
Viney 2012 Clean‐contaminated Caeasarean section	236 NR	Saline irrigation No irrigation	‐	‐	‐	‐	‐	‐	Median discharge day: 3 in both groups
Antibacterial irrigation vs non‐antibacterial irrigation
Al‐Shehri 1994 Mixed Appendicits	254 1 month	Antibiotic Saline	‐	‐	‐	Abscess RR not estimable 0 events			No group data
Baker 1994 Clean‐contaminated Colorectal	330 6 weeks	Antiseptic Saline	RR 1.00 (0.25 to 3.92)	‐	‐	Abscess RR 2.0 (0.18 to 21.82)			No group data
Bourgeois 1985 Clean‐contaminated Caeasarean section	223 6 weeks	Antibiotic irrigation Saline irrigation (No irrigation)	‐	‐	‐	Specific complication only	‐	‐	Difference in means ‐1.08 (‐1.25 to ‐0.92)
Browne 1978 Dirty Peritonitis	35 NR	Antiseptic irrigation Saline irrigation	RR 7.39 (0.41 to 133.24)	‐	‐	‐			‐
Carl 2000 Clean‐contaminated Caeasarean section	40 4‐6 weeks	Antibiotic Saline	‐	‐	‐	‐			‐
Case 1987 Clean Breast	54 6 weeks	Antibiotic Saline	‐	‐	‐	‐			‐
Chang 2006 Clean Spinal	244 2 weeks, long‐term follow‐up to 19 months	Antiseptic Saline	‐	All 6 participants with SSI received these; all in saline group	5/6 infections positive for MRSA	‐			‐
Cheng 2005 Clean Spinal	417 2 weeks long ‐term follow ‐up to mean 15.5 months	Antiseptic Saline	‐	‐	‐	‐			‐
Dashow 1986 Clean‐contaminated Caeasarean section	360 NR	4 antibiotics Saline	‐	‐	‐	Abscess RR not estimable 0 events			‐
Greig 1987 Mixed Colorectal	129 1 month	Antibiotic Saline	No secondary outcomes were reported
Halsall 1981 Mixed Appendicitis	192 4 weeks	Antiseptic Saline	‐	‐	‐	‐			Difference in means not estimable (6.4 vs 6.6)
Kokavec 2008 Clean Orthopaedic	162 mean 7‐8 months (range 2‐14 months) (primary outcome)	Antiseptic Saline	No secondary outcomes were reported						‐
Kubota 1999 Dirty Perforated appendicitis	16 NR	Antiseptic Saline	‐	‐	‐	Abscess RR 0.33 (0.02 to 7.14)			Difference in means ‐10.60 (‐19.06 to ‐2.14)
Kubota 2015 Dirty Perforated appendicitis	44 30 days	Antiseptic Saline	‐	‐	‐	Abscess RR 0.83 (0.06 to 12.49)			Difference in means ‐0.70 (‐3.31 to 1.91)
Levin 1983 Clean‐contaminated Caeasarean section	128 8 weeks	Antibiotic Saline	‐	‐	‐	Specific complication only			Difference in means ‐0.35 (‐1.06 to 0.36)
Lord 1983 Mixed Gastrointestinal/colorectal	200 NR	Antibiotic Saline	RR 1.67 (0.41 to 6.79)	‐	Specific organisms	Specific complication only			‐
Magann 1993 Clean‐contaminated Caeasarean section	100 NR	Antibiotic Saline	‐	‐	‐	Specific complication only			‐
Marti 1979 Contaminated Appendicitis	162 4 days; longer follow‐up unclear	Antibiotic Saline	‐	‐	‐	Specific complication only			‐
Mirsharifi 2008 Clean‐contaminated Cholecystectomy	102 6 weeks	Antibiotic Saline	No secondary outcomes were reported
Moylan 1968 Clean‐contaminated Abdominal	260 Until discharge	Antibiotic Saline	‐	‐	Kanamycin resistance Kanamycin: 12/12 Saline: "over half" of 23	Specific complication only			‐
Neeff 2016 Clean‐contaminated Colorectal	197 NR	Antiseptic Saline	No secondary outcomes were reported
Oestreicher 1989 Mixed General surgery	540 NR	Antiseptic Saline	No secondary outcomes were reported						‐
Oleson 1980 Dirty Perforated appendicitis	33 Mean 8 days (5‐16	Antibiotic irrigation Saline irrigation No irrigation	‐	‐	‐	Abscess RR not estimable 0 events			Medians 13 (9‐20 13 (10‐22)
Oller 2015 Clean Breast	51 NR	Antibiotic 1/ Antibiotic 2 Saline	RR not estimable, 0 events	‐	‐	‐			Medians 3 (1‐3) 3 (1‐3)
Rambo 1972 Dirty Peritonitis	94 NR	Antibiotic Saline	RR 0.71 (0.25 to 2.01)	‐	Specific organisms	Abscess grouped with another event ‐ not estimable			‐
Ruiz‐Tovar 2011 Clean‐contaminated Colorectal	128 NR	Antibiotic Saline	No secondary outcomes were reported
Ruiz‐Tovar 2012 Clean‐contaminated Colorectal	108 30 days	Antibiotic Saline	RR 0.50 (0.05 to 5.35)	‐	‐	Abscess RR 0.14 (0.01 to 2.65)			Medians 6 (5‐32) 6.5 (5‐14)
Ruiz‐Tovar 2013 Clean Breast	40 2 weeks	Antibiotic Saline	RR not estimable, 0 events	‐	‐	Overall RR not estimable 0 events			Medians 3 (1‐3) 3 (1‐3)
Ruiz‐Tovar 2016a Clean‐contaminated Colorectal	106 30 days	Antibiotic Saline	RR 1.00 (0.06 to 15.57)	‐	‐	Specific complication only			Medians 6.5 (5‐14) 6 (5‐32)
