SURGICAL INFECTIONS

Volume 19, Number 00, 2018 Review Article

ª Mary Ann Liebert, Inc.
DOI: 10.1089/sur.2018.156

Antiseptic Irrigation as an Effective Interventional

Strategy for Reducing the Risk of Surgical Site Infections

Charles E. Edmiston, Jr,1 Maureen Spencer,2 and David Leaper3

Abstract

A surgical site infection (SSI) can occur at several anatomic sites related to a surgical procedure: Superficial or
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deep incisional or organ/space. The SSIs are the leading cause of health-care–associated infection (HAI) in
industrialized Western nations. Patients in whom an SSI develops require longer hospitalization, incur sig-
nificantly greater treatment costs and reduction in quality of life, and after selective surgical procedures
experience higher mortality rates. Effective infection prevention and control requires the concept of the SSI care
bundle, which is composed of a defined number of evidence-based interventional strategies, because of the
many risk factors that can contribute to the development of an SSI. Intra-operative irrigation has been a
mainstay of surgical practice for well over 100 years, but lacks standardization and compelling evidence-based
data to validate its efficacy. In an era of antibiotic stewardship, with a widespread prevalence of bacterial
resistance to multiple antibiotic agents, there has emerged an interest in using intra-operative antiseptic irri-
gation to reduce microbial contamination in the surgical site before closure and possibly reduce the need for
antibiotic agents. This approach has gained added appeal in an era of biomedical device implantation, especially
with the recognition that most, if not all, device-related infections are associated with biofilm formation. This
review focuses on the limited, evidence-based rationale for the use of antiseptic agents as an effective risk
reduction strategy for prevention of SSIs.

Keywords: antibiotic irrigation; antibiotic stewardship; antiseptic; chlorhexidine gluconate; intra-operative

wound irrigation; povidone iodine; surgical site infection

H istorically, the primary role of intra-operative

wound irrigation was to remove tissue debris, metabolic
waste, and tissue exudate from the surgical field before site
While intra-operative irrigation is common surgical prac-
tice, the 2016 recommendations from both the World Health
Organization (WHO), WHO Global Guidelines for the Pre-
closure. It has been proposed that intra-operative wound ir- vention of Surgical Site Infections, and the American College
rigation (IOWI) represents an economical approach to re- of Surgeon/Surgical Infection Society Surgical Site Infection
ducing the risk of SSI [1]. Unfortunately, the technique of Guidelines offer little insight or recommendations on the
operative site is highly variable in relation to the volume of practice [4,5]. The 2017 Centers for Disease Control and
fluid used to irrigate the surgical site and to the type of sup- Prevention Guidelines for the Prevention of Surgical Site
plements, such as antimicrobial agents, added to traditional Infection, however, and the online publication of the Wis-
saline lavage. Intra-operative irrigation commonly is prac- consin Division of Public Health Supplemental Guidance for
ticed by all surgical practitioners because it is reasonable to the Prevention of Surgical Site Infection published online in
reduce possible microbial contamination, clearing the site of January 2017 both recommend the use of an antiseptic agent
blood and removing necrotic tissue or purulent material, as an additive to intra-operative lavage (irrigation) [6,7].
before closure. While a recent systematic review and meta- Traditionally, warmed physiologic saline has been accepted
analysis suggests that IOWI has a significant beneficial effect universally as the irrigation fluid of choice, because it was
in reducing the risk of post-operative SSI in selected surgical widely available and safe for all surgical site surfaces includ-
disciplines, the process clearly lacks standardization [2,3]. ing the peritoneal and pleural cavities (serosal mesothelium).

1
Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
2
Accelerate Diagnostics, Inc., Tucson, Arizona.
3
Institute of Skin Integrity and Infection Prevention University of Huddersfield, Huddersfield, United Kingdom.

1
 2 EDMISTON ET AL.

