Abstract：
Surgical site infection (SSI) is the most common postoperative complication and substantially increases health-care costs. Published meta-analyses and international guidelines differ with regard to which preoperative skin antiseptic solution and concentration has the highest efficacy. We aimed to compare the efficacy of different skin preparation solutions and concentrations for the prevention of SSIs, and to provide an overview of current guidelines.
This systematic review and network meta-analysis compared different preoperative skin antiseptics in the prevention of SSIs in adult patients undergoing surgery of any wound classification. We searched for randomised controlled trials (RCTs) in MEDLINE, Embase, and Cochrane CENTRAL, published up to Nov 23, 2021, that directly compared two or more antiseptic agents (ie, chlorhexidine, iodine, or olanexidine) or concentrations in aqueous and alcohol-based solutions. We excluded paediatric, animal, and non-randomised studies, and studies not providing standard preoperative intravenous antibiotic prophylaxis. Studies with no SSIs in both groups were excluded from the quantitative analysis. Two reviewers screened and reviewed eligible full texts and extracted data. The primary outcome was the occurrence of SSI (ie, superficial, deep, and organ space). We conducted a frequentist random effects network meta-analysis to estimate the network effects of the skin preparation solutions on the prevention of SSIs. A risk-of-bias and Grading of Recommendations, Assessment, Development, and Evaluation assessment were done to determine the certainty of the evidence. This study is registered with PROSPERO, CRD42021293554.
Overall, 2326 articles were identified, 33 studies were eligible for the systematic review, and 27 studies with 17 735 patients reporting 2144 SSIs (overall incidence of 12·1%) were included in the quantitative analysis. Only 2·0-2·5% chlorhexidine in alcohol (relative risk 0·75, 95% CI 0·61-0·92) and 1·5% olanexidine (0·49, 0·26-0·92) significantly reduced the rate of SSIs compared with aqueous iodine. For clean surgery, we found no difference in efficacy between different concentrations of chlorhexidine in alcohol. Seven RCTs were at high risk of bias, 24 had some concerns, and two had low risk of bias. Heterogeneity across the studies was moderate (I2=27·5%), and netsplitting did not show inconsistencies between direct and indirect comparisons. Five of ten studies that mentioned adverse events related to the skin preparation solutions reported no adverse events, and five reported a total of 56 mild events (mainly erythema, pruritus, dermatitis, skin irritation, or mild allergic symptoms); none reported a substantial difference in adverse events between groups.
For adult patients undergoing a surgical procedure of any wound classification, skin preparation using either 2·0-2·5% chlorhexidine in alcohol or 1·5% olanexidine is most effective in the prevention of SSIs. For clean surgery, no specific concentration of chlorhexidine in alcohol can be recommended. The efficacy of olanexidine was established by a single randomised trial and further investigation is needed.
Dutch Association for Quality Funds Medical Specialists.
This systematic review and network meta-analysis compared different preoperative skin antiseptics in the prevention of SSIs in adult patients undergoing surgery of any wound classification. We searched for randomised controlled trials (RCTs) in MEDLINE, Embase, and Cochrane CENTRAL, published up to Nov 23, 2021, that directly compared two or more antiseptic agents (ie, chlorhexidine, iodine, or olanexidine) or concentrations in aqueous and alcohol-based solutions. We excluded paediatric, animal, and non-randomised studies, and studies not providing standard preoperative intravenous antibiotic prophylaxis. Studies with no SSIs in both groups were excluded from the quantitative analysis. Two reviewers screened and reviewed eligible full texts and extracted data. The primary outcome was the occurrence of SSI (ie, superficial, deep, and organ space). We conducted a frequentist random effects network meta-analysis to estimate the network effects of the skin preparation solutions on the prevention of SSIs. A risk-of-bias and Grading of Recommendations, Assessment, Development, and Evaluation assessment were done to determine the certainty of the evidence. This study is registered with PROSPERO, CRD42021293554.
Overall, 2326 articles were identified, 33 studies were eligible for the systematic review, and 27 studies with 17 735 patients reporting 2144 SSIs (overall incidence of 12·1%) were included in the quantitative analysis. Only 2·0-2·5% chlorhexidine in alcohol (relative risk 0·75, 95% CI 0·61-0·92) and 1·5% olanexidine (0·49, 0·26-0·92) significantly reduced the rate of SSIs compared with aqueous iodine. For clean surgery, we found no difference in efficacy between different concentrations of chlorhexidine in alcohol. Seven RCTs were at high risk of bias, 24 had some concerns, and two had low risk of bias. Heterogeneity across the studies was moderate (I2=27·5%), and netsplitting did not show inconsistencies between direct and indirect comparisons. Five of ten studies that mentioned adverse events related to the skin preparation solutions reported no adverse events, and five reported a total of 56 mild events (mainly erythema, pruritus, dermatitis, skin irritation, or mild allergic symptoms); none reported a substantial difference in adverse events between groups.
For adult patients undergoing a surgical procedure of any wound classification, skin preparation using either 2·0-2·5% chlorhexidine in alcohol or 1·5% olanexidine is most effective in the prevention of SSIs. For clean surgery, no specific concentration of chlorhexidine in alcohol can be recommended. The efficacy of olanexidine was established by a single randomised trial and further investigation is needed.
