Joint clinical practice guidelines for antimicrobial prophylaxis in surgery from the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Surgical Infection Society, and the Society for Healthcare Epidemiology of America note that there is no additional benefit of topically administered antimicrobial irrigation solutions, pastes, or washes when used as adjuncts to parenteral antimicrobial prophylaxis, and that additional data are needed to support this practice. One study did show possible benefits for cefazolin 1 g/L bladder and intraabdominal irrigation as an adjunct to cefazolin IV for surgical site infection prophylaxis. [1]
A guideline update by the American College of Surgeons and Surgical Infection Society also states that there is insufficient evidence to recommend routine use of topical antimicrobial therapy to decrease the risk of surgical site infection (SSI). [2]
The Centers for Disease Control and Prevention (CDC) guideline for the prevention of SSI states that there are uncertain trade-offs between the benefits and harms of intraoperative antimicrobial irrigation and that no recommendation could be made regarding its use. These guidelines. however, say aqueous iodophor solutions can be considered for irrigation of deep or subcutaneous tissues. [3]
A 2010 review discusses the lack of literature surrounding the use of topical antibiotics during neurosurgery. Of the ten papers reviewed, only one was published after the year 2000 (range, 1947 to 1999). Some papers include agents that are not (or no longer) available in the United States. All included papers are considered low-quality evidence, with five (50%) being case series and one being an expert opinion editorial from 1982. [4]
An in vitro study evaluated the antiseptic ability of chlorhexidine, povidone-iodine, sodium hypochlorite, and triple antibacterial (bacitracin, gentamicin, and polymyxin) when used for irrigation at 1, 5, and 10 minutes. Results found chlorhexidine 0.05% and 0.1% at all three exposure times, povidone-iodine 10% at all three exposure times, and povidone-iodine 3.5% at 10 minutes only were effective at eradicating Staphylococcus epidermidis from biofilms. All concentrations and all exposure times of sodium hypochlorite and triple antibacterial solution were not effective. [6]
Total hip/knee replacement:
While not an antimicrobial agent, povidone-iodine lavage before wound closure has been investigated in a meta-analysis to determine rates of postoperative infections. Based on 7 studies, the investigation found an overall odds ratio for infection rate to be 0.67 (95% CI 0.38 to 1.19; p=0.17) for the use of povidone-iodine. Subgroup analysis did not reveal any significant differences either. While there may be a lower risk of infection with povidone-iodine, the results have demonstrated an overall lack of protection against postoperative infection. [7]
Breast implants:
A meta-analysis observing the effectiveness of breast pocket antimicrobial irrigation found significant reductions in clinical infection (risk ratio 0.52; 95% CI 0.33 to 0.81) and capsular contracture (risk ratio 0.36; 95% CI 0.16 to 0.83). Irrigation from the included studies consisted of a combination antibiotic irrigation or was unspecified. One study reported significant reduction in infection rates with cephalothin 1g + saline 1L + epinephrine 1 mg versus saline + epinephrine control. Another study reported significant reduction in capsular contracture using cefuroxime 750 mg + povidone-iodine 10 mL + gentamicin 80 mg + saline 15 mL compared to no irrigation. Other combinations may be useful but the other studies had bacitracin included in the regime or did not specify the antibiotic irrigation. [8]
A systematic review found that studies of antibiotic irrigation for implant-based breast augmentation were characterized by low-quality and high risk of bias. Only one retrospective study within the review observed an irrigation solution without bacitracin: povidone-iodine + cefuroxime + gentamicin diluted in sodium chloride. The solution had a lower rate of capsular contracture compared to standard systemic prophylaxis. The author of the systematic review believes the combination with povidone-iodine may have influenced this behavior. [9]
Cardiac/ICD implants:
The American College of Cardiology Foundation/American Heart Association Task Force and the Heart Rhythm Society's 2012 guidelines for device implant therapy of cardiac rhythm abnormalities do not provide recommendations for antibiotic irrigation. [10]
An international survey of cardiologists specializing in arrhythmia found that most utilize intraoperative antimicrobial pocket irrigation during cardiovascular implantable electronic device (CIED) infection prophylaxis. From 487 responses (response rate: 23.3%; 28.2% from the U.S.), 87% utilize antimicrobial irrigation or eluting pouch. Bacitracin was the most commonly utilize antimicrobial agent followed by vancomycin (39%), and a general cephalosporin agent (29%). The applicability of the results are limited as the survey merely gauges the provider's preferences or referencing the hospital policies. [11]
A meta-analysis for prevention of CIED pocket infection using antimicrobial pocket irrigation found significant protection (relative risk 0.42; 95% CI 0.24 to 0.75 for first-line therapy and 0.24; 95% CI 0.20 to 0.58 for second-line therapy). Antimicrobials that showed protection includes general 3rd-generation cephalosporins, ceftriaxone, cefoperazone/tazobactam, azithromycin, and combination amikacin/gentamicin. However, the studies that include povidone-iodine, clindamycin, cefazolin, and gentamicin did not observe significant protection against pocket infection. Despite overall protection being determined, the inconsistent results from individual studies leave a possibility that there is no benefit seen to irrigation. Furthermore, most studies were from China which has a different microbial landscape compared to the U.S. [12]