Wondirrigatie

Beoordeeld: 01-12-2024

Uitgangsvraag

Wat is het effect van verschillende oplossingen voor profylactische, intra-operatieve, incisionele wondirrigatie op het risico van postoperatieve wondinfecties bij chirurgische patiënten?

Aanbeveling

Onderstaande aanbevelingen hebben betrekking op de wondholte en niet op de preoperatieve huiddesinfectie:

Gebruik een (steriel) antisepticum opgelost in water (niet in alcohol) voor profylactische, intra-operatieve, incisionele wondirrigatie ter preventie van postoperatieve wondinfecties.^*#

* Tenzij er bij specifieke operaties, kans is op weefselschade of als de patiënt bekend is met allergie.

^# Voor schone chirurgische interventies kan geen specifieke aanbeveling worden gedaan.

Gebruik geen antibioticum/antibiotica opgelost in water wegens lagere bewijskracht, risico op resistentie ontwikkeling, en gelijk effect aan antiseptica.
Gebruik niet enkel een zoutoplossing wegens beperkte effectiviteit.

Houd bij het prioriteren van chirurgische wonden voor wondirrigatie rekening met de a priori kans op POWI.

Overwegingen

Voor- en nadelen van de interventie en de kwaliteit van het bewijs

Bij de nieuwste inzichten voor de GRADE methodologie wordt rekening gehouden met klinische relevantie van een effect, waarbij voor- en nadelen tegen elkaar af worden gewogen. Deze methode verschilt hierin met de GRADE zoals toegepast op de andere modules binnen de richtlijn. Toelichting op de gehanteerde methode is te vinden in GRADE assessment onder het tabblad 'Evidence tabellen'. Uit deze door Groenen et al. gehanteerde methode volgt een hoge bewijskracht voor een klinisch significant effect van wondirrigatie met antiseptica opgelost in water op het verminderen van postoperatieve wondinfecties (POWI) ten opzichte van spoelen met zoutoplossing of niet spoelen.

Voor wondirrigatie met antibiotica opgelost in water is redelijke bewijskracht ten opzichte van spoelen met zoutoplossing en lage bewijskracht ten opzichte van niet spoelen dan de wond voor reductie van POWI. Daarnaast is er redelijk bewijs dat er weinig tot geen verschil is in effect tussen wondirrigatie met zoutoplossing en niet irrigeren. Er is weinig tot geen verschil in effect op POWI tussen wondirrigatie met antiseptica en antibiotica opgelost in water, maar de bewijskracht hiervoor is zeer laag.

Alleen in de subgroep voor niet gecontamineerde chirurgie werden afwijkende resultaten gevonden. Binnen deze subgroep werd alleen voor wondirrigatie met antiseptica opgelost in water ten opzichte van wondirrigatie met zoutoplossing een significant effect gevonden. De bewijskracht van de effecten binnen deze subgroep is echter niet vastgesteld door gebrek aan data.

Waarden en voorkeuren van patiënten (en evt. hun verzorgers)

Het spoelen van de wond is geen voorkeursgevoelige beslissing. Echter, indien er bekende specifieke (huid)reacties van de patiënt op een bepaald antisepticum zijn, dient hier rekening mee te worden gehouden. Controleer daarom altijd of er bekende huidreacties zijn op een antisepticum.

Kosten (middelenbeslag)

Er is geen kosteneffectiviteitsanalyse beschikbaar. Echter is POWI een kostbare complicatie en draagt de reductie hiervan meer bij aan kostenbesparing dan de minimale individuele extra kosten voor een antisepticum opgelost in water.

Aanvaardbaarheid, haalbaarheid en implementatie

De interventie wordt reeds in wisselende mate ingezet, afhankelijk van soort ingreep, centrum en voorkeur operateur. Er zijn geen zorgen over de aanvaardbaarheid, haalbaarheid en implementatie. De antiseptica die voor wondirrigatie gebruikt kunnen worden moeten in water opgelost zijn. Deze producten zijn als oplossing in water beschikbaar en verkrijgbaar. In de statements on method of wound irrigation is te zien welke verschillende oplossingen er gebruikt zijn in de studies voor bijvoorbeeld povidone-iodine worden concentraties tussen de 0,35 en 10% gehanteerd.

Rationale van de aanbeveling: weging van argumenten voor en tegen de interventies

Deze netwerk meta-analyse laat een significant voordeel zien van intra-operatieve, incisionele wondirrigatie met zowel een antisepticum als een antibioticum ter preventie van postoperatieve wondinfecties, vergeleken met wondirrigatie met zoutoplossing en geen wondirrigatie.

Wondirrigatie met een antisepticum opgelost in water geniet de voorkeur boven antibioticum opgelost in water om de volgende redenen:

Het effect van antiseptica kent een hogere bewijskracht;
Er is weinig tot geen verschil in effect op POWI tussen irrigatie met antibiotica en antiseptica;
er zijn serieuze zorgen over de bacteriële resistentie tegen antibiotica. Daarentegen zijn er geen tekenen dat bacteriële gevoeligheid voor jodium of chloorhexidine over de tijd afneemt.

In de subgroep voor schone chirurgie werd alleen voor wondirrigatie met antiseptica opgelost in water ten opzichte van wondirrigatie met zoutoplossing een significant effect gevonden. De andere vergelijkingen laten zeer brede betrouwbaarheidsintervallen zien, hoogstwaarschijnlijk als gevolg van het uitdunnen van data (slechts 11/41 geïncludeerde RCTs analyseren schone chirurgie) en daarmee het verlies aan statistische kracht, wat het moeilijk maakt om conclusies op subgroep niveau te trekken. Bovendien is een meta-regressie analyse niet mogelijk met de gebruikte methode (frequentist methode).

Onderbouwing

Achtergrond

Postoperatieve wondinfecties (POWI’s) zijn verantwoordelijk voor het merendeel van de complicaties na een operatie. Ze zijn geassocieerd met extra morbiditeit, mortaliteit, kosten en een verlengde opnameduur.^1,2 Het risico op een POWI kan worden verminderd door gebruik van profylactische intra-operatieve irrigatie van de incisiewond (pIOWI), waarbij vuil, stofwisselingsafval en exsudaat, mogelijk besmet met micro-organismen, voorafgaand aan het sluiten van de wond worden weggespoeld.³Er is een variëteit aan spoelvloeistoffen en toepassingsmethoden.

Internationale richtlijnen m.b.t. de preventie van POWI’s en eerder gepubliceerde (netwerk) meta-analyses geven tegenstrijdige aanbevelingen met betrekking tot het gebruik van pIOWI. Sinds de publicatie van de internationale richtlijnen zijn er veel RCTs over dit onderwerp gepubliceerd.

Conclusies

Surgical site infections (SSI)

Antibiotic vs antiseptic

Very low

GRADE

Antibiotic solutions may have little to no effect on SSI when compared with antiseptic solutions in surgical patients, but the evidence is very uncertain.

Antibiotic vs saline

Moderate

GRADE

Antibiotic solutions likely reduce SSI when compared with saline in surgical patients.

Antibiotic vs no irrigation

Low

GRADE

Antibiotic solutions may result in a reduction of SSI when compared with no irrigation in surgical patients.

Antiseptic vs saline

High

GRADE

Antiseptic solutions result in a reduction of SSI when compared with saline in surgical patients.

Antiseptic vs no irrigation

High
GRADE

Antiseptic solutions result in a reduction of SSI when compared with no irrigation in surgical patients.

Saline vs no irrigation

Moderate GRADE

Saline solutions likely result in little to no difference in SSI when compared with no irrigation in surgical patients.

Samenvatting literatuur

Description of studies

We included 41 RCTs in our systematic review and 37 RCTs in the network meta-analysis, due to lack of events in all arms in four studies. The study characteristics of the RCTs included in the systematic review are listed in study characteristics. Irrigation solutions were grouped into antiseptic, antibiotic, or saline solutions.

The antibiotics applied in a solution in the different studies were cefazolin, gentamicin, rifampicin, imipenem, clindamycin, ceftriaxone, metronidazole and bacitracin. All but two studies described the antibiotic solutions to be aqueous. All antiseptic solutions studied were aqueous. Most antiseptic solutions were iodine based, with 18 RCTs nvestigating iodine solutions ranging from 0.1% to 10% in concentration. Other antiseptics in the included RCTs were polyhexanide, chlorhexidine, hydrogen peroxide and ESAAS (Electrolyzed Strongly Acidic Aqueous Solution). In the saline irrigation group, all studies described irrigation with saline 0.9%, except for one RCT in which Ringers’ lactate was used. Volume of irrigation and application method varied among all studies and irrigation groups (Statements on method of wound irrigation).

Results

In total, 17,188 patients were included in the systematic review, reporting 1,328 SSI corresponding to an overall incidence of 7.7%. Figure 1 shows the forest plot for the efficacy of the different types of irrigation solutions compared to no irrigation; the league table for this data is presented in Table 1. Antibiotic (RR 0.46 [95% CI 0.29 - 0.73]) and antiseptic (RR 0.60 [0.95% CI 0.44 - 0.81]) solutions both showed a significant effect in reducing SSI when compared to no irrigation. Saline irrigation showed no significant effect (RR 0.83 [95% CI 0.63 - 1.09]) compared to no irrigation. The effects on SSI reduction of antibiotic solutions and antiseptic solutions were not significantly different (RR 0.77; 95% CI 0.50 - 1.19).

Results from the subgroup- and sensitivity analyses can be found in subgroup and sensitivity analyses .

Level of evidence of the literature

Full evaluation of the certainty of evidence and considerations for grading are detailed in Table 2 and GRADE assessment . GRADE assessment, incorporating minimally important difference, resulted in a high certainty of evidence for two comparisons (antiseptic versus saline irrigation and antiseptic versus no irrigation) and moderate certainty for two comparisons (antibiotic versus saline irrigation and saline versus no irrigation). Low certainty of evidence was found for the comparison of antibiotic versus no irrigation, and very low certainty for antibiotic versus antiseptic irrigation.