Copious quantities (up to 10 L) were often used for peritoneal tions adherent to the mesothelial surface at 48 hours post-
lavage [3,8,9]. Over the ensuing years, multiple combinations CLP compared with saline controls. This series of experi-
of antimicrobial agents including antibiotic agents, surfactants, ments found that after injury to the bowel, there is a rapid,
and antiseptics have been have used to further minimize the stable colonization of the peritoneal mesothelium that is re-
risk of bioburden before closure. In 2018, however, there is no sistant to multiple lavage, with or without antibiotic agents
established clinical standard for the practice of intra-operative [9]. Cultures from serial saline or antibiotic irrigation fluids
irrigation, which is surprising given the current focus on did document a reduced microbial burden, but those results
evidence-based practice guidelines. are misleading because they represented a reduction in the
number of non-adherent microbial populations within the
peritoneal fluid, justifying the old adage, ‘‘The solution to
Intra-Operative Antibiotic Irrigation
pollution is dilution.’’ Further, the study revealed that limited
in the Era of Antibiotic Stewardship
exposure (contact time) of an adherent microbial population
It was not long after the discovery of penicillin that sur- to a normal saline-antibiotic concentration exceeding the
gical practitioners proposed the addition of an antibiotic MIC90 was of itself insufficient to reduce the microbial bur-
agent to intra-operative peritoneal lavage (IOPL) [10]. An- den on the surface of the serosal mesothelium.
tibiotic agents were viewed as ‘‘wonder drugs’’ or ‘‘silver Several clinical studies, reported in general and orthopedic
bullets’’ and a panacea for all serious infectious processes, research communications, have documented the futility of
and little consideration was given to the concept of antibiotic adding antibiotic agents as an adjunctive strategy for reducing
resistance or whether or not the concentration within the ir- the risk of post-operative infection [12–15]. There is also
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rigation fluid was sufficient to eradicate the bacterial patho- compelling evidence that suggests that not only does antibiotic
gen. The practice of adding an antibiotic agent to an irrigation irrigation lack efficacy but may pose a potential threat. Re-
fluid is still widespread and persists in many surgical disci- ported cases of severe anaphylaxis after the use of irrigation
plines. A recent survey suggests that >50% of general surgeons, fluids containing bacitracin have been reported after cardiac,
including colorectal surgeons, and orthopedic surgeons still neurosurgical, general, and orthopedic surgical procedures
request antibiotic irrigation fluid for their cases, followed by [16]. Additional reports have suggested that neomycin or
neurosurgical and spinal (30%–39%), and cardiothoracic vancomycin, used as an additive to irrigation fluid, has been
surgeons (26%), with the lowest by obstetrics-gynecology associated with tissue irritation or systemic toxicity [17].
and plastic surgeons (22%–23%) [11]. In the current era of antibiotic stewardship, which is tasked
The fundamental flaw in the justification of that usage is a with promoting the appropriate use of antibiotic agents, the
failure to appreciate the mechanistic nature of how antibiotic use of antibiotic agents for intra-operative irrigation along
agents actually work; antimicrobial activity necessitates suffi- with the topical application of antibiotic into the surgical site
