The role of povidone-iodine versus saline irrigation in preventing surgical site infections in high body mass index patients: a systematic review and meta-analysis

Thiago de Albuquerque Farias CamarottiFaculty of Medicine, University of Pernambuco, Recife, Pernambuco, Brazil

Victoria Zecchin FerraraFaculty of Medicine and Surgery, University of Padua, Padua, Veneto, Italy

Vitória Ritter MaldanerUniversity of Vale do Itajaí, Itajaí, Santa Catarina, Brazil

Augusto Graziani e SousaAnápolis University Center, Anápolis, Goiás, Brazil

Enrico Prajiante BertolinoState University of Maringá, Paraná, Brazil

Maria CamarottiPernambuco’s Health College, Recife, Pernambuco, Brazil

Marcelo AverbachSírio-Libanês Institute of Education and Research, São Paulo, São Paulo, Brazil

DOI:

https://doi.org/10.3396/ijic.v21.23837

Keywords:

Surgical Site Infection, Povidone-iodine, High BMI, Normal Saline, Wound Irrigation

Abstract

Background: Surgical site infections (SSIs) are common complications post-surgery, associated with increased morbidity, healthcare costs, and prolonged recovery. High body mass index (BMI) patients face an elevated risk due to impaired wound healing and systemic inflammation. Wound irrigation with Polyvinylpyrrolidone Iodine (PVP-I) or normal saline (NS) is commonly used, but their comparative effectiveness in high-BMI patients remains unclear.

Objective: The study aims to evaluate whether PVP-I is more effective than NS in reducing SSIs in high-BMI surgical patients.

Design: Systematic review and meta-analysis.

Methods: PubMed, Embase, and Cochrane databases were searched up to December 2024 for randomized controlled trials (RCTs) and observational studies comparing PVP-I and NS for SSI prevention in high-BMI patients. Risk of bias was assessed using ROB 2 for RCTs and ROBINS-I for non-randomized studies. Odds ratios (OR) with 95% confidence intervals (CI) were pooled using a random-effects model in R Studio 4.4.2.

Results: Four studies with 604 high-BMI patients were included. The pooled analysis showed a decreased SSI rate in the PVP-I group, though not statistically significant (OR 0.58; 95% CI 0.29–1.13; P = 0.11; I² = 39.4%). Sensitivity analyses confirmed the robustness of findings.

Discussion: The effectiveness of PVP-I may depend on factors like surgery type and the patient’s clinical status. Although irrigation may have a protective effect, effective preventive strategies should consider the antiseptic agent and perioperative patient optimization.

Conclusion: This meta-analysis suggests that PVP-I irrigation may reduce SSIs in high-BMI patients, though statistical significance was not reached. Further research is needed to confirm its potential benefits.

How to Cite:

de Albuquerque Farias Camarotti, T., Zecchin Ferrara, V., Ritter Maldaner, V., Graziani e Sousa, A., Prajiante Bertolino, E., Camarotti, M., & Averbach, M. (2025). The role of povidone-iodine versus saline irrigation in preventing surgical site infections in high body mass index patients: a systematic review and meta-analysis. International Journal of Infection Control, 21. https://doi.org/10.3396/ijic.v21.23837

References

1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999 Apr; 27(2): 97–132; quiz 133–4; discussion 96. doi: 10.1016/S0196-6553(99)70088-X

2. Gillespie BM, Harbeck E, Rattray M, Liang R, Walker R, Latimer S, et al. Worldwide incidence of surgical site infections in general surgical patients: a systematic review and meta-analysis of 488,594 patients. Int J Surg Lond Engl 2021 Nov; 95: 106136. doi: 10.1016/j.ijsu.2021.106136

3. Surveillance of surgical site infections and prevention indicators in European hospitals – HAISSI protocol [Internet]. 2017. Available from: https://www.ecdc.europa.eu/en/publications-data/surveillance-surgical-site-infections-and-prevention-indicators-european [cited 27 February 2025].