Study characteristics

Study	SSI / N total	Treatment 1	Treatment 2	Type of surgery	Wound class §	SAP	ROB	Follow-up	SSI definition
Antibiotic vs Antiseptic (RR 0.77; 95% CI 0.50 – 1.19)
Inojie 2023	8 / 80	Gentamicin in saline	3.5% PI	Open spine surgery	1	Yes	Some concerns	30 days	CDC
Karuserci 2022*	2 / 200	Rifampicin in saline	10% PI	Caeserean section	2	Yes	Some concerns	30 days	CDC
Nguyen 2021	11 / 88	Cefazolin, gentamicin, and bacitracin in saline	0.05% chlorhexidine gluconate	Bilateral mastectomy with tissue expander reconstruction	1	Yes	Some concerns	28 days	CDC
Karuserci 2020*	28 / 200	Rifampicin in saline	10% PI	Gynecologic oncology surgery	2	Yes	High	30 days	CDC
Karusersi 2019*	7 / 200	Rifampicin in saline	10% PI	Benign gynecologic surgery	2	Yes	Some concerns	30 days	¶a
Antibiotic vs Saline (RR 0.56; 95% CI 0.37 – 0.83)
Zeb 2023	12 / 106	Imipenem in saline	Saline	Open appendectomy	2 – 4	Yes	Some concerns	3 weeks	NR
Karuserci 2022*	6 / 200	Rifampicin in saline	Saline	Caeserean section	2	Yes	Some concerns	30 days	CDC
Shah 2021	14 / 80	Imipenem in saline	Saline	Appendectomy	3 – 4	NR	Some concerns	NR	NR
Okunlola 2021	3 / 132	Ceftriaxone in saline	Saline	Neurosurgery	1	Yes	Some concerns	30 days	¶b
Karuserci 2020*	28 / 200	Rifampicin in saline	Saline	Gynecologic oncology surgery	2	Yes	High	30 days	CDC
Emile 2020*	17 / 150	Gentamicin in saline	Saline	Open appendectomy	1 – 3	Yes	Some concerns	6 weeks	CDC
Karusersi 2019*	13 / 200	Rifampicin in saline	Saline	Benign gynecologic surgery	2	Yes	Some concerns	30 days	¶a
Oller 2015	0 / 51	I. Gentamicin in saline II. Clindamycin in saline	Saline	Axillary lymph node dissection in breast cancer	1	Yes	Some concerns	2 weeks	NR
Ruiz-Tovar 2013¤	0 / 40	Gentamicin in saline	Saline	Elective axillary lymph node dissection due to axillary metastasis	1	Yes	Some concerns	NR	NR
Etaati 2012*	5 / 100	Cefazolin in saline	Saline	Caeserean section	2	Yes	High	1 week	¶c
Mirsharifi 2008	12 / 102	Cefazolin	Saline	Open cholecystectomy	2 – 3	NR	Some concerns	6 weeks	¶d
Bhargava 2006	28 / 60	Metronidazole in saline	Saline	Exploratory laparotomy	4	Yes	High	30 days	¶e
Antibiotic vs No irrigation (RR 0.46; 95% CI 0.29 – 0.73)
Emile 2020*	17 / 150	Gentamicin in saline	No irrigation	Open appendectomy	1 – 3	Yes	Some concerns	6 weeks	CDC
Etaati 2012*	5 / 150	Cefazolin in saline	No irrigation	Caeserean section	2	Yes	High	1 week	¶c
Köşüş 2010	12 / 1272	Rifamycin	No irrigation	Caeserean section	2	Yes	Some concerns	30 days	CDC
Antiseptic vs No irrigation (RR 0.60; 95% CI 0.44 – 0.81)
Mueller 2023*	44 / 394	0.04% polyhexanide	No irrigation	Emergency and elective abdominal laparotomy	2 – 4	Yes	Low	30 days	CDC
Al-Abdulla 2021*	16 / 80	1% PI	No irrigation	Open appendectomy	3 – 4	Yes	Some concerns	10 days	¶f
Haider 2018	43 / 600	1% PI	No irrigation	Clean elective surgery	1	Yes	Some concerns	4 weeks	¶f
Mahomed 2016	291 / 3270	10% PI	No irrigation	Caeserean section	2	Yes	Some concerns	4 weeks	CDC
Iqbal 2015	25 / 166	1% PI	No irrigation	Open appendectomy	3	Yes	Some concerns	30 days	¶f
Kokavec 2008	2 / 162	3.5% PI	No irrigation	Orthopedic surgery of proximal femur, hip and pelvis in pediatric patients	1	Yes	Some concerns	2 months	¶g
Antiseptic vs Saline (RR 0.72; 95% CI 0.57 – 0.93)
Mueller 2023*	68 / 587	0.04% polyhexanide	Saline	Emergency and elective abdominal laparotomy	2 – 4	Yes	Low	30 days	CDC
Maemoto 2023	60 / 950	10% PI	Saline	Elective gastroenterological surgery	2	Yes	Some concerns	30 days	CDC
Zhao 2023	20 / 340	1% PI	Saline	Radical gastrectomy	2	Yes	Some concerns	30 days	CDC
Karuserci 2022*	6 / 200	10% PI	Saline	Caeserean section	2	Yes	Some concerns	30 days	CDC
Maghsoudipour 2022	0 / 50	3% hydrogen peroxide	Saline	Rhinoplasty	1	NR	Some concerns	8 weeks	¶h
Al-Abdulla 2021*	14 / 80	1% PI	Saline	Open appendectomy	3 – 4	Yes	Some concerns	10 days	¶f
Cohen 2020¤	3 / 173	0.35% PI	Saline	Pediatric posterior spinal fusion	1	Yes	Some concerns	90 days	CDC
Akhavan - Sigari 2020	26 / 936	3.5% PI	Saline	Spinal fusion surgery	1	Yes	Some concerns	12 months	CDC
Karuserci 2020*	28 / 200	10% PI	Saline	Gynecologic oncology surgery	2	Yes	High	30 days	CDC
Strobel 2020	111 / 456	0.04% polyhexanide	Saline	Elective abdominal laparotomy	2 – 3	Yes	Some concerns	30 days	CDC
Karusersi 2019*	18 / 200	10% PI	Saline	Benign gynecologic surgery	2	Yes	Some concerns	30 days	¶a
Vinay 2019	16 / 180	5% PI	Saline	Elective laparotomy	2	Yes	Some concerns	4 weeks	CDC
De Luna 2017	3 / 50	3% PI	Saline	Spine surgery	1	Yes	Some concerns	30 days	CDC
Fei 2017	12 / 80	0.1% PI	Saline	Posterior lumbar interbody fusion surgery	1	NR	Some concerns	NR	NR
Neeff 2016	41 / 197	0.04% polyhexanide	Ringer’s solution	Colorectal surgery	2 – 4	NR	Some concerns	NR	NR
Takesue 2011	48 / 400	Electrolyzed Strongly Acidic Aqueous Solution	Saline	Elective colorectal surgery	2 – 3	Yes	Some concerns	30 days	¶a
Chang 2006	6 / 244	0.35% PI	Saline	Lumbosacral posterolateral fusion surgery	1	Yes	Some concerns	14 months	NR
Cheng 2005	7 / 414	0.35% PI	Saline	Spine surgery	1	Yes	Some concerns	6 months	¶i
Saline vs No Irrigation (RR 0.83; 95% CI 0.63- 1.09)
Mueller 2023*	50 / 397	Saline	No irrigation	Emergency and elective abdominal laparotomy	2 – 4	Yes	Low	30 days	CDC
Gomaa 2022	221 / 2890	Saline	No irrigation	Caeserean section	2	NR	Some concerns	30 days	¶j
Al-Abdulla 2021*	18 / 80	Saline	No irrigation	Open appendectomy	3 – 4	Yes	Some concerns	10 days	¶f
Gül 2021	18 / 230	Saline	No irrigation	Caeserean section	2	Yes	Some concerns	7 days	¶k
Emile 2020*	17 / 150	Saline	No irrigation	Open appendectomy	1 – 3	Yes	Some concerns	6 weeks	CDC
Aslan 2018	25 / 204	Saline	No irrigation	Caeserean section	2	Yes	Some concerns	30 days	NR
Etaati 2012*	5 / 150	Saline	No irrigation	Caeserean section	2	Yes	High	1 week	¶c
Güngördük 2010	36 / 520	Saline	No irrigation	Caeserean section	2	Yes	Some concerns	6 weeks	¶l
Al-Ramahi 2006	21 / 206	Saline	No irrigation	Abdominal gynecologic surgery	2	Yes	High	1 month	¶m
Platt 2003	0 / 30	Saline	No irrigation	Bilateral breast reduction	1	NR	Some concerns	8 weeks	NR
Cervantes-Sánchez 2000	12 / 255	Saline	No irrigation	Appendectomy	1 – 3	Yes	Some concerns	4 weeks	¶n
* Studies compare three wound irrigation solutions ¤ SSI secondary outcome, thus not adequately powered to detect SSI § 1: Clean, 2: Clean-contaminated, 3: Contaminated, 4: Dirty SSI definitions, other than CDC: ¶a: National Nosocomial Infections Surveillance System (NNIS).¹ ¶b: a modified scoring system: grade 0, normal healing; grade I, normal healing with mild erythema or epidermolysis; grade II, superficial wound infection with galeal/fascia intact; grade III, deep wound infection below the galeal/fascia but with intact dural; grade IIIa, no osteomyelitis; grade IIIb, with osteomyelitis; grade IIIc, with pachy meningitis; grade IV, meningitis without tissue breakdown excluding chemical meningitis; grade V, meningitis with breakdown of dural and fascia; grade VI, intracranial or intraspinal intradural abscess; grade Via, subdural empyema; grade Vib, intraparenchymal abscess; grade Vic, intraventricular abscess; grade Vid, combination. ¶c: at the time of discharge, the patients of all groups were trained to go to the hospital if they had fever or if they saw any erythema, swelling or discharge at the surgical site. Then, the patients were daily followed by telephone to see if they had signs of symptoms of SSIs. ¶d: infection was defined according to clinical symptoms: purulent discharge, pain, heat, swelling or erythema at site of the wound. Final diagnosis was made by the surgeon. ¶e: postoperatively, the wound was inspected after 48 h for any discharge, soakage, erythema, tenderness and pain. ¶f: Southampton grading: grade 0, healing is normal; grade I, normal healing + mild bruising; grade II, erythema / tenderness / heat; grade III, serous discharge; grade IV, purulent discharge. ¶g: infection was assumed when there was unexpected or increased pain, redness, swelling, increased temperature or discharge from the wound. ¶h: presence of infection was examined and reported as positive or negative. ¶i: infection was suspected when unusual pain, tenderness, erythema, induration, fever, or wound drainage was noted. Such findings were investigated with measurement of erythrocyte sedimentation rate, C-reactive protein, and bacteriological cultures from the operative site or blood. ¶j: tenderness, redness, hotness, swelling, purulent discharge. ¶k: purulent discharge or erythema, fever, induration, and tenderness in the surgical site, which required separation of the incision, indicated an infection. ¶l: wound infection was diagnosed when a wound drained purulent material or serosanguineous fluid in association with induration, warmth and tenderness. Suspected wound infections were opened for confirmation and wound cultures were taken. Haematoma, seroma, or wound breakdown in the absence of the previously discussed signs was not considered a wound infection. ¶m: defined as wound discontinuation associated with purulent discharge from the wound and local tenderness, hotness, and/or redness within 1 month of surgery. ¶n: a wound was considered to be infected accordingly to Krukowski et al.² when there was a collection of pus or a positive bacteriologic culture from a wound discharge (as described by Ljunqvist³). CDC, Centers for Disease Control and Prevention; N, number of patients; NR, not reported; PI, povidone iodine; ROB, risk of bias; RR, relative risk; SAP, systemic antibiotic prophylaxis; SSI, surgical site infection; 95% CI, 95% confidence interval 1 Emori, T. G. et al. National nosocomial infections surveillance system (NNIS): description of surveillance methods. Am J Infect Control 19, 19-35, doi:10.1016/0196-6553(91)90157-8 (1991). 2 Krukowski, Z. H., Irwin, S. T., Denholm, S. & Matheson, N. A. Preventing wound infection after appendicectomy: a review. Br J Surg 75, 1023-1033, doi:10.1002/bjs.1800751023 (1988). 3 Ljungqvist, U. Wound Sepsis after Clean Operations. Lancet 1, 1095-1097, doi:10.1016/s0140-6736(64)91291-7 (1964).