Dutch Association for Quality Funds Medical Specialists.
摘要：
手术部位感染（SSI）是最常见的术后并发症，并大大增加了医疗保健成本。已发布的荟萃分析和国际指南在哪些术前皮肤防腐剂溶液和浓度具有最高疗效方面存在差异。我们的目的是比较不同的皮肤准备溶液和浓度预防SSIs的功效，并提供当前指南的概述。
本系统综述和网络荟萃分析比较了不同的术前皮肤防腐剂在预防任何伤口分类手术的成年患者SSIs中的作用。我们搜索了MEDLINE的随机对照试验(RCT)，Embase,和CochraneCENTRAL,截至2021年11月23日发布，直接比较了两种或多种防腐剂(即，氯己定,碘，或奥兰西定）或在水性和醇基溶液中的浓度。我们排除了儿科，动物,和非随机研究，和研究未提供标准的术前静脉内抗生素预防。定量分析中排除了两组均无SSIs的研究。两名审稿人筛选并审查了符合条件的全文，并提取了数据。主要结果是SSI的发生(即，肤浅的,深,和器官空间)。我们进行了频繁随机效应网络荟萃分析，以评估皮肤准备解决方案对预防SSIs的网络效应。偏差风险和建议分级，评估,发展,并进行评估评估以确定证据的确定性。这项研究在PROSPERO注册，CRD42021293554。
总的来说，确定了2326篇文章，33项研究符合系统评价的条件，定量分析中纳入了27项研究，其中17735例患者报告2144个SSIs（总发生率为12·1％）。与碘水溶液相比，仅2·0-2·5％的氯己定（相对风险0·75，95％CI0·61-0·92）和1·5％的奥兰西定（0·49，0·26-0·92）显着降低了SSIs的发生率。对于清洁手术，我们发现不同浓度的氯己定在酒精中的疗效没有差异。七个随机对照试验有很高的偏倚风险，24有一些担忧，和两个有低风险的偏见。研究中的异质性是中等的(I2=27·5%)，并且网络拆分没有显示直接比较和间接比较之间的不一致。提到与皮肤制剂溶液相关的不良事件的10项研究中有5项没有报告不良事件。5例报告了56例轻度事件（主要是红斑，瘙痒,皮炎,皮肤刺激,或轻度过敏症状）；没有报告组间不良事件的实质性差异。
对于接受任何伤口分类外科手术的成年患者，使用2·0-2·5％的氯己定或1·5％的奥兰西定在预防SSIs方面最有效。对于清洁手术，可以推荐在酒精中没有特定浓度的氯己定。奥兰西定的疗效是通过一项随机试验确定的，需要进一步研究。
荷兰质量基金医疗专家协会。
本系统综述和网络荟萃分析比较了不同的术前皮肤防腐剂在预防任何伤口分类手术的成年患者SSIs中的作用。我们搜索了MEDLINE的随机对照试验(RCT)，Embase,和CochraneCENTRAL,截至2021年11月23日发布，直接比较了两种或多种防腐剂(即，氯己定,碘，或奥兰西定）或在水性和醇基溶液中的浓度。我们排除了儿科，动物,和非随机研究，和研究未提供标准的术前静脉内抗生素预防。定量分析中排除了两组均无SSIs的研究。两名审稿人筛选并审查了符合条件的全文，并提取了数据。主要结果是SSI的发生(即，肤浅的,深,和器官空间)。我们进行了频繁随机效应网络荟萃分析，以评估皮肤准备解决方案对预防SSIs的网络效应。偏差风险和建议分级，评估,发展,并进行评估评估以确定证据的确定性。这项研究在PROSPERO注册，CRD42021293554。
总的来说，确定了2326篇文章，33项研究符合系统评价的条件，定量分析中纳入了27项研究，其中17735例患者报告2144个SSIs（总发生率为12·1％）。与碘水溶液相比，仅2·0-2·5％的氯己定（相对风险0·75，95％CI0·61-0·92）和1·5％的奥兰西定（0·49，0·26-0·92）显着降低了SSIs的发生率。对于清洁手术，我们发现不同浓度的氯己定在酒精中的疗效没有差异。七个随机对照试验有很高的偏倚风险，24有一些担忧，和两个有低风险的偏见。研究中的异质性是中等的(I2=27·5%)，并且网络拆分没有显示直接比较和间接比较之间的不一致。提到与皮肤制剂溶液相关的不良事件的10项研究中有5项没有报告不良事件。5例报告了56例轻度事件（主要是红斑，瘙痒,皮炎,皮肤刺激,或轻度过敏症状）；没有报告组间不良事件的实质性差异。
对于接受任何伤口分类外科手术的成年患者，使用2·0-2·5％的氯己定或1·5％的奥兰西定在预防SSIs方面最有效。对于清洁手术，可以推荐在酒精中没有特定浓度的氯己定。奥兰西定的疗效是通过一项随机试验确定的，需要进一步研究。
荷兰质量基金医疗专家协会。
