Is there evidence to support the use of antiseptic solutions, such as povidone-iodine (iodine) or chlorhexidine gluconate (CHG), for wound irrigation or abdominal compartment irrigation to reduce infection?

Antiseptic Wound and Abdominal Irrigation for Infection Prevention

Direct Recommendation

The evidence supports using antiseptic solutions (specifically povidone-iodine) for incisional wound irrigation to reduce surgical site infections, but NOT antibiotic irrigation, and the evidence for intra-abdominal/peritoneal irrigation remains insufficient to make a strong recommendation. 1

---

Incisional Wound Irrigation

Antiseptic Solutions (Povidone-Iodine)

Povidone-iodine incisional wound irrigation demonstrates benefit in reducing SSIs, though recent data suggest this recommendation requires reconsideration pending higher-quality trials. 1

• Aqueous povidone-iodine solution for incisional wound irrigation in clean and clean-contaminated wounds shows statistically significant benefit (OR 0.31; 95% CI 0.13-0.73), translating to 50 fewer SSIs per 1,000 procedures. 1, 2

• High-certainty evidence from a 2024 network meta-analysis demonstrates that antiseptic solutions reduce SSIs compared to no irrigation (RR 0.60; 95% CI 0.44-0.81). 3

• The World Society of Emergency Surgery (2023) acknowledges povidone-iodine's association with lower SSI rates compared to saline-only irrigation, though this evidence derives primarily from elective surgery settings. 1

• Recent Chinese and Japanese RCTs challenge povidone-iodine superiority, prompting the recommendation that future prospective high-quality trials are needed before definitive conclusions. 1

Antibiotic Irrigation - NOT RECOMMENDED

Antibiotic irrigation should NOT be used for wound irrigation. 1

• Antibiotic irrigation shows no significant benefit in reducing SSIs (OR 1.16; 95% CI 0.64-2.12) and contributes to antimicrobial resistance. 1, 2

• The 2023 World Society of Emergency Surgery guidelines explicitly recommend against antibiotic irrigation in clean, clean-contaminated, and contaminated surgical fields. 1

• Low-certainty evidence from a 2024 meta-analysis suggests avoiding antibiotic wound irrigation due to inferior evidence quality and global antimicrobial resistance concerns, despite showing RR 0.46 (95% CI 0.29-0.73). 3

Saline Irrigation

• Saline irrigation alone shows no statistically significant difference compared to no irrigation (RR 0.83; 95% CI 0.63-1.09). 3

• Standard saline irrigation without pressure application is not effective in reducing SSIs. 1

• Pulse pressure irrigation with saline demonstrates benefit compared to normal saline irrigation (OR 0.30; 95% CI 0.08-0.86). 1

Chlorhexidine Gluconate (CHG)

• Laboratory and animal studies using aqueous 0.05% chlorhexidine gluconate show favorable results, but clinical evidence remains limited and requires further evaluation. 4

• Chlorhexidine is generally considered less effective than povidone-iodine for wound irrigation. 5

---

Intra-Abdominal/Peritoneal Irrigation

Current Evidence Status

There is insufficient evidence to support or refute routine intra-abdominal irrigation for infection prevention. 1

• The 2023 ERAS Society guidelines recommend routine abdominal irrigation as part of an SSI reduction bundle (along with fascial wound protectors and glove/instrument changes), with moderate evidence level and strong recommendation grade. 1

• The clinical practice of intra-operative peritoneal lavage is highly variable and depends solely on surgeon preference, with limited standardization. 4

• Evidence comparing irrigation versus no irrigation in the abdominal cavity shows substantial heterogeneity and controversial results. 5

---

Practical Implementation Algorithm

For Incisional Wounds:

1. Clean and Clean-Contaminated Wounds:

   • Use aqueous povidone-iodine solution for incisional wound irrigation before closure. 1, 2, 3
   • Apply with sufficient pressure to remove debris and contamination. 1
   • Avoid antibiotic irrigation. 1

2. Contaminated and Dirty Wounds:

   • Consider povidone-iodine irrigation, especially with significant soil or foreign material contamination. 6
   • Ensure thorough irrigation until no visible debris remains. 6, 7

3. Superficial Wounds/Abrasions:

   • Running tap water or sterile saline are preferred over antiseptic agents for most superficial wounds. 6, 7
   • Povidone-iodine may be considered only for heavily contaminated wounds with high infection risk. 6

For Abdominal Compartment:

1. Emergency Laparotomy:

   • Consider abdominal irrigation as part of a comprehensive SSI prevention bundle (including wound protectors, glove changes, new closure instruments). 1
   • Evidence quality is moderate; practice remains surgeon-dependent. 1, 4

2. Avoid:

   • Routine prophylactic intra-abdominal drains (high-quality evidence against routine use). 1

---

Critical Caveats and Pitfalls

Evidence Quality Concerns

• All wound irrigation studies demonstrate considerable risk of bias, large heterogeneity, and variable follow-up periods (as short as 5-10 days). 1

• The certainty of evidence for povidone-iodine is LOW, requiring cautious clinical application balanced against potential impaired wound healing and bacterial resistance risks. 1

Contradictory Evidence

• Norman et al. Cochrane review supports antibacterial irrigation over non-antibacterial irrigation, while de Jonge et al. systematic review shows antibiotic irrigation offers no benefit and contributes to antimicrobial resistance. 1

• This contradiction highlights the need for future high-quality prospective trials to clarify optimal irrigation techniques. 1

Wound Healing Considerations

• Vigorous irrigation may remove protective immunologic cells necessary for natural healing progression through inflammation, granulation, and re-epithelialization. 1

• Irrigation must be vigorous enough to remove contamination but gentle enough to avoid tissue trauma or driving bacteria deeper into wounds. 1

Resistance and Safety

• No development of resistance has been shown for commonly used antiseptic solutions (povidone-iodine, octenidine, polyhexanide) when contraindications are observed. 8

• Antiseptic solutions demonstrate effectiveness against biofilms and multi-drug resistant pathogens. 8