Statements on method of wound irrigation

Study	Statements on method of wound irrigation
Mueller 2023	After randomization, patients received IOWI with 1000 ml of a 0·04% PHX solution, IOWI with 1000 ml NaCl 0·9%, or no irrigation. The wound was rinsed carefully with the respective solution and the excess was removed by suction. Debris and blood clots were removed from the wound using irrigation and suction. The wound was left moistened with the irrigation solution to ensure sufficient contact time (> 10 min).
Maemoto 2023	IOWI is performed for one minute with 40 mL of aqueous 10% PVP-I (POVIDONE-IODINE solution 10% “MEIJI”; Meiji Seika Pharma Co., Ltd., Tokyo, Japan) in the study group, and the same procedure is performed with 100 mL of saline (Isotonic Sodium Chloride Solution “Hikari”; Hikari Pharmaceutical Co., Ltd., Tokyo, Japan) in the control group.
Zhao 2023	After closing the peritoneal sutures with size 0 VICRYL Plus (Johnson & Johnson - Ethicon Endo-Surgery, Inc., Cincinnati, OH, USA), the wound was irrigated with either 500 mL of 1% PVI solution or 500 ml of 0.9% NS. Size 4-0 VICRYL Plus intradermic sutures were used in all patients.
Inoje 2023	Patients randomized into Group A had their spine wound irrigated with saline containing gentamicin solution (a liter of normal saline mixed with 80 mg of gentamicin injection) in a quantity sufficient to fill the wound to the level of the skin without overflow. The saline containing gentamicin solution was maintained in the incision for 3 minutes, after which the wound was flushed with the remaining saline containing gentamicin solution. Group B patients’ wounds were irrigated with a liter of 3.5% diluted PI solution. The surgical wound was filled with PI in a volume sufficient to fill the wound to the level of the skin without overflow. The PI solution was maintained in the incision for 3 minutes, after which the wound was flushed with the remaining dilute PI solution.
Zeb 2023	Before the wound was stitched up, the tissues in group I were irrigated with one litre of saline containing one gramme of imipenem (1 mg/ml), while group II received one litre of regular saline.
Karuserci 2022	All subcutaneous tissues were irrigated with 250 ml of saline. Then 3–5ml 10% povidone-iodine in group 2 and 250 mg/3 ml rifampicin in group 3 was applied directly on the subcutaneous tissue without diluting. The excess liquid was cleaned off and the subcutaneous tissue scrubbed with gauze.
Gomaa 2022	Subcutaneous irrigation by 200cc saline before closure of the skin.
Maghsoudipour 2022	Irrigation with hydrogen peroxide or placebo was performed right before closure of the surgical site with sutures, using irrigation syringes prepared by a pharmacist at the time they were needed. In the intervention group, hydrogen peroxide 3% solution was used, while 0.9% sodium chloride solution was used in the placebo group.
Al-Abdulla 2021	In this study group A, before skin closure, subcutaneous tissue was irrigated by 1% povidone iodine using 10cc syringe, kept there for 2 to 3 minute and then aspirated. Group B the subcutaneous tissue was washed by normal saline using 10cc syringe. Group C no irrigation was done.
Shah 2021	NR
Nguyen 2021	TAS contained 1 g of cefazolin, 50,000 U of bacitracin, and 80 mg of gentamicin in 500 mL of normal saline. Both the Tissue Expander and mastectomy pocket were bathed in the respective solutions, and a 1-minute dwell time was employed based on data presented on the IrriSept website reporting similar efficacy with 1- or 5-minute exposure times for most organisms.
Okunlola 2021	The patients in the subject group received 2 g of intravenous ceftriaxone (Roche-Rocephin) at induction of anaesthesia followed by 1 g 12 hourly for 24 h post-operatively and intra-operative wound irrigation with 250 mg/ml of ceftriaxone in normal saline. The patients in the control group received 2 g of intravenous (Roche-Rocephin) at induction of anaesthesia followed by 1 g 12 hourly for 24 h post-operatively and intraoperative wound irrigation with plain normal saline. The irrigation was done by jet and or droplets from 50 ml syringe.
Gül 2021	The subcutaneous tissue was irrigated with 200 ml of saline solution (0.9% NaCl) in patients in the experimental group (Group 1, n=115), and not irrigated in those in the control group (n=115) before the skin was closed.
Cohen 2020	After the initial culture collection, nonviable tissues were debrided and the wound was soaked for 3 minutes with enough 0.35% PVP-I or sterile saline to be in contact with the entire wound. No antibiotics were added to sterile saline. The wound was then irrigated with 2 L of saline regardless of randomization to limit confounding, since PVP-I must be irrigated with saline.
Akhavan - Sigari 2020	Before bone grafting, the surgical wounds in the normal ssaline group were filled and soaked with 0.9% normal saline, suction was performed; the irrigation being repeated three times. In the PVI group, surgical wounds were irrigated with PVI 3% to fill and soak the wound for two minutes followed by normal saline irrigation.
Karuserci 2020	All subcutaneous tissues were irrigated with 250 mL of saline. Then 10 mL of 10 % povidone-iodine in Group 2 and 500 mg/6 mL of rifampicin in Group 3 was applied directly on the subcutaneous tissue without being diluted. The excess liquid was cleaned off and the subcutaneous tissue scrubbed with a gauze.
Strobel 2020	At the end of the operation, the peritoneal cavity was rinsed routinely with 0.9% sodium chloride solution at body temperature (Braun, Melsungen, Germany). Before closure of fascia, instruments and gloves were changed. After the closure of fascia, subcutaneous irrigation with 250mL 0.9% saline (Braun, Melsungen, Germany) or 250mL antiseptic 0.04% polyhexanide solution (Serasept2, Serag-Wiessner) was done according to the randomization list. The application time for polyhexanide was 10 minutes and for saline as biologically inactive agent 1 minute.
Emile 2020	In group I, upon closure of the peritoneum gentamicin-saline solution (160 mg of gentamicin in 400 ml of normal saline 0.9%) was used by a 20-cm syringe for irrigation of every layer of the wound before its closure. The first layer was between the peritoneal membrane and the internal oblique muscles, the second layer was between the approximated internal oblique muscles and the external oblique aponeurosis, and finally the third layer (the subcutaneous space) after closure of the external oblique aponeurosis (Fig. 1). In group II, layer by layer irrigation of the wound with normal saline solution was performed in a similar manner. In group III, layer-by-layer closure of the surgical wound with polyglactin 2/0 sutures took place without irrigation.
Karuserci 2019	All subcutaneous tissues were irrigated with 250 ml of saline. Then 500 mg/6 ml of rifampicin in group 2 and 10 ml of povidone iodine in group 3 was applied directly on the subcutaneous tissue without dilution. The excess liquid was cleaned off and the subcutaneous tissue scrubbed with gauze.
Vinay 2019	In Group A, the incision site was treated with 400 ml, 0.9% normal saline and 100 ml 5% povidone-iodine solution. In Group B, the incision site was treated with 500 ml 0.9% normal saline solution.
Haider 2018	In group A, before skin closure subcutaneous tissues were irrigated with 5 ml 1 % PVI solution in normal saline. The solution was kept in wound for five minutes then aspirated. In group B, no irrigation was done.
Aslan 2018	Before the subcutaneous tissue closure in the saline group the subcutaneous saline irrigation was performed with a 200cc of saline (0.9%NaCl). No subcutaneous irrigation was applied in the control group before the skin closure.
De Luna 2017	In group A, before applying the bone graft, low-pressure irrigation (Bio Pulse, Leader Medica) with PVP-I diluted to a 3% concentration (30 g/l) in 2 litres of saline for between 5 and 10 minutes was performed and then washed out by 1 litre of sodium chloride solution through a pulse irrigation device. In group B, low-pressure irrigation with 2 litres of saline solution for between 5 and 10 minutes was performed before applying bone graft.
Fei 2017	The incision was flushed with 0.1% iodine solution (volume: 200 ml) and soaked for 2 min, then the incisions were flushed with normal saline under adequate hemostasis conditions. The incisions were flushed with saline solution in the usual way.
Mahomed 2016	The intervention was wound irrigation with about 50 mls of 10% aqueous PVI solution (Betadine group). The solution in a bowl was poured in and around the incision site.
Neeff 2016	NR
Oller 2015	All patients underwent a first lavage of the axillary surgical bed with physiologic saline. Group 1 underwent a second lavage with saline. Group 2 had a second lavage with a 240-mg gentamicin solution (Group 2), and Group 3 had a second lavage with a 600-mg clindamycin solution.
Iqbal 2015	In the study group A, before skin closure, the subcutaneous tissue was irrigated with 4-5 cc of 1% diluted povidone-iodine solution. The solution was sprayed into the subcutaneous wound with the help of a 5cc syringe, kept there for 2-3 minutes and was then aspirated. However, in the control group B, no irrigation was done.
Ruiz-Tovar 2013	In both groups, prior to the lavage, a microbiological sample from the surgical bed was obtained with a swab (sample 1), followed by a lavage with 500 ml normal saline. After aspiration of the saline, a new microbiological sample was obtained (sample 2). In Group 1 a second lavage with 500 ml normal saline was performed, while in Group 2 the second lavage was performed with an antibiotic solution, including gentamicin (240 mg) dissolved in 500 ml normal saline.
Etaati 2012	In one group, after the surgery and before closing up the patients, 2 grams of cefazolin in 5 cc of distilled water were used to irrigate the patients. In the second group, 150 cc of normal saline was used to irrigate the patients and in the last group, no irrigation was used.
Takesue 2011	In the ESAAS group the surgical wound was irrigated with at least 500 mL of ESAAS after the completion of fascial suture. In the saline solution group, the same amount of saline solution was used for wound irrigation.
Güngördük 2010	In the study group, before skin closure, the subcuticular tissue was irrigated with 100 ml of sterile saline with a 30–60 ml syringe. The skin was then closed using a 3-0 Vicryl suture. In the control group, the subcuticular tissue was not irrigated with sterile saline and the skin was closed using a 3-0 Vicryl suture.
Köşüş 2010	In the second group subcutaneous tissue was irrigated with rifamycin SV/ 250 mg, before closure of subcutaneous tissue.
Kokavec 2008	Approximately 1 ml of betadine was diluted by adding approx. 30 ml of sterile saline solution to a concentration of about 0.35% povidone iodine for perioperative use (2-3 minutes)
Mirsharifi 2008	One gram of injectable cefazolin was used to wash the wound after the surgery and just before closing the incision site, and the control group was without topical antibiotic.
Bhargava 2006	In group A the wound was irrigated with normal saline and in group B 50–100mL of metronidazole (from a single manufacturer). The concentration used was 500 mg/100 mL, which was infiltrated in the subcutaneous tissues making sure that the area of infiltration exceeds that of the incision.
Chang 2006	In group 1 composed of patients with odd serial numbers (study group), wounds were irrigated with 0.35% povidone-iodine solution to soak for 3 min, followed by an irrigation with 2000 c.c. of normal saline to remove povidone-iodine solution. No more wound irrigation was given after. In contrast, group 2 with patients even numbered (control group) was wound irrigated only with 2000 c.c. of normal saline.
Al-Ramahi 2006	The 104 patients in the odd number group (group 1), underwent wound irrigation with 50 mL of normal saline solution (NaCl 0.9%) following surgery and before skin closure. The 102 patients in the even-number group (group 2) received no wound irrigation.
Cheng 2005	The commercially available betadine solution used had a concentration of 10% povidoneiodine (100 mg of povidoneiodine per 1 mL of solution). Approximately 5 mL of povidoneiodine was diluted with normal saline to achieve a 0.35% povidoneiodine (3.5% betadine) solution for use during operation. The wound was irrigated with copious amounts of normal saline (2000 mL) after betadine solution irrigation. In group 2, irrigation with copious normal saline (2000 mL) was performed alone.
Platt 2003	Each breast was preinfiltrated with 300 mL saline containing adrenaline diluted to 1:500,000, lignocaine, and hyaluronidase (Hyalase; CP Pharmaceuticals Ltd, Wrexham, UK). Infiltration was performed uniformly throughout the breast using a spinal needle and syringe, sparing the pedicle.
Cervantes-Sánchez 2000	Group I (control) was treated with surgery and prophylactic systemic antibiotics and group II (experimental) was treated with surgery, antibiotics, and wound syringe pressure irrigation as follows: after closure of the fascial planes, we irrigated the subcutaneous fat tissue with 300 ml of normal saline solution, delivered with a 20-ml syringe with a 19-gauge intravenous (IV) catheter, applying to the embolus the force of one hand, at a distance of 2 cm from the wound tissues, aspirating the fluid collected in the wound with a bulb syringe.
ESAAS, Electrolyzed Strongly Acidic Aqueous Solution; IOWI, intraoperative wound irrigation; NaCl, sodiumchloride; NR, not reported PHX, polyhexanide; PI, povidone-iodine; PVI, povidone-iodine; PVP-I, povidone-iodine; TAS, Triple Antibiotic Solution; NR, not reported

Subgroup and sensitivity analyses

The forest plots show the network relative risks (RR) with corresponding 95% confidence intervals (CI) compared with no irrigation.

In the lower triangle of the league tables the network RR with corresponding 95% CI are shown. The upper triangle shows the RR of only the direct comparisons (comparable with a regular pairwise meta-analysis).

For instance, in Bijlage 6.a, the first column (in the lower triangle) shows the network RR with corresponding 95% CI of antibiotic compared with the other irrigation solutions. The last column (upper triangle) shows the direct RR with corresponding 95% CI of no irrigation compared with the other irrigation solutions.