cient contact time to allow the antibiotic agent to bind to its would be viewed as inappropriate. The reason is that most
target site within the cell membrane (i.e., beta-lactams, gly- clinical studies purporting benefit are of poor quality, and
copeptides) or internal cytoplasmic structures (i.e., aminogly- there exists a probably of risk of exerting selective pressure
cosides, quinolones). Further, effective antimicrobial activity is among gram-positive and gram-negative microbial popula-
dependent on a persistent drug concentration that is above the tions, potentiating the emergence of antimicrobial resistance
MIC90, the concentration of the antibiotic agent that is required [11,18–22]. Finally, a recent systematic review and meta-
to kill 90% of the targeted microbial population. Neither of analysis found that the addition of antibiotic agents to irri-
these requirements is met during the process of antibiotic ir- gation fluid provided no benefit in reducing the risk of inci-
rigation, because the irrigating fluid is evacuated rapidly from sional site infection in the abdomen or mediastinum [23].
the cavity. The pharmacokinetics/pharmacodynamics of the
irrigation process is essentially unknown.
Intra-Operative Irrigation in the Presence
The mechanistic failure of antibiotic irrigation was ad-
of an Implantable Biomedical Device
dressed in a laboratory study published in 1990. A series of
Sprague-Dawley rats underwent cecal ligation and puncture Device-related infections are preceded by biofilm forma-
(CLP) to stimulate fecal peritonitis. The investigators found tion, and the presence of an acute biofilm on the surface of an
that gram-negative Enterobacteriaceae rapidly colonized the implantable device makes organisms (gram-positive or
serosal mesothelium and were the predominant flora harvested negative) recalcitrant to traditional antibiotic irrigation or
at four hours post-CLP. After eight hours, anaerobic bacteria, therapy [24]. An effective intra-operative irrigation strategy
specifically Bacteroides fragilis, represented the predominant would then entail selection of an agent that can be delivered
microbial population adherent to the serosal mesothelium (5.6 to the tissues in a safe and effective concentration and that is
log10 cfu/mg tissue). At 24 hours, the aerobic and anaerobic rapidly cidal in the presence of a biofilm mediated device-
microbial populations adherent to the serosal mesothelial associated infection. As reported in an earlier publication, the
surfaces were 7.1 and 9.1 log10 cfu/mg tissue, respectively. concept of using an antiseptic agent for intra-operative site
Extended serial peritoneal saline lavage (100-ml · 10) was irrigation is not new and harkens back to the Listerian con-
effective in significantly reducing microbial counts in the cept of antiseptic surgical practice.
peritoneal fluid. Saline lavage, however, had no impact on Both in vitro and animal studies suggest that adding an
dislodging the adherent aerobic/anaerobic microbial popula- antiseptic agent, often with surfactant properties, to intra-
tions from the surface of the serosal mesothelium. operative irrigation fluid may assist in preventing the ad-
In a parallel series of studies, the addition of cefazolin, herence of biofilm-forming bacteria to the surface of the
kanamycin, or metronidazole alone or in combination failed biomedical device. Two recent in vitro studies have investi-
to significantly reduce (or dislodge) the microbial popula- gated the benefits of using an antiseptic agent as an additive to
 INTRA-OPERATIVE ANTISEPTIC SURGICAL SITE IRRIGATION 3