Ruiz‐Tovar 2016b Clean‐contaminated Bariatric surgery	80 30 days	Antibiotic Saline	RR 0.33 (0.01 to 7.95)	‐	‐	Overall RR 0.50 (0.05 to 5.30)			‐
Schein 1990 Dirty Abdominal infection	87 2 weeks	Antibiotic Saline	RR 0.50 (0.14 to 1.81)	‐	‐	Overall RR 0.56 (0.21 to 1.46) Abscess RR 0.33 (0.01 to 7.86)			Difference in means not estimable 10 vs 13
Silverman 1986 Mixed Gastrointestinal/colorectal	159 6 weeks	Antibiotic Saline	‐	‐	‐	Abscess RR 0.96 (0.43 to 2.13) Specific additional complication	RR 6.10 (0.32 to 116.28)		‐
Sindelar 1979 Mixed General Surgery	500 12 weeks	Antiseptic Saline	No secondary outcomes were reported
Takesue 2011 Clean‐contaminated Colorectal	400 30 days (total 3 months)	Antiseptic Saline	‐	‐	MRSA 4/14 vs 8/24 MSSA 0/14 vs 3/24	‐			‐
Tighe 1982 Contaminated Appendix	131 NR	Antiseptic Non‐antibacterial (No irrigation)	‐	53/131 participants "distributed evenly across the groups"	‐	‐	‐	‐	No group data
Vallance 1985 Dirty Peritonitis	53 1 month	Antiseptic Saline	RR 0.61 (0.17 to 2.16)	‐	‐	‐			Difference in means ‐0.70 (‐3.32 to 1.92)
Comparisons of two different agents in the same class
Brown 2007 Clean‐contaminated Uterine	449 28‐56 days	2 non‐antibacterials Icodextrin Ringer's solution	RR not estimable ‐ 0 events	‐	‐	Total: RR 0.99 (0.96 to 1.02) Treatment‐related RR 1.42 (0.98 to 2.05) Serious RR 1.20 (0.80 to 1.78) Serious treatment‐related RR 0.71 (0.29 to 1.73)	‐	‐	‐
Dashow 1986 Clean‐contaminated Caeasarean section	360 NR	4 antibiotics (Saline) Cephapirin Cefamandole Moxalactam Ampicillin	‐	‐	‐	Abscess: no effect estimate calculable ‐ 0 events Other specific events	‐	‐	‐
Levin 1983 Clean‐contaminated Caeasarean section	128 8 weeks	2 antibiotics (Saline) Cephapirin Cefoxitin	‐	‐	‐	Specific event data only	‐	‐	Difference in means 0.10 (‐0.78 to 0.58)
Marti 1979 Contaminated Appendicitis	162 4 days; longer follow‐up unclear	2 antibiotics (Saline) Epicillin Lincomycin	‐	‐	‐	1 abscess in antibiotic groups; no group data	‐	‐	‐
Mohd 2010 Clean Cardiac	190 6 weeks	2 antiseptics Povidone iodine Dermacyn	4 deaths but no group data; group data for composite outcome with reopening of chest	‐	‐	‐	RR 8.80 (0.48 to 161.11)	‐	‐
Oller 2015 Clean Breast	51 NR	2 antibiotics Clindamycin Gentamicin	RR not estimable, 0 events	‐	‐	‐	‐	‐	Median 3 (1‐3) in each group
Peterson 1990 Clean‐contaminated Caeasarean section	207 113 in relevant groups 2 weeks + (primary outcome)	2 antibiotics Cefazolin Cefamandole	No secondary outcomes were reported
Shimizu 2011 Clean Brain	20 10 days	2 non‐antibacterials Saline Artificial CSF	‐	‐	‐	2 participants in each group, included MRI data. RR not calculated	‐	‐‐	‐
Trew 2011 Clean‐contaminated Uterine	498 4‐16 weeks	2 non‐antibacterials Icodextrin Ringer's solution	RR not estimable ‐ 0 events	‐		Total: RR 0.95 (0.73 to 1.24) Treatment‐related RR 1.16 (0.60 to 2.23)	‐	‐	‐
Vallance 1985 Dirty Peritonitis	53 1 month	2 antiseptics (Saline) Povidone iodine Chlorhexidine	RR 0.45 (0.05 to 3.90) within 4 days, no group data for later events	‐	‐	‐	‐	‐	Difference in means 3.30 (0.53 to 3.90)
Comparison of pulsatile versus standard irrigationdelivery
Hargrove 2006 Clean Orthopaedic	356 30 days or discharge	Pulsatile saline Standard saline	No group data	‐	No group data "half" SSI positive for MRSA	‐	‐	‐	‐
Nikfarjam 2014 Clean‐contaminated Abdominal	137 1 month	Pulsatile saline Standard saline	‐	No group data: 14/16 SSI treated	Qualitative data on organisms isolated	Complications, not wound infections RR 1.31 (0.87 to 1.97)	RR 0.56 (0.14 to 2.26)	RR 1.41 (0.53 to 3.73)	Median 9 (5 ‐45) 9 (4‐71)
More details of interventions can be found in Table 1 and Characteristics of included studies 1 Elliott is a four‐armed trial with a factorial design, arms with and without iv antibiotics are combined CI: confidence interval; CSF: cerebrospinal fluid; MRI: magnetic resonance imaging; MRSA: methicillin‐resistant Staphylococcus aureus; RR: risk ratio; SSI: surgical site infection