A. Only clean surgery (CDC wound classification I)

Forest plot

League table

Antibiotic	1.29 [0.34; 4.84]	2.00 [0.15; 27.20]	-
1.95 [0.59; 6.42]	Antiseptic	0.17 [0.07; 0.43]	0.65 [0.21; 2.04]
0.40 [0.10; 1.60]	0.21 [0.08; 0.51]	Saline	-
1.26 [0.24; 6.59]	0.65 [0.21; 2.04]	3.12 [0.73; 13.35]	No irrigation

B. Excluding studies with only clean surgery

Forest plot

League table

Antibiotic	1.04 [0.41; 2.60]	0.55 [0.36; 0.84]	0.19 [0.06; 0.58]
0.61 [0.39; 0.95]	Antiseptic	0.79 [0.62; 1.02]	0.81 [0.56; 1.17]
0.52 [0.35; 0.77]	0.85 [0.67; 1.07]	Saline	0.77 [0.57; 1.03]
0.42 [0.27; 0.66]	0.68 [0.52; 0.90]	0.80 [0.63; 1.03]	No irrigation

C. Only upper-middle and high income countries

Forest plot

League table

Antibiotic	0.82 [0.37; 1.84]	0.45 [0.19; 1.10]	0.04 [0.00; 0.74]
0.63 [0.31; 1.27]	Antiseptic	0.68 [0.50; 0.92]	0.81 [0.48; 1.35]
0.46 [0.23; 0.92]	0.73 [0.54; 0.97]	Saline	0.76 [0.48; 1.18]
0.39 [0.18; 0.83]	0.61 [0.41; 0.92]	0.85 [0.58; 1.24]	No irrigation

D. Only low and lower-middle income countries

Forest plot

League table

Antibiotic	7.00 [0.80; 61.57]	0.63 [0.37; 1.08]	0.25 [0.07; 0.91]
0.97 [0.46; 2.03]	Antiseptic	0.56 [0.24; 1.31]	0.68 [0.34; 1.37]
0.62 [0.37; 1.03]	0.64 [0.35; 1.15]	Saline	0.71 [0.40; 1.25]
0.50 [0.26; 0.95]	0.51 [0.29; 0.90]	0.80 [0.50; 1.30]	No irrigation

E. Excluding studies with high risk of bias

Forest plot

League table

Antibiotic	0.79 [0.30; 2.09]	0.59 [0.32; 1.09]	0.18 [0.05; 0.63]
0.72 [0.42; 1.24]	Antiseptic	0.68 [0.51; 0.91]	0.76 [0.51; 1.14]
0.54 [0.32; 0.90]	0.74 [0.57; 0.97]	Saline	0.72 [0.50; 1.03]
0.43 [0.24; 0.76]	0.60 [0.43; 0.82]	0.80 [0.59; 1.09]	No irrigation

F. Only studies with adequate description of systemic antibiotic prophylaxis

Forest plot

League table

Antibiotic	1.06 [0.49; 2.30]	0.52 [0.30; 0.91]	0.18 [0.06; 0.61]
0.73 [0.44; 1.21]	Antiseptic	0.67 [0.49; 0.92]	0.75 [0.46; 1.21]
0.52 [0.32; 0.83]	0.71 [0.53; 0.95]	Saline	0.71 [0.47; 1.06]
0.41 [0.24; 0.70]	0.56 [0.39; 0.80]	0.79 [0.56; 1.11]	No irrigation

Zoeken en selecteren

A systematic review of the literature was performed to answer the following question:

What is the effect of prophylactic intra-operative incisional wound irrigation using antiseptic, antibiotic or saline solutions (i) versus other solutions in adult patients undergoing surgical procedures (p) in the prevention of SSI?

P: Adults undergoing any surgical procedure

I: Prophylactic intra-operative incisional wound irrigation using antiseptic, antibiotic or saline solutions

C: Prophylactic intra-operative incisional wound irrigation using other antiseptic, antibiotic or saline solutions or no irrigation

O: SSI

Relevant outcome measures

The guideline development group considered occurrence of SSI as a crucial outcome measure for decision making. The working group defined thresholds for clinically relevant outcomes in accordance with current GRADE guidance and methodology.

Search and select (Methods)

The databases Medline (PubMed), Excerpta Medica Database (EMBASE) and Cochrane Central Register of Controlled Trial (CENTRAL) were searched with relevant search terms until June 12, 2023. The detailed search strategy is available on request via https://richtlijnendatabase.nl/. The systematic literature search resulted in 1583 hits. Studies were selected based on the following inclusion criteria: unpublished and published RCTs that investigated the effect of prophylactic incisional intra-operative wound irrigation on SSI rates in any type of surgery, using antiseptic, antibiotic, or saline solutions, compared to each other or to no irrigation. Other solutions investigated in the literature (e.g., castile soap by Bhandari et al)⁴ were not included because they did not fit into either an antiseptic or an antibiotic profile. Furthermore, studies investigating intra-cavity lavage (i.e. abdominal, peritoneal or mediastinal) or surgical lavage of any other kind were excluded. 146 studies were initially selected based on title and abstract screening. After reading the full text, 105 studies were excluded (see the table with reasons for exclusion in Reasons for exclusion after full text review ) and 41 studies were included.

Results
Forty-one studies were included in the systematic review and 37 RCTs in the network meta-analysis of the literature. Important study characteristics and results and quality assessments are summarized in the evidence tables and risk of bias tables under the 'evidence tabellen' tab and 'Study characteristics' under the 'Samenvatting literatuur' tab.

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Evidence tabellen

GRADE assessment

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to evaluate the the certainty of the evidence using a minimally contextualized approach for direct, indirect and the complete network meta-analysis evidence sequentially.

Minimally important benefit, -harm, or trivial to no effect was chosen as the target estimate based on the point estimate in relation to the minimally important difference. Considering the inherently different trade-offs between saline, antiseptic and antibiotic irrigation with respect to concerns on resistance and other adverse effects we defined different minimally important differences (MID) for these interventions. In line, the precedent set by the long standing practice to reserve surgical antibiotic prophylaxis for clean-contaminated procedures (unless special considerations such as the use of implant material apply), we defined the MID as 3.5% for the routine use of antibiotic irrigation based on the upper limit of the incidence of SSI in clean procedures at the time (5%) and the RR of SSI after the use of surgical antibiotic prophylaxis in common clean-contaminated procedures (0.35). The MID for other interventions was defined as 2% based on the default for appreciable benefit and harm of 25% and the SSI incidence of 8% without irrigation in the presented data.

Since all included studies are randomised controlled trials, the rating for the GRADE starts high for all direct comparisons. Starting GRADE for the indirect evidence was based on the lowest of the two most dominant first order direct comparisons contributing to the indirect evidence. Starting GRADE for the network meta-analysis evidence was based on the highest certainty of evidence of the contributing direct and indirect evidence or whichever of the two was available.

Each comparison can be downgraded due to one of the following reasons:

Risk of bias
Of the 41 studies included in the network meta-analysis, four had an overall “High risk of bias”. Due to the network meta-analysis, this may have an effect on all the network estimates of all comparisons. We performed a (network) sensitivity meta-analysis excluding studies with high risk of bias. The results were comparable with the overall analysis, and downgrading for risk of bias was not needed.
Inconsistency
Low, moderate, and high inconsistency were characterized using the first and third quantiles of the empirical distribution of non-pharmacological interventions on subjective outcomes. For the direct evidence, -1 downgrade for inconsistency was necessary for the comparison antibiotic versus antiseptic (I² = 50.6%, τ² = 1.12). Coherence was only applied to the network meta-analysis evidence. For the assessment of coherence both the point estimates, confidence intervals and outcomes from the Separate Indirect from Direct Design Evidence node splitting (Appendix 5) analysis were interpreted in context.
Indirectness
Transitivity was only applied to indirect evidence. Due to the broad inclusion criteria and consequential clinical heterogeneity some intransitivity was anticipated. We evaluated transitivity by comparing the SSI incidence in the common control group between the two contributing direct comparisons and considered relative differences larger than 25% sufficient concern for downgrading.
Imprecision
Imprecision was only applied to the final evaluation of the evidence. Imprecision was evaluated taking the minimally important differences into account and assessing the optimal information size in case of large effects by calculating the ratio between the lowest and highest boundary of the confidence interval with a threshold for downgrading of 2.5.
Publication bias
The comparison-adjusted funnel plot showed in Appendix 8 shows no sign of small-study effects.

Network evidence

For all comparisons, both direct and indirect evidence are available. Therefore, we used the highest of the two certainty ratings as the certainty rating for the NMA estimate. The certainty of the network estimate can be upgraded if precision is greater than direct or indirect estimates.

Comparison

Direct evidence
(Classic)

Indirect evidence
(Transitivity)

Network meta-analysis
(Incoherence)

Relative Risk (95%CI)

Certainty of evidence

Relative Risk (95%CI)

Certainty of evidence

Relative Risk (95%CI)

Certainty of evidence

Target

Antibiotic vs antiseptic

1.07

(0.51 – 2.24)

ÅOOO

very low

0.64

(0.37 – 1.10)

ÅÅOO

low

0.77

(0.50 – 1.19)

ÅOOO

very low

Trivial to no effect

Antibiotic vs saline

0.57

(0.37 – 0.90)

ÅÅÅO

moderate

0.59

(0.20 - 1.75)

ÅOOO

very low

0.56

(0.37 – 0.83)

ÅÅÅO

moderate

Minimally important benefit

Antibiotic vs no irrigation

0.19

(0.06 – 0.59)

ÅÅOO

low

0.55

(0.34 - 0.90)

ÅOOO

very low

0.46

(0.29 - 0.73)

ÅÅOO
low

Minimally important benefit

Antiseptic vs saline

0.67

(0.51 – 0.88)

ÅÅÅÅ

high

1.00

(0.61 – 1.65)

ÅOOO

very low

0.72

(0.57 – 0.93)

ÅÅÅÅ

high

Minimally important benefit

Antiseptic vs no irrigation

0.77

(0.52 – 1.13)

ÅÅÅO

moderate

0.40

(0.24 – 0.66)

ÅÅOO

low

0.60

(0.44 – 0.81)

ÅÅÅÅ

high

Minimally important benefit

Saline vs no irrigation

0.75

(0.54 – 1.04)

ÅÅÅO

moderate

1.10

(0.59 – 2.08)

ÅOOO

very low

0.83

(0.63 – 1.09)

ÅÅÅO

moderate

Trivial to no effect

Comparison	Reasons for downgrading
Comparison	Direct evidence	Indirect evidence	Network meta-analysis
Antibiotic vs antiseptic	-1 inconsistency -3 imprecision	-1 imprecision	-2 imprecision
Antibiotic vs saline	-1 imprecision	-3 imprecision -1 intransivity	-1 imprecision
Antibiotic vs no irrigation	-2 imprecision	-1 intransivity -1 imprecision	-1 incoherence -1 imprecision
Antiseptic vs saline	no downgrade	-3 imprecision	no downgrade
Antiseptic vs no irrigation	-1 imprecision	-1 intransivity	no downgrade
Saline vs no irrigation	-1 imprecision	-1 intransitivity -3 imprecision	-1 imprecision

GRADE conclusions surgical site infections (SSI)

Antibiotic vs antiseptic

Very low

GRADE

Antibiotics solutions may have little to no effect on SSI when compared with antiseptic solutions in surgical patients but the evidence is very uncertain.

Antibiotic vs saline

Moderate

GRADE

Antibiotic solutions likely reduce SSI when compared with saline in surgical patients.

Antibiotic vs no irrigation

Low

GRADE

Antibiotic solutions may result in a reduction of SSI when compared with no irrigation in surgical patients.

Antiseptic vs saline

High

GRADE

Antiseptic solutions result in a reduction of SSI when compared with saline in surgical patients.

Antiseptic vs no irrigation

High
GRADE

Antiseptic solutions result in a reduction of SSI when compared with no irrigation in surgical patients.

Saline vs no irrigation

Moderate GRADE

Saline solutions likely result in little to no difference in SSI when compared with saline in surgical patients.

Figures and Tables

Figure 1: Forest plot

The forest plot shows the efficacy of different wound irrigation solutions in the prevention of surgical site infections (SSI) compared to no irrigation. Data are relative risk (RR) with corresponding 95% confidence interval (CI).

Table 1: League table

Antibiotic	1.07 [0.51; 2.24]	0.57 [0.37; 0.90]	0.19 [0.06; 0.59]
0.77 [0.50; 1.19]	Antiseptic	0.67 [0.51; 0.88]	0.77 [0.52; 1.13]
0.56 [0.37; 0.83]	0.72 [0.57; 0.93]	Saline	0.75 [0.54; 1.04]
0.46 [0.29; 0.73]	0.60 [0.44; 0.81]	0.83 [0.63; 1.09]	No irrigation

The league table is a square matrix showing all pairwise comparisons in the network meta-analysis. In the lower triangle of the league table the network relative risks (RR) with corresponding 95% confidence intervals (CI) are shown. The upper triangle shows the relative risks of only the direct comparisons (comparable with a regular pairwise meta-analysis).

For instance, the first column (in the lower triangle) shows the network RR with corresponding 95% CI of antibiotic compared with the other irrigation solutions. The last column (upper triangle) shows the direct RR with corresponding 95% CI of no irrigation compared with the other irrigation solutions.