physiologic saline irrigation. A laboratory biofilm-forming effective inclusive strategy to reduce the risk of infection after
strain of Staphylococcus epidermidis was allowed to propa- spinal instrumentation operation [27]. In a separate study,
gate in 96-well plastic dishes, followed by exposure to intra-operative irrigation with PI plus the administration of
chlorhexidine gluconate (CHG) (0.025%, 0.05%, and 0.1%), vancomycin powder before site closure was deemed to be an
povidone iodine (PI) (0.35%, 1.0%, 3.5%, and 10%), sodium effective strategy for preventing SSI after spine operation. The
hypochlorite (0.125%, 0.25%, and 0.5%), and a triple anti- level of evidence for this study was poor, however [28].
biotic solution (bacitracin 50,000 U/L, gentamicin 80 mg/L, While PI irrigation has gained clinical favor, especially
and polymyxin 500,000 U/L) for one, five and 10 minutes. within orthopedic surgical procedures, a recognized side ef-
The CHG 0.05% and 0.1% at all three exposure times, 10% fect of PI irrigation is chrondrotoxicity on articular cartilage.
PI at all three exposure times, and 3.5% PI at 10 minutes were The extent of superficial chondrocyte death appears to be
effective at eradicating the staphylococcal biofilm, whereas significantly greater at higher concentrations of PI solutions.
all concentrations and exposure time for sodium hypochlorite While 0.35% PI solution was the least chondrotoxic of all
and triple antibiotic solution were not effective at resolving concentrations, it has been observed to reduce cell viability
the staphylococcal biofilm. The study suggests that a con- significantly if applied for longer than one minute [29]. In
centration of 0.05% CHG was effective at killing biofilm- addition to chondrocyte toxicity, the antimicrobial activity of
based S. epidermidis with a short exposure time (one minute PI is diminished in the presence of blood or tissue protein,
or less). Alternatively, PI was capable of killing a sessile which may marginalize its antimicrobial activity as an intra-
biofilm-forming strain of Staphylococcus but required a 30- operative lavage additive [17,20,29].
fold increase in concentration at a clinically relevant expo- Chlorhexidine gluconate has been used as both a pre-
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sure period (10% PI for 1 min) or a 10-fold increased con- operative and intra-operative surgical site irrigation fluid,
centration at triple the exposure time (3.5% PI for 10 min). documenting a faster onset of cidal activity compared with PI
Unfortunately, a 10-minute irrigation interval is not clinically [30,31]. In a recent study of the use of 0.05% CHG intra-
realistic because most intra-operative irrigations last less than operative irrigation in hip and knee arthroplasty, 411 total
1–2 minutes. Further, a 10% solution of PI is recommended knee arthroplasty (TKA) and 253 total hip arthroplasty
for external use only [25]. (THA) patients served as a historic control while 248 TKA
Aqueous CHG is a cationic-chlorinated biguanide with and 138 THA patients were enrolled in a CHG irrigation
broad spectrum activity and has been documented to disrupt group. A single surgeon performed all of the operations.
the bacterial cell membrane within 20–30 seconds. In vitro, The control THA patients underwent an intra-operative
time-kill kinetics document a greater than six-log reduction irrigation with 0.9% saline followed by a two-minute wash