Table 4. Summary of secondary outcomes

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Comparison 1. All irrigation versus no irrigation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 SSI Show forest plot	14	6106	Risk Ratio (M‐H, Random, 95% CI)	0.87 [0.68, 1.11]

1.1 clean or clean‐contaminated	7	4801	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.82, 1.21]
1.2 contaminated or dirty	7	1305	Risk Ratio (M‐H, Random, 95% CI)	0.74 [0.47, 1.16]
2 Adverse events Show forest plot	3	403	Risk Ratio (M‐H, Random, 95% CI)	1.05 [0.76, 1.44]

3 Abscess Show forest plot	3	331	Risk Ratio (M‐H, Random, 95% CI)	0.91 [0.54, 1.54]

4 Mortality Show forest plot	2	280	Risk Ratio (M‐H, Random, 95% CI)	0.86 [0.36, 2.04]

5 Hospital stay Show forest plot	7	1597	Mean Difference (IV, Random, 95% CI)	‐0.13 [‐0.38, 0.12]

6 Return to theatre (reoperation) Show forest plot	2	3247	Risk Ratio (M‐H, Random, 95% CI)	0.72 [0.28, 1.84]

7 Readmission to hospital Show forest plot	2	3247	Risk Ratio (M‐H, Random, 95% CI)	0.70 [0.10, 4.90]

Comparison 1. All irrigation versus no irrigation

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Comparison 2. Antibacterial irrigation versus non‐antibacterial irrigation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 SSI Show forest plot	30	5141	Risk Ratio (M‐H, Random, 95% CI)	0.57 [0.44, 0.75]

1.1 clean	4	680	Risk Ratio (M‐H, Random, 95% CI)	0.16 [0.03, 0.89]
1.2 clean‐contaminated	13	2210	Risk Ratio (M‐H, Random, 95% CI)	0.57 [0.40, 0.79]
1.3 contaminated or dirty	13	2251	Risk Ratio (M‐H, Random, 95% CI)	0.61 [0.40, 0.92]
2 Wound dehiscence Show forest plot	3	660	Risk Ratio (M‐H, Random, 95% CI)	1.26 [0.65, 2.45]

3 Adverse events Show forest plot	3	178	Risk Ratio (M‐H, Random, 95% CI)	0.55 [0.22, 1.34]

4 Abscess Show forest plot	9	1309	Risk Ratio (M‐H, Random, 95% CI)	0.82 [0.42, 1.62]

5 Mortality Show forest plot	11	1121	Risk Ratio (M‐H, Random, 95% CI)	0.81 [0.48, 1.36]

6 Hospital stay Show forest plot	7	635	Mean Difference (IV, Random, 95% CI)	‐0.85 [‐1.60, ‐0.09]

7 Return to theatre (reoperation) Show forest plot	2	403	Risk Ratio (M‐H, Random, 95% CI)	1.26 [0.12, 13.60]

Comparison 2. Antibacterial irrigation versus non‐antibacterial irrigation

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Comparison 3. Icodextrin versus lactated Ringer's solution

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality Show forest plot	2	875	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

2 Adverse events Show forest plot	2	875	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.96, 1.02]

3 Treatment‐related adverse events Show forest plot	2	875	Risk Ratio (M‐H, Random, 95% CI)	1.35 [0.98, 1.86]

Comparison 3. Icodextrin versus lactated Ringer's solution

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Comparison 4. Standard irrigation versus pulsatile irrigation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 SSI Show forest plot	2	484	Risk Ratio (M‐H, Random, 95% CI)	0.34 [0.19, 0.62]

Comparison 4. Standard irrigation versus pulsatile irrigation

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