Table 2: GRADE assessment

Comparison

Direct evidence
(Classic)

Indirect evidence
(Transitivity)

Network meta-analysis
(Incoherence)

Relative Risk (95%CI)

Certainty of evidence

Relative Risk (95%CI)

Certainty of evidence

Relative Risk (95%CI)

Certainty of evidence

Target

Antibiotic vs antiseptic

1.07

(0.51 – 2.24)

ÅOOO

very low

0.64

(0.37 – 1.10)

ÅÅOO

low

0.77

(0.50 – 1.19)

ÅOOO

very low

Trivial to no effect

Antibiotic vs saline

0.57

(0.37 – 0.90)

ÅÅÅO

moderate

0.59

(0.20 - 1.75)

ÅOOO

very low

0.56

(0.37 – 0.83)

ÅÅÅO

moderate

Minimally important benefit

Antibiotic vs no irrigation

0.19

(0.06 – 0.59)

ÅÅOO

low

0.55

(0.34 - 0.90)

ÅOOO

very low

0.46

(0.29 - 0.73)

ÅÅOO
low

Minimally important benefit

Antiseptic vs saline

0.67

(0.51 – 0.88)

ÅÅÅÅ

high

1.00

(0.61 – 1.65)

ÅOOO

very low

0.72

(0.57 – 0.93)

ÅÅÅÅ

high

Minimally important benefit

Antiseptic vs no irrigation

0.77

(0.52 – 1.13)

ÅÅÅO

moderate

0.40

(0.24 – 0.66)

ÅÅOO

low

0.60

(0.44 – 0.81)

ÅÅÅÅ

high

Minimally important benefit

Saline vs no irrigation

0.75

(0.54 – 1.04)

ÅÅÅO

moderate

1.10

(0.59 – 2.08)

ÅOOO

very low

0.83

(0.63 – 1.09)