in 60 seconds for most health-care–associated pathogens, with dilute PI. The TKA control patients underwent intra-
including multiple drug resistant (MDRO) gram-positive/ operative irrigation with 0.9% saline as the only interven-
negative pathogens [8]. In a separate analysis, a concentra- tional treatment. In the CHG group, the intra-operative irri-
tion of 0.05% CHG was effective (<five-log reduction) in gation protocol involved a primary lavage with 0.9% saline
preventing a biofilm-forming strain of S. aureus (MRSA) followed by a one-minute soak with 0.05% CHG. There was
from colonizing the surface of four distinct synthetic surgical no statistically significant difference observed between the
mesh segments compared with a saline control (p < 0.01). In a two interventional groups. A post-hoc analysis, however,
follow-up animal study, intra-operative irrigation with 0.05% suggested that the study was significantly underpowered [31].
was effective in resolving polypropylene mesh infections. It is obvious from laboratory and animal studies that 0.05%
Surgical mesh was used to repair a 1 · 2 cm abdominal defect CHG offers some unique advantages over PI, especially in
in Sprague-Dawley rats, followed by inoculation with 3.0- terms of its ability to penetrate and disrupt microbial biofilms
log10 cfu/mL of MRSA recovered from a clinical incisional on the surface of biomedical devices. In light of the low rate
hernia infection. After 15 minutes, the mesh segments were of infection in total joint replacement operations (*2.0%),
irrigated for 60 seconds with either physiologic saline or however, future efforts to validate the efficacy of 0.05% CHG
aqueous 0.05% CHG, followed by closure with polypropyl- will require a robust multi-center, randomized clinical trial.
ene. At 7 days the animals were sacrificed.
All physiologic saline-irrigated mesh segments (N = 8)
Does Intra-Operative Antiseptic Irrigation Pose
were infected with a microbial biofilm (mean, 6.3-log10 cfu/
a Risk for Development of Resistance?
cm2 mesh segment), while one of eight mesh segments that
had been irrigated with 0.05% CHG demonstrated a staphy- Bacterial cells can express intrinsic or acquired resistance
lococcal biofilm (2.3-log10 cfu/cm2 mesh segment), resulting to selective antimicrobial agents; currently, the primary
in an 82.5% reduction in the risk of a MRSA biofilm- concern among the advocates of antibiotic stewardship is the
mediated mesh infection compared with physiologic saline probable risk that selective antiseptic agents may increase the
controls (p < 0.001) [8]. risk of antibiotic resistance, which is then transferable to
other microbial populations [32–35]. While there is some
similarity to the mechanisms of resistance between antibiotic
Clinical Efficacy of Intra-Operative Irrigation
and antiseptic agents, antibiotic agents usually have a sin-
with Antiseptic Additives
gular mechanism of action, whereas antiseptic agents such as
Various concentrations of PI have been shown to be effec- triclosan and chlorhexidine have primary and secondary
tive in vitro against resistant S. aureus (MRSA), and a sys- mechanisms that involve the outer bacterial membrane and
tematic review of PI found a reduction of the incidence of SSI other membrane-like structures associated with organelles
in various surgical applications [23,26]. As part of an within the cytoplasm. Antiseptic (biocidal) activity is rapid,
evidence-based surgical care bundle, PI was shown to be an occurring within 30–60 seconds of contact with the bacterial
 4 EDMISTON ET AL.

