Meta-Analysis of High Quality Randomised Controlled Trials Testing Alcoholic Chlorhexidine Skin Preparation or Triclosan Coated Sutures to Reduce Surgical Site Infection

Background: The World Health Organisation and the UK’s National Institute of Clinical Excellence recommend alcoholic chlorhexidine skin preparation and triclosan coated sutures to prevent surgical site infections (SSI). Existing meta-analyses that include high risk of bias studies combined with recent publication of large randomised trials together justify an updated meta-analysis of high quality randomised controlled trials (RCTs).  Methods: A systematic review was performed to identify high quality RCTs testing either alcoholic chlorhexidine skin preparation (versus aqueous povidone-iodine) and/or triclosan coated sutures (versus uncoated sutures), until September 2021. Patients undergoing clean-contaminated, contaminated, or dirty surgery were included. We pre-defined the characteristics of a high quality trial through an expert consensus process that modified the Cochrane Risk of Bias tool specifically for RCTs with a primary outcome of SSI.  Findings: Four high quality RCTs (n=7,467 patients) were included that tested alcoholic chlorhexidine. There was no significant difference in SSI rates between alcoholic chlorhexidine and aqueous povidone-iodine (17.9% vs 19.8%, OR 0.84, 95% CI 0.65-1.06, p=0.205). Five high quality RCTs were included that tested triclosan coated sutures (n=8,619 patients), with no significant difference between coated and uncoated sutures (16.7% vs 18.5%, OR 0.81, 95% CI 0.65-1.08, p=0.177). Stratified analyses demonstrated consistent results for clean-contaminated surgery, but only one trial was included that addressed contaminated/dirty surgery for either interventions.  Interpretation: Contrary to previous meta-analyses, this study did not show 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 strong recommendations for their routine use. Funding Information: National Institute for Health Research (NIHR) Global Health Research Unit. Declaration of Interests: The authors have no conflicts of interest to declare.