ÅÅÅO

moderate

Trivial to no effect

Network evidence

GRADE = Grading of Recommendations Assessment, Development and Evaluation

Elaborate risk of bias assessment

Reasons for exclusion after full text review

	Study	Reason for exclusion
1	Abdelrahman 2020¹	No data available
2	Actrn 2020²	Intra-cavity lavage
3	Actrn 2012³	Outcome, comparison or setting not of interest
4	Akhavan-Sigari 2019⁴	Conference abstract of included study (Akhavan-Sigari 2020)⁵
5	Aneja 2022⁶	Study protocol
6	Arslan 2020⁷	No randomisation
7	Baker 1994⁸	Before the year 2000
8	Bhandari 2015⁹	Outcome, comparison or setting not of interest
9	Bourgeois 1985¹⁰	Before the year 2000
10	Calkins 2019¹¹	Same data as Calkins 2020¹²
11	Calkins 2020¹²	Outcome, comparison or setting not of interest
12	Conover 1984¹³	Before the year 2000
13	Ctri 2023¹⁴	Study protocol
14	Ctri 2022¹⁵	Study registration: no data available
15	Ctri 2021¹⁶	Study registration: no data available
16	Ctri 2021¹⁷	Study registration: intra-cavity lavage
17	Ctri 2012¹⁸	Study registration: no data available
18	De Jong 1982¹⁹	Before the year 2000
19	Dineen 2015²⁰	No randomisation
20	Donnenfeld 1986²¹	Before the year 2000
21	Drks 2022²²	Intra-cavity lavage
22	Drks 2014²³	No randomisation
23	Drks 2013²⁴	Study registration: no data available
24	Elliott 1986²⁵	Before the year 2000
25	Englund 2019²⁶	No randomisation
26	Euctr 2017²⁷	Study protocol of included study (Mueller 2023)²⁸
27	Freischlag 1984²⁹	Before the year 2000
28	Greig 1987³⁰	Before the year 2000
29	Hargrove 2006³¹	Outcome, comparison or setting not of interest
30	Harrigill 2003³²	Intra-cavity lavage
31	Irct20140503017537N, 2019³³	Study protocol
32	Irct20200126046261N, 2020³⁴	Study protocol
33	Isrctn 2005³⁵	Intra-cavity lavage
34	Karuserci 2021³⁶	Same data as included study (Karuserci 2022)³⁷
35	Kellum 1985³⁸	Before the year 2000
36	Ko 1992³⁹	Before the year 2000
37	Lavery 1986⁴⁰	Before the year 2000
38	Levin 1983⁴¹	Before the year 2000
39	Lindsey 1982⁴²	Before the year 2000
40	Liu 2017⁴³	Intra-cavity lavage
41	Lord 1983⁴⁴	Before the year 2000
42	Lord 1977⁴⁵	Before the year 2000
43	Maatman 2019⁴⁶	Intra-cavity lavage
44	Maemoto 2021⁴⁷	Study protocol of included study (Maemoto 2023)⁴⁸
45	Magann 1993⁴⁹	Before the year 2000
46	Mahomed 2016⁵⁰	Conference abstract of included study (Mahomed 2016)⁵¹
47	Marti 1979⁵²	Before the year 2000
48	Mashbari 2018⁵³	Intra-cavity lavage
49	Mathelier 1992⁵⁴	Before the year 2000
50	Mohd 2010⁵⁵	Outcome, comparison or setting not of interest
51	Moradi 2019⁵⁶	Intra-cavity lavage
52	Mueller 2017⁵⁷	Study protocol of included study (Mueller 2023)²⁸
53	Nct 2022⁵⁸	Study protocol
54	Nct 2022⁵⁹	Study protocol
55	Nct 2022⁶⁰	Study protocol
56	Nct 2020⁶¹	Study protocol
57	Nct 2020⁶²	Study protocol of included study (Emile 2020)⁶³
58	Nct 2019⁶⁴	Study protocol of included study (Strobel 2020)⁶⁵
59	Nct 2018⁶⁶	Study protocol
60	Nct 2018⁶⁷	Study protocol of included study (Emile 2020)⁶³
61	Nct 2017⁶⁸	Intra-cavity lavage
62	Nct 2016⁶⁹	Intra-cavity lavage
63	Nct 2015⁷⁰	Same data as included study (Nguyen 2021)⁷¹
64	Nct 2015⁷²	Study protocol of included study (Cohen 2020)⁷³
65	Nct 2014⁷⁴	Outcome, comparison or setting not of interest
66	Nct 2012⁷⁵	No data available
67	Nct 2012⁷⁶	Study protocol of included study (Etaati 2012)⁷⁷
68	Nct 2011⁷⁸	Intra-cavity lavage
69	Nct 2008⁷⁹	Study protocol of included study (Bhandari 2015)⁹
70	Nikfarjam 2014⁸⁰	Outcome, comparison or setting not of interest
71	Oestreicher 1989⁸¹	Before the year 2000
72	Patellugari 2020⁸²	Outcome, comparison or setting not of interest
73	Pitt 1980⁸³	Before the year 2000
74	Pitt 1982⁸⁴	Before the year 2000
75	Pollock 1978⁸⁵	Before the year 2000
76	Quiroga-Garza 2017⁸⁶	Outcome, comparison or setting not of interest
77	Rambo 1972⁸⁷	Before the year 2000
78	Rogers 1983⁸⁸	Before the year 2000
79	Ruiz-Tovar 2016⁸⁹	Intra-cavity lavage
80	Ruiz-Tovar 2011⁹⁰	Intra-cavity lavage
81	Ruiz-Tovar 2012⁹¹	Intra-cavity lavage
82	Ruiz-Tovar 2016⁹²	Same data as Ruiz-Tovar 2016⁸⁹
83	Salamat 2022⁹³	Outcome, comparison or setting not of interest
84	Schottel 2016⁹⁴	Outcome, comparison or setting not of interest
85	Silverman 1986⁹⁵	Before the year 2000
86	Sindelar 1985⁹⁶	Before the year 2000
87	Sindelar 1979⁹⁷	Before the year 2000
88	Sindelar 1977⁹⁸	Before the year 2000
89	Sood 1985⁹⁹	Before the year 2000
90	Tanaka 2015¹⁰⁰	Intra-cavity lavage
91	Tanphiphat 1978¹⁰¹	Before the year 2000
92	Tctr 2021¹⁰²	Study protocol
93	Temizkan 2016¹⁰³	Intra-cavity lavage
94	Terzi 2015¹⁰⁴	Conference abstract of Arslan 2020⁷
95	Tighe 1982¹⁰⁵	Before the year 2000
96	Umin 2019¹⁰⁶	Study protocol of included study (Maeomoto 2023)⁴⁸
97	Umin 2012¹⁰⁷	Intra-cavity lavage
98	Umin 2011¹⁰⁸	Intra-cavity lavage
99	Vinay 2020¹⁰⁹	Conference abstract of included study (Vinay 2019)¹¹⁰
100	Viney 2012¹¹¹	Intra-cavity lavage
101	Weiss 2013¹¹²	Outcome, comparison or setting not of interest
102	Wu 1992¹¹³	Before the year 2000
103	Wu 1991¹¹⁴	Before the year 2000
104	Yang 2021¹¹⁵	Intra-cavity lavage
105	Yazdi 2014¹¹⁶	Outcome, comparison or setting not of interest
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Wound sepsis after colorectal surgery: the effect of cefotetan lavage. Chemioterapia 6, 595-596, doi:doi: (1987). 31 Hargrove, R. et al. Does pulse lavage reduce hip hemiarthroplasty infection rates? Journal of hospital infection 62, 446‐449, doi:doi:10.1016/j.jhin.2005.07.012 (2006). 32 Harrigill, K. M., Miller, H. S. & Haynes, D. E. The effect of intraabdominal irrigation at cesarean delivery on maternal morbidity: A randomized trial. Obstetrics and Gynecology 101, 80-85, doi:doi:https://dx.doi.org/10.1016/S0029-7844%2802%2902466-3 (2003). 33 Irct20140503017537N. The effects of hydrogen peroxide irrigation on postoperative complications of rhinoplasty. https://trialsearch.who.int/Trial2.aspx?TrialID=IRCT20140503017537N6, doi:doi: (2019). 34 Irct20200126046261N. The effect of Gentamicin at cesarean section infection. https://trialsearch.who.int/Trial2.aspx?TrialID=IRCT20200126046261N1, doi:doi: (2020). 35 Isrctn. Intraabdominal irrigation at caesarean delivery and infectious morbidity: randomised controlled trial (RCT). https://trialsearch.who.int/Trial2.aspx?TrialID=ISRCTN64436929, doi:doi: (2005). 36 Komurcu Karuserci, O. & Sucu, S. Subcutaneous irrigation with rifampicin vs. povidone-iodine for the prevention of incisional surgical site infections following caesarean section: a prospective, randomised, controlled trial. Journal of obstetrics and gynaecology, doi:doi: (2021). 37 Komurcu Karuserci, O. & Sucu, S. Subcutaneous irrigation with rifampicin vs. povidone-iodine for the prevention of incisional surgical site infections following caesarean section: a prospective, randomised, controlled trial. Journal of Obstetrics and Gynaecology 42, 951-956, doi:doi:https://dx.doi.org/10.1080/01443615.2021.1964453 (2022). 38 Kellum, R. B., Roberts, W. E., Harris, J. B., Khansur, N. & Morrison, J. C. Effect of intrauterine antibiotic lavage after cesarean birth on postoperative morbidity. Journal of reproductive medicine 30, 527‐529, doi:doi: (1985). 39 Ko, W., Lazenby, W. D., Zelano, J. A., Isom, O. W. & Krieger, K. H. Effects of shaving methods and intraoperative irrigation on suppurative mediastinitis after bypass operations. Annals of thoracic surgery 53, 301‐305, doi:doi:10.1016/0003-4975(92)91337-9 (1992). 40 Lavery, J. P. et al. Mezlocillin prophylaxis against infection after cesarean section: a comparison of techniques. Southern medical journal 79, 1248‐1251, doi:doi:10.1097/00007611-198610000-00013 (1986). 41 Levin, D. K., Gorchels, C. & Andersen, R. Reduction of post-cesarean section infectious morbidity by means of antibiotic irrigation. Am J Obstet Gynecol 147, 273-277, doi:doi:10.1016/0002-9378(83)91110-9 (1983). 42 Lindsey, D., Nava, C. & Marti, M. Effectiveness of penicillin irrigation in control of infection in sutured lacerations. Journal of trauma 22, 186‐189, doi:doi:10.1097/00005373-198203000-00002 (1982). 43 Liu, J. et al. A contrast study of Dermacyn on enterocoely irrigate to control intraoperative infection. Minerva chirurgica 72, 121‐124, doi:doi:10.23736/S0026-4733.16.07192-3 (2017). 44 Lord, J. W., LaRaja, R. D., Daliana, M. & Gordon, M. T. Prophylactic antibiotic wound irrigation in gastric, biliary, and colonic surgery. American journal of surgery 145, 209‐212, doi:doi:10.1016/0002-9610(83)90064-8 (1983). 45 Lord, J. W., Rossi, G. & Daliana, M. Intraoperative antibiotic wound lavage: an attempt to eliminate postoperative infection in arterial and clean general surgical procedures. Annals of surgery 185, 634‐641, doi:doi:10.1097/00000658-197706000-00004 (1977). 46 Maatman, T. K. et al. Antibiotic irrigation during pancreatoduodenectomy to prevent infection and pancreatic fistula: A randomized controlled clinical trial. Surgery (United States) 166, 469-475, doi:doi:https://dx.doi.org/10.1016/j.surg.2019.05.053 (2019). 47 Maemoto, R. et al. Superiority trial comparing intraoperative wound irrigation with aqueous 10% povidone–iodine to saline for the purpose of reducing surgical site infection after elective gastrointestinal surgery: study protocol for a randomised controlled trial. BMJ open 11, doi:doi:10.1136/bmjopen-2021-051374 (2021). 48 Maemoto, R. et al. Aqueous Povidone-Iodine Versus Normal Saline For Intraoperative Wound Irrigation on The Incidence of Surgical Site Infection in Clean-Contaminated Wounds After Gastroenterological Surgery: A Single-Institute, Prospective, Blinded-Endpoint, Randomized Controlled Trial. Annals of Surgery 277, 727-733, doi:10.1097/Sla.0000000000005786 (2023). 49 Magann, E. F. et al. Preoperative skin preparation and intraoperative pelvic irrigation: impact on post-cesarean endometritis and wound infection. Obstetrics and gynecology 81, 922‐925, doi:doi: (1993). 50 Mahomed, K., Ibiebele, I. & Buchanan, J. Povidone-Iodine wound irrigation prior to skin closure at caesarean section to prevent surgical site infection: A randomised controlled trial. BJOG: An International Journal of Obstetrics and Gynaecology 123, 146-147, doi:doi:https://dx.doi.org/10.1111/1471-0528.14106 (2016). 51 Mahomed, K., Ibiebele, I. & Buchanan, J. The Betadine trial - antiseptic wound irrigation prior to skin closure at caesarean section to prevent surgical site infection: A randomised controlled trial. Australian & New Zealand Journal of Obstetrics & Gynaecology 56, 301-306, doi:doi:10.1111/ajo.12437 (2016). 52 Marti, M. C. & Moser, G. Prevention of parietal septic complications by irrigation of the surgical wound. Helvetica chirurgica acta 45, 739‐742, doi:doi: (1979). 53 Mashbari, H. et al. A randomized controlled trial on intra-abdominal irrigation during emergency trauma laparotomy; Time for yet another paradigm shift. Bulletin of Emergency and Trauma 6, 100-107, doi:doi:https://dx.doi.org/10.29252/beat-060203 (2018). 54 Mathelier, A. C. A comparison of postoperative morbidity following prophylactic antibiotic administration by combined irrigation and intravenous route or by intravenous route alone during cesarean section. Journal of perinatal medicine 20, 177‐182, doi:doi:10.1515/jpme.1992.20.3.177 (1992). 55 Mohd, A. R., Ghani, M. K., Awang, R. R., Su Min, J. O. & Dimon, M. Z. Dermacyn irrigation in reducing infection of a median sternotomy wound. Heart surgery forum 13, E228‐232, doi:doi:10.1532/HSF98.20091162 (2010). 56 Moradi, M., Alemrajabi, M., Negahi, A., Vaseghi, H. & Arminfard, A. Gentamicin-clindamycin lavage on post-operational pain and infection in laparoscopic colectomy surgery. Colorectal disease 21, 17‐, doi:doi: (2019). 57 Mueller, T. C. et al. 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A Randomized Controlled Trial on Wound Irrigation in Open Appendectomy. https://clinicaltrials.gov/show/NCT04332809, doi:doi: (2020). 63 Emile, S. H., Elfallal, A. H., Abdel-Razik, M. A., El-Said, M. & Elshobaky, A. A randomized controlled trial on irrigation of open appendectomy wound with gentamicin- saline solution versus saline solution for prevention of surgical site infection. International Journal of Surgery 81, 140-146, doi:doi:https://dx.doi.org/10.1016/j.ijsu.2020.07.057 (2020). 64 Nct. Reduction of Postoperative Wound Infections by Antiseptica? https://clinicaltrials.gov/show/NCT04055233, doi:doi: (2019). 65 Strobel, R. M. et al. Reduction of Postoperative Wound Infections by Antiseptica (RECIPE)?: A Randomized Controlled Trial. Annals of surgery 272, 55-64, doi:doi:https://dx.doi.org/10.1097/SLA.0000000000003645 (2020). 66 Nct. Subcutaneous Tissue Irrigation With Povidone Iodine in Decreasing the Rate of Surgical Site Infection Following Cesarean Section. https://clinicaltrials.gov/show/NCT03549702, doi:doi: (2018). 67 Nct. Role of Wound Irrigation With Saline-gentamicin in Prevention of Wound Infection After Appendectomy. https://clinicaltrials.gov/show/NCT03773224, doi:doi: (2018). 68 Nct. The Effect of Intraabdominal Saline Irrigation in Abdominal Hysterectomies. https://clinicaltrials.gov/show/NCT03085732, doi:doi: (2017). 69 Nct. Betadine Irrigation in Cesarean Section. https://clinicaltrials.gov/show/NCT02865993, doi:doi: (2016). 70 Nct. Surgical Site Infection With 0.05% Chlorhexidine (CHG) Compared to Triple Antibiotic Irrigation. https://clinicaltrials.gov/show/NCT02395614, doi:doi: (2015). 71 Nguyen, L. et al. Post-Mastectomy Surgical Pocket Irrigation with Triple Antibiotic Solution vs Chlorhexidine Gluconate: A Randomized Controlled Trial Assessing Surgical Site Infections in Immediate Tissue Expander Breast Reconstruction. Aesthetic Surgery Journal 41, NP1521-NP1528, doi:doi:https://dx.doi.org/10.1093/asj/sjab290 (2021). 72 Nct. Bacterial Contamination: iodine vs Saline Irrigation in Pediatric Spine Surgery. https://clinicaltrials.gov/show/NCT02527512, doi:doi: (2015). 73 Cohen, L. L. et al. Why Irrigate for the Same Contamination Rate: wound Contamination in Pediatric Spinal Surgery Using Betadine Versus Saline. Journal of pediatric orthopedics 40, e994‐e998, doi:doi:10.1097/BPO.0000000000001620 (2020). 74 Nct. IrrSept vs. Standard of Care in Prevention of Surgical Site Infections. https://clinicaltrials.gov/show/NCT02255487, doi:doi: (2014). 75 Nct. The Use of Diluted Povidone Iodine Irrigation in Spine Surgery. https://clinicaltrials.gov/show/NCT01577524, doi:doi: (2012). 76 Nct. Effect of Cefazolin and Normal Saline Irrigation on Surgical Site Infections (SSIs). https://clinicaltrials.gov/show/NCT01566734, doi:doi: (2012). 77 Etaati, Z. R., M.; Rajaee, M.; Askari, A.; Hosseini, S. Cefazoline or Normal Saline Irrigation Doesn’t Reduce Surgical Site Infections After Cesarean. International Electronic Journal of Medicine (IEJM) 1, 6-11 (2012). 78 Nct. Effect of Peritoneal Lavage With Clindamycin-gentamicin Solution on Postoperative Colorectal Cancer Infection in Elective Surgery. https://clinicaltrials.gov/show/NCT01378832, doi:doi: (2011). 79 Nct. Fluid Lavage of Open Wounds. https://clinicaltrials.gov/show/NCT00788398, doi:doi: (2008). 80 Nikfarjam, M. et al. Pressurized pulse irrigation with saline reduces surgical-site infections following major hepatobiliary and pancreatic surgery: randomized controlled trial. World journal of surgery 38, 447-455, doi:doi:https://dx.doi.org/10.1007/s00268-013-2309-x (2014). 81 Oestreicher, M. & Tschantz, P. 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British journal of surgery 65, 76‐80, doi:doi:10.1002/bjs.1800650204 (1978). 86 Quiroga-Garza, A. et al. A Prospective, Randomized, Controlled Clinical Trial to Assess Use of 2% Lidocaine Irrigation to Prevent Abdominal Surgical Site Infection. Ostomy/wound management 63, 12‐21, doi:doi: (2017). 87 Rambo, W. M. Irrigation of the peritoneal cavity with cephalothin. American journal of surgery 123, 192‐195, doi:doi:10.1016/0002-9610(72)90332-7 (1972). 88 Rogers, D. M., Blouin, G. S. & O'Leary, J. P. Povidone-iodine wound irrigation and wound sepsis. Surgery, gynecology & obstetrics 157, 426‐430, doi:doi: (1983). 89 Ruiz-Tovar, J., Llavero, C., Muñoz, J. L., Zubiaga, L. & Diez, M. Effect of Peritoneal Lavage with Clindamycin-Gentamicin Solution on Post-Operative Pain and Analytic Acute-Phase Reactants after Laparoscopic Sleeve Gastrectomy. Surg Infect (Larchmt) 17, 357-362, doi:doi:10.1089/sur.2015.196 (2016). 90 Ruiz-Tovar, J. et al. Evaluation of the effect of intabdominal irrigation with normal saline and a with a gentamicin-clindamicin solutionon the appearance of postoperative intrabdominal abscess and wound infection after elective surgery for colorectal cancer. Surgical Infections 12, A15, doi:doi:https://dx.doi.org/10.1089/sur.2011.9918 (2011). 91 Ruiz-Tovar, J. et al. Effect of peritoneal lavage with clindamycin-gentamicin solution on infections after elective colorectal cancer surgery. Journal of the American College of Surgeons 214, 202-207, doi:doi:https://dx.doi.org/10.1016/j.jamcollsurg.2011.10.014 (2012). 92 Ruiz-Tovar, J. et al. Effect of Peritoneal Lavage with Clindamycin-Gentamicin Solution during Elective Colorectal Cancer Surgery on the Oncologic Outcome. Surgical Infections 17, 65-70, doi:doi:10.1089/sur.2015.064 (2016). 93 Salamat, N., Khawaja, M. A. & Amir, W. Comparison of the Outcome of Gentamycin Lavage Versus Normal Saline Lavage for Axillary Dissection in Modified Radical Mastectomy. Pakistan journal of medical and health sciences 16, 159‐160, doi:doi:10.53350/pjmhs22169159 (2022). 94 Schottel, P. Wound irrigation pressure did not affect reoperation rate after open fracture repair, but normal saline solution was better than castile soap. Journal of bone and joint surgery - american volume 98, 871‐, doi:doi:10.2106/JBJS.16.00210 (2016). 95 Silverman, S. H., Ambrose, N. S. & Youngs, D. J. The effect of peritoneal lavage with tetracycline solution of postoperative infection. A prospective, randomized, clinical trial. Diseases of the Colon and Rectum 29, 165-169, doi:doi:http://dx.doi.org/10.1007/BF02555014 (1986). 96 Sindelar, W. F., Brower, S. T., Merkel, A. B. & Takesue, E. I. Randomised trial of intraperitoneal irrigation with low molecular weight povidone-iodine solution to reduce intra-abdominal infectious complications. Journal of hospital infection 6, 103‐114, doi:doi:10.1016/s0195-6701(85)80054-2 (1985). 97 Sindelar, W. F. & Mason, G. R. Irrigation of subcutaneous tissue with povidone-iodine solution for prevention of surgical wound infections. Surgery, gynecology & obstetrics 148, 227‐231, doi:doi: (1979). 98 Sindelar, W. F. & Mason, G. R. Efficacy of povidone-iodine irrigation in prevention of surgical wound infections. Surgical forum 28, 48‐51, doi:doi: (1977). 99 Sood, S., Kapur, B. M., Gupta, A. & Shriniwas, n. Role of intra-operative wound lavage in post-operative wound infection. Indian journal of medical research 81, 92‐95, doi:doi: (1985). 100 Tanaka, K. et al. Randomized clinical trial of peritoneal lavage for preventing surgical site infection in elective liver surgery. Journal of Hepato-Biliary-Pancreatic Sciences 22, 446-453, doi:doi:https://dx.doi.org/10.1002/jhbp.222 (2015). 101 Tanphiphat, C. et al. Wound infection in emergency appendicectomy: a prospective trial with tropical ampicillin and antiseptic solution irrigation. 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Prevention of post-operative infection by uterine and intraperitoneal irrigation with ampicillin during cesarean section. International journal of experimental and clinical chemotherapy 4, 132‐136, doi:doi: (1991). 115 Yang, H. K. et al. Extensive peritoneal lavage with saline after curative gastrectomy for gastric cancer (EXPEL): a multicentre randomised controlled trial. The lancet. Gastroenterology & hepatology 6, 120‐127, doi:doi:10.1016/S2468-1253(20)30315-0 (2021). 116 Yazdi, H., Moradi, A. & Herbort, M. The effect of gentamicin in irrigating solutions on articular infection prophylaxis during arthroscopic ACL reconstruction. Archives of Orthopaedic and Trauma Surgery 134, 257-261, doi:doi:https://dx.doi.org/10.1007/s00402-013-1910-7 (2014).