cell. Antibiotic agents require a longer contact time with the with 17 psi (Group 2). Gender, age, surgical time, amount of
bacterial cell, which under optimal conditions results in an blood loss, whether associated with diabetes mellitus,
inhibitory or cidal activity several hours after continuous smoking, and amount of irrigation solution were comparable
antibiotic exposure. between the two groups. Physiologic saline was used as the
lavage fluid.
Intra-operative irrigations were performed three times, and
Intra-Operative Irrigation:
after final irrigation, culture specimens were obtained from
Volume and Delivering Strategies
muscle layers and inter-vertebral spaces and the microbial
The optimal volume of fluid used for abdominal irrigation recovery compared between the two groups. There were 79
that will prevent incisional SSIs (both deep and superficial), cases in Group 1 and 59 cases in Group 2. Operative time was
dehiscence, and fistula formation and improve 30-day death longer (p = 0.011), and the amount of irrigation saline was
in trauma patients is unknown. A three-arm parallel clinical larger (p = 0.042) in Group 2. Bacteria were recovered from
superiority randomized controlled trial, comparing different the posterior muscle layer in 8/79 cases (10.1%) in Group 1
volumes of effluent (5, 10, and 20 L), has been conducted in and 1/59 cases (1.6%) in Group 2. This was statistically
trauma patients (both blunt and penetrating). A total of 204 significant (p = 0.046). Cultures obtained from the inter-
patients were randomized to one of three groups; 5 L (Group vertebral space were positive in 6/79 cases (7.6%) in Group 1
1), 10 L (Group 2), or 20 L (Group 3). Patients were com- and 5/59 cases (8.5%) in Group 2. There was no difference
parable with respect to age, gender distribution, admission between the two groups (p = 0.546). S. epidermidis, S. aureus,
Injury Severity Score, and mechanism of injury, estimated S. hominis, and S. saprophyticus were obtained in decreasing
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blood loss, and degree of contamination. The mortality rate order of frequency. The investigators found that pulsed irri-
overall was 1.96% (4/204). No differences were noted with gation was more effective compared with bulb syringe irri-
respect to contamination, wound infection, fistula formation, gation in the posterior muscle layer. In the inter-vertebral
or dehiscence. space, however, both methods were found to be insufficient to
The 20 L group (Group 3) documented a trend toward in- eradicate microbial contamination [38].
creased incidence of deep incisional SSI, compared with the Peri-prosthetic joint infections (PJI) are representative of a
5 L (Group 1) (p = 0.051) and 10 L (Group 2) (p = 0.057) biofilm-mediated infection. In acute PJI, irrigation and de-
groups. This did not reach statistical significance, however. bridement with component retention has a high failure rate in
The result of this study clearly suggests that using more ir- some studies. A recent investigation found that pulse lavage
rigation fluid in the presence of excessive surgical site con- irrigation is ineffective at removing biofilm from TKA
tamination does not reduce post-operative complications or components. The S. aureus biofilm mass and location were
affect death; and it may actually predispose patients to in- visualized on arthroplasty materials using a photon collection
creased incidence of abscess formation [36]. camera and laser scanning confocal microscopy. While
In orthopedic operations, bone and polymethyl methacry- continuous pulse lavage with saline resulted in substantial
late (PMMA) debris and particles generated during TKA may reduction in biofilm signal intensity, the reduction was less
cause third-body wear (abrasive wear when hard particles than a 10-fold decrease. These results suggest that saline
such as bone or PMMA fragments embed in soft surfaces, pulse-irrigation was not effective in removing the biofilm
such as polyethylene). The volume of saline lavage used mass below a necessary bioburden level to prevent recurrence
during these procedures is highly variable and not standard- of acute infection in TKA [39]. This study clearly documents
ized. In an investigation to assess the optimal volume of intra- the need to look beyond the use of traditional saline irrigation
operative saline lavage to remove PMMA fragments, subjects and investigate the role of antiseptic pulse lavage with CHG
underwent cemented TKA and pulse lavage with 8 L of sterile as an effective strategy for eliminating biofilm formation on
saline using a pulsatile irrigator. Aspirated fluid was collected implantable biomedical devices.
in a 1 L aliquot, and the number and size of bone and PMMA A recent review has explored the experimental and clinical
particles quantified. evidence associated with the use of pressure irrigation, and
Image analysis revealed that the number of particles peaked while experimental evidence demonstrates a benefit for this
at first lavage and gradually decreased over the eight consec- technology to eliminate bacteria and foreign debris in soft
utive lavages. Significant differences were found between the tissue surgical sites, there is no standard of practice associated
first compared with second, second compared with third, and with this technology. Further, clinical trials that document a
third compared with fourth lavage. No significant differences benefit are usually underpowered and often retrospective [40].
were found beyond the fourth lavage, however. This study The theoretical benefit behind power or pulse-lavage is
found that that a total volume of 4 L was effective at removing based on the forcible removal of bacteria and debris using a
residual PMMA particles during TKA arthroplasty [37]. ‘‘jet’’ of fluid—in most cases, saline. After traumatic injury
Pulsed irrigation has been used for more than 50 years, to the skin, the inflammatory phase is responsible for the
especially in orthopedic and trauma procedures. In selective extravasation of fibrinogen, which is rapidly converted to
surgical procedures such as spine operations, however, there fibrin. The fibrin creates a weblike structure within the
has been no study validating the efficacy of pulsed irrigation wound; on one hand, it offers a protective coating to the
compared with bulb syringe irrigation. In a recent study, surface of the wound but it can also entrap bacteria within the
consecutive patients undergoing posterior lumbar inter-body weblike matrix. The bacterial contamination of the wound
fusion were investigated. Those who underwent procedures most likely originates at the time of traumatic injury or
during the first three months were irrigated by bulb syringe contamination may occur at the time of operation. The use of
(Group 1) and those who underwent procedures during the conventional gravity irrigation that is delivered under low
next three months were irrigated using a pulsatile irrigator pressure is unlikely to alter the fibrin web or sufficiently
 INTRA-OPERATIVE ANTISEPTIC SURGICAL SITE IRRIGATION 5

