Alcoholic chlorhexidine skin preparation or triclosan-coated sutures to reduce surgical site infection: a systematic review and meta-analysis of high-quality randomised controlled trials

Adesoji O. Ademuyiwa, Adewale O. Adisa, Simon Bach, Aneel Bhangu, Ewen Harrison, Jc Allen Ingabire, Parvez D Haque, Lawani Ismail, James Glasbey, Dhruva Ghosh, Bryar Kadir, Sivesh K Kamarajah, Elizabeth Li, Rachel Lillywhite, Harvinder Mann, Janet Martin, Antonio Ramos De La Madina, Rachel Moore, Dion Morton, Dmitri NepogodievFaustin Ntirenganya, Thomas Pinkney, Peter Pockney, Omar Omar, Joana Simoes, Neil Smart, Donna Smith, Stephen Tabiri, Elliot Taylor, Richard Wilkin

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Background: WHO and the UK's National Institute for Health and Care Excellence recommend alcoholic chlorhexidine skin preparation and triclosan-coated sutures to prevent surgical site infections (SSIs). Existing meta-analyses that include studies at high risk of bias, combined with the recent publication of large, randomised trials, justify an updated meta-analysis of high-quality randomised controlled trials (RCTs). We aimed to test the rates of SSI according to skin preparation solutions (ie, alcoholic chlorhexidine vs aqueous povidone-iodine) and types of sutures (ie, coated vs uncoated). Methods: In this systematic review and meta-analysis, we searched MEDLINE, Embase, Pubmed, and Cochrane Library databases, with no language restrictions, to identify high-quality RCTs testing either alcoholic chlorhexidine skin preparation (vs aqueous povidone-iodine) or triclosan-coated sutures (vs uncoated sutures), or both, published from database inception to Sept 1, 2021. Patients who received clean-contaminated, contaminated, or dirty surgery were included. We predefined the characteristics of a high-quality trial through an expert consensus process to develop an enhanced Cochrane risk of bias-2 tool specifically for RCTs with a primary outcome of SSI. Data were extracted from published reports. Meta-analysis was performed using a random-effects model and heterogeneity was assessed using the I 2 statistic. This systematic review and meta-analysis was prospectively registered in PROSPERO, CRD42021267220. Findings: Of 942 studies identified, 933 were excluded. Four high-quality RCTs (n=7467 patients) were included that tested alcoholic chlorhexidine. No significant difference in SSI rates was noted between alcoholic chlorhexidine and aqueous povidone-iodine (17·9% [667 of 3723 patients] vs 19·8% [740 of 3744 patients]; odds ratio 0·84 [95% CI 0·65–1·06]; p=0·21, I 2=53·1%). Five high-quality RCTs were included that tested triclosan-coated sutures (n=8619 patients), with no significant difference noted between triclosan-coated and uncoated sutures (16·8% [733 of 4360 patients] vs 18·4% [784 of 4259 patients]; OR 0·90 [95% CI 0·74–1·09]; p=0·29, I 2=36·4%). Interpretation: Contrary to previous meta-analyses, this study did not show a benefit from either alcoholic chlorhexidine skin preparation or triclosan-coated sutures, both of which are more expensive than other readily available alternatives. Global and national guidance should be reconsidered to remove recommendations for their routine use. Funding: National Institute for Health Research (NIHR) Global Health Research Unit.

Original languageEnglish
Pages (from-to)1242-1251
Number of pages10
JournalThe Lancet Infectious Diseases
Issue number8
Early online date26 May 2022
Publication statusPublished - 1 Aug 2022

Bibliographical note

Funding Information:
This research was funded by the National Institute for Health Research (NIHR; NIHR 16.136.79) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK Government. The academic investigators retained full independence and autonomy for study conduct, including design, data collection, interpretation, and reporting.

Publisher Copyright:
© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license


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