Verantwoording

Autorisatiedatum en geldigheid

Laatst beoordeeld : 01-12-2024

Laatst geautoriseerd : 01-12-2024

Geplande herbeoordeling : 01-12-2026

Initiatief en autorisatie

Initiatief:

Nederlandse Vereniging voor Heelkunde
Samenwerkingsverband Richtlijnen Infectiepreventie

Geautoriseerd door:

Nederlands Oogheelkundig Gezelschap
Nederlandse Internisten Vereniging
Nederlandse Orthopaedische Vereniging
Nederlandse Vereniging voor Anesthesiologie
Nederlandse Vereniging voor Dermatologie en Venereologie
Nederlandse Vereniging voor Heelkunde
Nederlandse Vereniging voor Keel-Neus-Oorheelkunde en Heelkunde van het Hoofd-Halsgebied
Nederlandse Vereniging voor Kindergeneeskunde
Nederlandse Vereniging voor Medische Microbiologie
Nederlandse Vereniging voor Neurochirurgie
Nederlandse Vereniging voor Obstetrie en Gynaecologie
Nederlandse Vereniging voor Plastische Chirurgie
Nederlandse Vereniging voor Thoraxchirurgie
Verpleegkundigen en Verzorgenden Nederland
Vereniging voor Hygiëne en Infectiepreventie in de Gezondheidszorg
Patiëntenfederatie Nederland
Landelijke Vereniging van Operatieassistenten
Nederlandse Vereniging van Anesthesiemedewerkers

Algemene gegevens

De ontwikkeling/herziening van deze richtlijnmodule werd ondersteund door het Kennisinstituut van de Federatie Medisch Specialisten (www.demedischspecialist.nl/kennisinstituut) en werd gefinancierd uit de Kwaliteitsgelden Medisch Specialisten (SKMS). De financier heeft geen enkele invloed gehad op de inhoud van de richtlijnmodule.

Samenstelling werkgroep

Voor het ontwikkelen van de richtlijnmodules 2 tot 16 is in 2020 op initiatief van de NVvH een multidisciplinaire werkgroep ingesteld, bestaande uit vertegenwoordigers van alle relevante specialismen (zie hiervoor de Samenstelling van de werkgroep) die betrokken zijn bij de zorg voor preventie van postoperatieve wondinfecties. Daarnaast is in 2022 op initiatief van het Samenwerkingsverband Richtlijnen Infectiepreventie (SRI) een separate multidisciplinaire werkgroep samengesteld voor de herziening van de WIP-richtlijn over postoperatieve wondinfecties: module 17-22. De ontwikkelde modules van beide werkgroepen zijn in deze richtlijn samengevoegd.

Belangenverklaringen

De Code ter voorkoming van oneigenlijke beïnvloeding door belangenverstrengeling is gevolgd. Alle werkgroepleden hebben schriftelijk verklaard of zij in de laatste drie jaar directe financiële belangen (betrekking bij een commercieel bedrijf, persoonlijke financiële belangen, onderzoek financiering) of indirecte belangen (persoonlijke relaties, reputatiemanagement) hebben gehad. Gedurende de ontwikkeling of herziening van een module worden wijzigingen in belangen aan de voorzitter doorgegeven. De belangenverklaring wordt opnieuw bevestigd tijdens de commentaarfase.

Een overzicht van de belangen van werkgroepleden en het oordeel over het omgaan met eventuele belangen vindt u in onderstaande tabel. De ondertekende belangenverklaringen zijn op te vragen bij het secretariaat van het Kennisinstituut van de Federatie Medisch Specialisten.

Werkgroeplid	Functie	Nevenfuncties	Gemelde belangen	Ondernomen actie
Mevr. prof. dr. M.A. Boermeester	Chirurg	* Medisch Ethische Commissie, Amsterdam UMC, locatie AMC * Antibiotica Commissie, Amsterdam UMC	Persoonlijke financiële belangen Hieronder staan de beroepsmatige relaties met bedrijfsleven vermeld waarbij eventuele financiële belangen via de AMC Research B.V. lopen, dus institutionele en geen persoonlijke gelden zijn: Skillslab instructeur en/of spreker (consultant) voor KCI/3M, Smith&Nephew, Johnson&Johnson, Gore, BD/Bard, TELABio, GDM, Medtronic, Molnlycke. Persoonlijke relaties Geen. Extern gefinancierd onderzoek Institutionele grants van KCI/3M, Johnson&Johnson en New Compliance. Intellectuele belangen en reputatie Ik maak me sterk voor een 100% evidence-based benadering van maken van aanbevelingen, volledig transparant en reproduceerbaar. Dat is mijn enige belang in deze, geen persoonlijk gewin. Overige belangen Geen.	Extra kritische commentaarronde.
Dhr. dr. M.J. van der Laan	Vaatchirurg	Vice voorzitter Consortium Kwaliteit van Zorg NFU, onbetaald	Persoonlijke financiële belangen Geen. Persoonlijke relaties Geen. Extern gefinancierd onderzoek Geen. Intellectuele belangen en reputatie Geen. Overige belangen Geen.	Geen.
Dhr. dr. W.C. van der Zwet	Arts-microbioloog	Lid Regionaal Coördinatie Team, Limburgs infectiepreventie & ABR Zorgnetwerk (onbetaald)
Dhr. dr. D.R. Buis	Neurochirurg	Lid Hoofdredactieraad Tijdschrift voor Neurologie & Neurochirurgie - onbetaald
Dhr. dr. J.H.M. Goosen	Orthopaedisch Chirurg	Inhoudelijke presentaties voor Smith&Nephew en Zimmer Biomet. Deze worden vergoed per uur.
Mw. drs. H. Jalalzadeh	Arts-onderzoeker	Geen.	Persoonlijke financiële belangen Geen. Persoonlijke relaties Geen. Extern gefinancierd onderzoek Geen. Intellectuele belangen en reputatie Geen. Overige belangen Geen.	Geen.
Dhr. dr. N. Wolfhagen	AIOS chirurgie
Mw. drs. H. Groenen	Arts-onderzoeker
Dhr. dr. F.F.A. Ijpma	Traumachirurg
Dhr. dr. P. Segers	Cardiothoracaal chirurg
Mw. Y.E.M. Dreissen	AIOS neurochirurgie
Dhr. R.R. Schaad	Anesthesioloog

Inbreng patiëntenperspectief

Er werd aandacht besteed aan het patiëntenperspectief door uitnodigen van de Patiëntenfederatie Nederland voor de invitational conference. De verkregen input is meegenomen bij het opstellen van de uitgangsvragen, de keuze voor de uitkomstmaten en bij het opstellen van de overwegingen. De conceptmodules zijn tevens voor commentaar voorgelegd aan de Patiëntenfederatie Nederland en de eventueel aangeleverde commentaren zijn bekeken en verwerkt. Voor de modules 17-22 was de patiëntfederatie vertegenwoordigd in de werkgroep.

Wkkgz & Kwalitatieve raming van mogelijke substantiële financiële gevolgen

Bij de richtlijn is conform de Wet kwaliteit, klachten en geschillen zorg (Wkkgz) een kwalitatieve raming uitgevoerd of de aanbevelingen mogelijk leiden tot substantiële financiële gevolgen. Bij het uitvoeren van deze beoordeling zijn richtlijnmodules op verschillende domeinen getoetst (zie het stroomschema op de Richtlijnendatabase).

Uit de kwalitatieve raming blijkt dat er waarschijnlijk geen substantiële financiële gevolgen zijn.

Voor module 8 (Negatieve druktherapie) geldt dat uit de toetsing volgt dat de aanbeveling(en) breed toepasbaar zijn (5.000 - 40.000 patiënten). Tevens volgt uit de toetsing dat het geen nieuwe manier van zorgverlening of andere organisatie van zorgverlening betreft. Er worden daarom geen substantiële financiële gevolgen verwacht.

Voor de overige modules en aanbevelingen geldt dat uit de toetsing volgt dat de aanbeveling(en) breed toepasbaar zijn (>40.000 patiënten). Tevens volgt uit de toetsing dat het overgrote deel (±90%) van de zorgaanbieders en zorgverleners al aan de norm voldoet en het geen nieuwe manier van zorgverlening of andere organisatie van zorgverlening betreft. Ook wordt geen toename in het aantal in te zetten voltijdsequivalenten aan zorgverleners verwacht of een wijziging in het opleidingsniveau van zorgpersoneel. Er worden daarom geen substantiële financiële gevolgen verwacht.

Methode ontwikkeling

Evidence based

Implementatie

Zie voor de implementatie het implementatieplan in het tabblad 'Bijlagen'.

Werkwijze

AGREE

Deze richtlijnmodule is opgesteld conform de eisen vermeld in het rapport Medisch Specialistische Richtlijnen 2.0 van de adviescommissie Richtlijnen van de Raad Kwaliteit. Dit rapport is gebaseerd op het AGREE II instrument (Appraisal of Guidelines for Research & Evaluation II; Brouwers, 2010).

Knelpuntenanalyse en uitgangsvragen

Tijdens de voorbereidende fase inventariseerde de werkgroepen de knelpunten in de zorg voor patiënten die chirurgie ondergaan. Tevens zijn er knelpunten aangedragen door middel van een invitational conference. De verslagen hiervan zijn opgenomen onder aanverwante producten.

Op basis van de uitkomsten van de knelpuntenanalyse zijn door de werkgroep concept-uitgangsvragen opgesteld en definitief vastgesteld.

Uitkomstmaten

Na het opstellen van de zoekvraag behorende bij de uitgangsvraag inventariseerde de werkgroep welke uitkomstmaten voor de patiënt relevant zijn, waarbij zowel naar gewenste als ongewenste effecten werd gekeken. Hierbij werd een maximum van acht uitkomstmaten gehanteerd. De werkgroep waardeerde deze uitkomstmaten volgens hun relatieve belang bij de besluitvorming rondom aanbevelingen, als cruciaal (kritiek voor de besluitvorming), belangrijk (maar niet cruciaal) en onbelangrijk. Tevens definieerde de werkgroep tenminste voor de cruciale uitkomstmaten welke verschillen zij klinisch (patiënt) relevant vonden.

Methode literatuursamenvatting

Een uitgebreide beschrijving van de strategie voor zoeken en selecteren van literatuur is te vinden onder ‘Zoeken en selecteren’ onder Onderbouwing. Indien mogelijk werd de data uit verschillende studies gepoold in een random-effects model. De beoordeling van de kracht van het wetenschappelijke bewijs wordt hieronder toegelicht.

Beoordelen van de kracht van het wetenschappelijke bewijs

De kracht van het wetenschappelijke bewijs werd bepaald volgens de GRADE-methode. GRADE staat voor ‘Grading Recommendations Assessment, Development and Evaluation’ (zie http://www.gradeworkinggroup.org/). De basisprincipes van de GRADE-methodiek zijn: het benoemen en prioriteren van de klinisch (patiënt) relevante uitkomstmaten, een systematische review per uitkomstmaat, en een beoordeling van de bewijskracht per uitkomstmaat op basis van de acht GRADE-domeinen (domeinen voor downgraden: risk of bias, inconsistentie, indirectheid, imprecisie, en publicatiebias; domeinen voor upgraden: dosis-effect relatie, groot effect, en residuele plausibele confounding).

GRADE onderscheidt vier gradaties voor de kwaliteit van het wetenschappelijk bewijs: hoog, redelijk, laag en zeer laag. Deze gradaties verwijzen naar de mate van zekerheid die er bestaat over de literatuurconclusie, in het bijzonder de mate van zekerheid dat de literatuurconclusie de aanbeveling adequaat ondersteunt (Schünemann, 2013; Hultcrantz, 2017).

GRADE	Definitie
Hoog	er is hoge zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt; het is zeer onwaarschijnlijk dat de literatuurconclusie klinisch relevant verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.
Redelijk	er is redelijke zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt; het is mogelijk dat de conclusie klinisch relevant verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.
Laag	er is lage zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt; er is een reële kans dat de conclusie klinisch relevant verandert wanneer er resultaten van nieuw grootschalig onderzoek aan de literatuuranalyse worden toegevoegd.
Zeer laag	er is zeer lage zekerheid dat het ware effect van behandeling dichtbij het geschatte effect van behandeling ligt; de literatuurconclusie is zeer onzeker.