remove bacteria entrapped within the mesh. Pulse irrigation, devices provide little risk reduction and economic benefit
however, is thought to produce shear forces sufficient to after laparotomy [46,47].
dislodge contaminating organisms from within the fibrin Another possible approach could be to integrate site pro-
sheath by overcoming the adhesive force between the bac- tection with continuous intra-operative lavage. A prospective
teria and host tissues. multi-center pilot study was conducted in 86 eligible patients
While the theoretical principle behind the perceive benefit undergoing elective colorectal resections that utilized a novel
of power irrigation is sound, the question of whether this ir- incision retractor-protector sleeve that combines continuous
rigation process effectively removes bacteria from the wound irrigation and barrier protection [48]. Bacterial culture swabs
or drives the organisms deeper into the tissues continues to be were collected from the incision edge before device place-
debated. Failure to adequately remove acute biofilm adds to ment and from the exposed and protected incision edge be-
the risk of infection, promoting delayed healing, which may be fore device removal. The primary and secondary end-points
associated with a delay in the inflammation component of were the rate of enteric and overall bacterial contamination
healing, or promotes inappropriate excessive inflammatory on the exposed incision edge compared with the protected
responses through delay or disorganization of the wound incision edge, respectively.
healing cascades. Persisting biofilm enhances nitric oxide At the time of operation, the device was placed by inserting
production, free radial oxygen species, matrix metalloprotei- the bottom ring into the abdomen and expanding the upper
nases, and excessive white cell activation [41]. retraction ring. The device was connected to the operat-
This question was addressed partially in an experimental ing room’s standard suction mechanism and a bag of sterile
study involving a porcine surgical site model that was con- irrigation solution. Before placing the device within the
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taminated with Serratia marcescens. The investigators irri- surgical site, incisional wall cultures were obtained. The
gated the site by either a piston syringe using eight psi or continuous irrigation fluid rate was 5–16 mL/min. Incisional
pulse lavage using 70 psi. The lavage fluid penetrated deeper site cultures were obtained after the operation was completed.
into the tissues under the higher pressure; the rate of infection The innovative wound retractor-protector device was asso-
was equivalent in both experimental models but higher in a ciated with a 66% reduction in overall bacterial contamina-
‘‘no-lavage’’ control group. It was the authors’ opinion that tion at the protected incision edge compared with the exposed
bacteria were not displaced (driven deeper) into the tissues by incision edge (11.9% vs. 34.5%, p < 0.001), and 71% reduc-
the increased pressure irrigation but did suggest that the tion in enteric bacterial contamination (9.5% vs. 33.3%,
process may damage host tissues, thereby exacerbating the p < 0.001). The investigators found no adverse events attrib-
infectious process [42]. uted to device use.
In a separate analysis using ex vivo ovine muscle, inves- The results of the study suggest that a novel wound
tigators found that lower lavage pressure (three psi) was more retractor-protector that combines continuous irrigation and
effective at removing bacteria than high pulse lavage rates barrier protection was associated with a significant reduction
(6–19 psi). The higher psi rates were associated with dis- in bacterial contamination in patients undergoing colorectal
placement (sequestering) of bacteria into the deeper tissues surgery. The primary end-points of this pilot study were a
[43]. The debate is likely to continue with advocates on both reduction in site contamination and device safety and not the
sides, championing the use or either low or high psi for site reduction in SSI. While the choice of irrigation fluids was left
cleansing or debridement before closure at the end of a sur- to individual surgeons, 97% of the patients received an
gical procedure. aminoglycoside combined with metronidazole, clindamycin,
What is actually lacking in this discussion is the question, or bacitracin, again reflecting the continued bias toward using
‘‘What is the optimal lavage solution?’’ The historic control an antibiotic agent for intra-operative irrigation. In the de-
has been physiologic saline, but it offers no residual activity; velopment of future randomized, controlled trials using this
an antibiotic lavage solution for pressure irrigation is fraught technology, the study protocol should include an antiseptic
with the same criticism that was discussed in an earlier sec- agent, the most effective antiseptic agent being 0.05%
tion (increased risk of resistant organisms); contact time is aqueous CHG.
too limited to have any residual activity. Use of an antiseptic
agent that has a high tissue binding potential, however, such
Moving Forward
as afforded by CHG, would provide a measure of residual
activity sufficient for a wide range of gram-positive or gram- For the past 100 years, the practice of surgical site irriga-
negative surgical site pathogens. Povidone iodine is less tion has taken a pragmatic, if not dogmatic pathway. Most
likely to afford any sufficient residual activity because of its studies supporting the benefit of selective irrigation fluids for
potential to be inactivated by blood or tissue protein [20,30]. intra-operative lavage have been hindered by haphazard de-
sign, institutional bias, and have been poorly powered. The
development of ‘‘antibiotic cocktails’’ for intra-operative
Melding Intra-Operative Lavage while Protecting
lavage represents a fundamental lack of knowledge of the
the Surgical Site
pharmacokinetic and pharmacodynamic nature of antibiotic
Preventing contamination of the surgical site or reducing agents. They ignore that exposure of contaminating flora
the bacterial burden within the site at the time of closure within the surgical site to sub-therapeutic concentrations
through the use of barrier protectors in addition to intra- fosters the emergence of resistance. The benefits of using an
operative lavage may have promise and is an ongoing stra- antiseptic agent such as CHG rather than saline or an anti-
tegic focus to reduce the risk of post-operative infection biotic agent are obvious: Rapid bactericidal activity (multiple
[15,44,45], Two recent studies, however—a meta-analysis mechanisms of action), residual activity, sustained activity in
and well conducted trial— found that surgical site protector the presence of blood or tissue protein, tissue safety, and a
 6 EDMISTON ET AL.

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meta-analysis of published data. J Wound Care 2017;26:
20–25. E-mail: [email protected]