Bij het beoordelen (graderen) van de kracht van het wetenschappelijk bewijs in richtlijnen volgens de GRADE-methodiek spelen grenzen voor klinische besluitvorming een belangrijke rol (Hultcrantz, 2017). Dit zijn de grenzen die bij overschrijding aanleiding zouden geven tot een aanpassing van de aanbeveling. Om de grenzen voor klinische besluitvorming te bepalen moeten alle relevante uitkomstmaten en overwegingen worden meegewogen. De grenzen voor klinische besluitvorming zijn daarmee niet één op één vergelijkbaar met het minimaal klinisch relevant verschil (Minimal Clinically Important Difference, MCID). Met name in situaties waarin een interventie geen belangrijke nadelen heeft en de kosten relatief laag zijn, kan de grens voor klinische besluitvorming met betrekking tot de effectiviteit van de interventie bij een lagere waarde (dichter bij het nuleffect) liggen dan de MCID (Hultcrantz, 2017).

Overwegingen (van bewijs naar aanbeveling)

Om te komen tot een aanbeveling zijn naast (de kwaliteit van) het wetenschappelijke bewijs ook andere aspecten belangrijk en worden meegewogen, zoals aanvullende argumenten uit bijvoorbeeld de biomechanica of fysiologie, waarden en voorkeuren van patiënten, kosten (middelenbeslag), aanvaardbaarheid, haalbaarheid en implementatie. Deze aspecten zijn systematisch vermeld en beoordeeld (gewogen) onder het kopje ‘Overwegingen’ en kunnen (mede) gebaseerd zijn op expert opinion. Hierbij is gebruik gemaakt van een gestructureerd format gebaseerd op het evidence-to-decision framework van de internationale GRADE Working Group (Alonso-Coello, 2016a; Alonso-Coello 2016b). Dit evidence-to-decision framework is een integraal onderdeel van de GRADE methodiek.

Formuleren van aanbevelingen

De aanbevelingen geven antwoord op de uitgangsvraag en zijn gebaseerd op het beschikbare wetenschappelijke bewijs en de belangrijkste overwegingen, en een weging van de gunstige en ongunstige effecten van de relevante interventies. De kracht van het wetenschappelijk bewijs en het gewicht dat door de werkgroep wordt toegekend aan de overwegingen, bepalen samen de sterkte van de aanbeveling. Conform de GRADE-methodiek sluit een lage bewijskracht van conclusies in de systematische literatuuranalyse een sterke aanbeveling niet a priori uit, en zijn bij een hoge bewijskracht ook zwakke aanbevelingen mogelijk (Agoritsas, 2017; Neumann, 2016). De sterkte van de aanbeveling wordt altijd bepaald door weging van alle relevante argumenten tezamen. De werkgroep heeft bij elke aanbeveling opgenomen hoe zij tot de richting en sterkte van de aanbeveling zijn gekomen.

In de GRADE-methodiek wordt onderscheid gemaakt tussen sterke en zwakke (of conditionele) aanbevelingen. De sterkte van een aanbeveling verwijst naar de mate van zekerheid dat de voordelen van de interventie opwegen tegen de nadelen (of vice versa), gezien over het hele spectrum van patiënten waarvoor de aanbeveling is bedoeld. De sterkte van een aanbeveling heeft duidelijke implicaties voor patiënten, behandelaars en beleidsmakers (zie onderstaande tabel). Een aanbeveling is geen dictaat, zelfs een sterke aanbeveling gebaseerd op bewijs van hoge kwaliteit (GRADE gradering HOOG) zal niet altijd van toepassing zijn, onder alle mogelijke omstandigheden en voor elke individuele patiënt.

Implicaties van sterke en zwakke aanbevelingen voor verschillende richtlijngebruikers
	Sterke aanbeveling	Zwakke (conditionele) aanbeveling
Voor patiënten	De meeste patiënten zouden de aanbevolen interventie of aanpak kiezen en slechts een klein aantal niet.	Een aanzienlijk deel van de patiënten zouden de aanbevolen interventie of aanpak kiezen, maar veel patiënten ook niet.
Voor behandelaars	De meeste patiënten zouden de aanbevolen interventie of aanpak moeten ontvangen.	Er zijn meerdere geschikte interventies of aanpakken. De patiënt moet worden ondersteund bij de keuze voor de interventie of aanpak die het beste aansluit bij zijn of haar waarden en voorkeuren.
Voor beleidsmakers	De aanbevolen interventie of aanpak kan worden gezien als standaardbeleid.	Beleidsbepaling vereist uitvoerige discussie met betrokkenheid van veel stakeholders. Er is een grotere kans op lokale beleidsverschillen.

Organisatie van zorg

In de knelpuntenanalyse en bij de ontwikkeling van de richtlijnmodule is expliciet aandacht geweest voor de organisatie van zorg: alle aspecten die randvoorwaardelijk zijn voor het verlenen van zorg (zoals coördinatie, communicatie, (financiële) middelen, mankracht en infrastructuur). Randvoorwaarden die relevant zijn voor het beantwoorden van deze specifieke uitgangsvraag zijn genoemd bij de overwegingen. Meer algemene, overkoepelende, of bijkomende aspecten van de organisatie van zorg worden behandeld in de module Organisatie van zorg.

Commentaar- en autorisatiefase

De conceptrichtlijnmodule werd aan de betrokken (wetenschappelijke) verenigingen en (patiënt) organisaties voorgelegd ter commentaar. De commentaren werden verzameld en besproken met de werkgroep. Naar aanleiding van de commentaren werd de conceptrichtlijnmodule aangepast en definitief vastgesteld door de werkgroep. De definitieve richtlijnmodule werd aan de deelnemende (wetenschappelijke) verenigingen en (patiënt) organisaties voorgelegd voor autorisatie en door hen geautoriseerd dan wel geaccordeerd.

Adaptatie

Een aantal modules van deze richtlijn betreft een adaptatie van modules van de World Health Organization (WHO)-richtlijn ‘Global guidelines for the prevention of surgical site infection’ (WHO, 2018), te weten:

Module Normothermie
Module Immunosuppressive middelen
Module Glykemische controle
Module Antimicrobiële afdichtingsmiddelen
Module Wondbeschermers bij laparotomie
Module Preoperatief douchen
Module Preoperatief verwijderen van haar
Module Chirurgische handschoenen: Vervangen en type handschoenen
Module Afdekmaterialen en operatiejassen

Methode

Uitgangsvragen zijn opgesteld in overeenstemming met de standaardprocedures van het Kennisinstituut van de Federatie Medisch Specialisten.
De inleiding van iedere module betreft een korte uiteenzetting van het knelpunt, waarbij eventuele onduidelijkheid en praktijkvariatie voor de Nederlandse setting wordt beschreven.
Het literatuuronderzoek is overgenomen uit de WHO-richtlijn. Afhankelijk van de beoordeling van de actualiteit van de richtlijn is een update van het literatuuronderzoek uitgevoerd.
De samenvatting van de literatuur is overgenomen van de WHO-richtlijn, waarbij door de werkgroep onderscheid is gemaakt tussen ‘cruciale’ en ‘belangrijke’ uitkomsten. Daarnaast zijn door de werkgroep grenzen voor klinische besluitvorming gedefinieerd in overeenstemming met de standaardprocedures van het Kennisinstituut van de Federatie Medisch Specialisten, en is de interpretatie van de bevindingen primair gebaseerd op klinische relevantie van het gevonden effect, niet op statistische significantie. In de meta-analyses zijn naast odds-ratio’s ook relatief risico’s en risicoverschillen gerapporteerd.
De beoordeling van de mate van bewijskracht is overgnomen van de WHO-richtlijn, waarbij de beoordeling is gecontroleerd op consistentie met de standaardprocedures van het Kennisinstituut van de Federatie Medisch Specialisten (GRADE-methode; http://www.gradeworkinggroup.org/). Eventueel door de WHO gerapporteerde bewijskracht voor observationele studies is niet overgenomen indien ook gerandomiseerde gecontroleerde studies beschikbaar waren.
De conclusies van de literatuuranalyse zijn geformuleerd in overeenstemming met de standaardprocedures van het Kennisinstituut van de Federatie Medisch Specialisten.
In de overwegingen heeft de werkgroep voor iedere aanbeveling het bewijs waarop de aanbeveling is gebaseerd en de aanvaardbaarheid en toepasbaarheid van de aanbeveling voor de Nederlandse klinische praktijk beoordeeld. Op basis van deze beoordeling is door de werkgroep besloten welke aanbevelingen ongewijzigd zijn overgenomen, welke aanbevelingen niet zijn overgenomen, en welke aanbevelingen (mits in overeenstemming met het bewijs) zijn aangepast naar de Nederlandse context. ‘De novo’ aanbevelingen zijn gedaan in situaties waarin de werkgroep van mening was dat een aanbeveling nodig was, maar deze niet als zodanig in de WHO-richtlijn was opgenomen. Voor elke aanbeveling is vermeld hoe deze tot stand is gekomen, te weten: ‘WHO’, ‘aangepast van WHO’ of ‘de novo’.

Voor een verdere toelichting op de procedure van adapteren wordt verwezen naar de Bijlage Adapteren.

Literatuur

Agoritsas T, Merglen A, Heen AF, Kristiansen A, Neumann I, Brito JP, Brignardello-Petersen R, Alexander PE, Rind DM, Vandvik PO, Guyatt GH. UpToDate adherence to GRADE criteria for strong recommendations: an analytical survey. BMJ Open. 2017 Nov 16;7(11):e018593. doi: 10.1136/bmjopen-2017-018593. PubMed PMID: 29150475; PubMed Central PMCID: PMC5701989.

Alonso-Coello P, Schünemann HJ, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Rada G, Rosenbaum S, Morelli A, Guyatt GH, Oxman AD; GRADE Working Group. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction. BMJ. 2016 Jun 28;353:i2016. doi: 10.1136/bmj.i2016. PubMed PMID: 27353417.

Alonso-Coello P, Oxman AD, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Vandvik PO, Meerpohl J, Guyatt GH, Schünemann HJ; GRADE Working Group. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines. BMJ. 2016 Jun 30;353:i2089. doi: 10.1136/bmj.i2089. PubMed PMID: 27365494.

Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L; AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010 Dec 14;182(18):E839-42. doi: 10.1503/cmaj.090449. Epub 2010 Jul 5. Review. PubMed PMID: 20603348; PubMed Central PMCID: PMC3001530.

Hultcrantz M, Rind D, Akl EA, Treweek S, Mustafa RA, Iorio A, Alper BS, Meerpohl JJ, Murad MH, Ansari MT, Katikireddi SV, Östlund P, Tranæus S, Christensen R, Gartlehner G, Brozek J, Izcovich A, Schünemann H, Guyatt G. The GRADE Working Group clarifies the construct of certainty of evidence. J Clin Epidemiol. 2017 Jul;87:4-13. doi: 10.1016/j.jclinepi.2017.05.006. Epub 2017 May 18. PubMed PMID: 28529184; PubMed Central PMCID: PMC6542664.

Medisch Specialistische Richtlijnen 2.0 (2012). Adviescommissie Richtlijnen van de Raad Kwalitieit. http://richtlijnendatabase.nl/over_deze_site/over_richtlijnontwikkeling.html

Neumann I, Santesso N, Akl EA, Rind DM, Vandvik PO, Alonso-Coello P, Agoritsas T, Mustafa RA, Alexander PE, Schünemann H, Guyatt GH. A guide for health professionals to interpret and use recommendations in guidelines developed with the GRADE approach. J Clin Epidemiol. 2016 Apr;72:45-55. doi: 10.1016/j.jclinepi.2015.11.017. Epub 2016 Jan 6. Review. PubMed PMID: 26772609.

Schünemann H, Brożek J, Guyatt G, et al. GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, 2013. Available from http://gdt.guidelinedevelopment.org/central_prod/_design/client/handbook/handbook.html.

World Health Organization. Global guidelines for the prevention of surgical site infection,

second edition. Geneva: World Health Organization; 2018. (https://www.who.int/publications/i/item/9789241550475, accessed 12 June 2023).

Zoekverantwoording

Zoekacties zijn opvraagbaar. Neem hiervoor contact op met de Richtlijnendatabase.

Richtlijnendatabase

Preventie van postoperatieve wondinfecties

Preventie van postoperatieve wondinfecties

Wondirrigatie

Uitgangsvraag

Aanbeveling

Overwegingen

Onderbouwing

Achtergrond

Conclusies

Samenvatting literatuur

Zoeken en selecteren

Referenties

Evidence tabellen

Verantwoording

Autorisatiedatum en geldigheid

Initiatief en autorisatie

Algemene gegevens

Samenstelling werkgroep

Belangenverklaringen

Inbreng patiëntenperspectief

Methode ontwikkeling

Implementatie

Werkwijze

Zoekverantwoording

Bijlagen