4. Badia JM, Casey AL, Petrosillo N, Hudson PM, Mitchell SA, Crosby C. Impact of surgical site infection on healthcare costs and patient outcomes: a systematic review in six European countries. J Hosp Infect 2017 May; 96(1): 1–15. doi: 10.1016/j.jhin.2017.03.004

5. World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000; 894: i–xii, 1–253.

6. Ho-Pham LT, Campbell LV, Nguyen TV. More on body fat cutoff points. Mayo Clin Proc 2011 Jun; 86(6): 584. doi: 10.4065/mcp.2011.0097

7. Watters WC, Baisden J, Bono CM, Heggeness MH, Resnick DK, Shaffer WO, et al. Antibiotic prophylaxis in spine surgery: an evidence-based clinical guideline for the use of prophylactic antibiotics in spine surgery. Spine J Off J North Am Spine Soc 2009 Feb; 9(2): 142–6. doi: 10.1016/j.spinee.2008.05.008

8. Schuster JM, Rechtine G, Norvell DC, Dettori JR. The influence of perioperative risk factors and therapeutic interventions on infection rates after spine surgery: a systematic review. Spine 2010 Apr 20; 35(9 Suppl): S125–137. doi: 10.1097/BRS.0b013e3181d8342c

9. Papadakis M. Wound irrigation for preventing surgical site infections. World J Methodol 2021 Jul 20; 11(4): 222–7. doi: 10.5662/wjm.v11.i4.222

10. Swaminathan C, Toh WH, Mohamed A, Nour HM, Baig M, Sajid M. Comparing the efficacy of povidone-iodine versus normal saline in laparotomy wound irrigation to prevent surgical site infections: a meta-analysis. Cureus. 15(12): e49853.

11. Ambe PC, Rombey T, Rembe JD, Dörner J, Zirngibl H, Pieper D. The role of saline irrigation prior to wound closure in the reduction of surgical site infection: a systematic review and meta-analysis. Patient Saf Surg 2020 Dec 22; 14(1): 47. doi: 10.1186/s13037-020-00274-2

12. Karuserci Ö, Balat Ö. Subcutaneous rifampicin versus povidone-iodine for the prevention of incisional surgical site infections following gynecologic oncology surgery – a prospective, randomized, controlled trial. Ginekol Pol 2020 Sep 30; 91: 513–8. doi: 10.5603/GP.a2020.0134

13. Zhao LY, Zhang WH, Liu K, Chen XL, Yang K, Chen XZ, et al. Comparing the efficacy of povidone-iodine and normal saline in incisional wound irrigation to prevent superficial surgical site infection: a randomized clinical trial in gastric surgery. J Hosp Infect 2023 Jan 1; 131: 99–106. doi: 10.1016/j.jhin.2022.10.005

14. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017 Aug 1; 152(8): 784–91. doi: 10.1001/jamasurg.2017.0904

15. Global guidelines for the prevention of surgical site infection [Internet]. Available from: https://www.who.int/publications/i/item/9789241550475 [cited 27 February 2025].

16. Surgical site infections: prevention and treatment [Internet]. National Institute for Health and Care Excellence: Clinical Guidelines. London: National Institute for Health and Care Excellence (NICE); 2020. Available from: http://www.ncbi.nlm.nih.gov/books/NBK542473/ [cited 27 February 2025].

17. Leaper D, Rochon M, Pinkney T, Edmiston CE. Guidelines for the prevention of surgical site infection: an update from NICE. Infect Prev Pract 2019 Nov 22; 1(3–4): 100026. doi: 10.1016/j.infpip.2019.100026

18. Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, de Vries F, et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis 2016 Dec 1; 16(12): e288–303. doi: 10.1016/S1473-3099(16)30402-9

19. Norman G, Atkinson RA, Smith TA, Rowlands C, Rithalia AD, Crosbie EJ, et al. Intracavity lavage and wound irrigation for prevention of surgical site infection. Cochrane Database Syst Rev 2017 Oct 30; 10(10): CD012234. doi: 10.1002/14651858.CD012234.pub2

20. Thom H, Norman G, Welton NJ, Crosbie EJ, Blazeby J, Dumville JC. Intra-cavity lavage and wound irrigation for prevention of surgical site infection: systematic review and network meta-analysis. Surg Infect 2021 Mar; 22(2): 144–67. doi: 10.1089/sur.2019.318

21. Groenen H, Bontekoning N, Jalalzadeh H, Buis DR, Dreissen YEM, Goosen JHM, et al. Incisional wound irrigation for the prevention of surgical site infection: a systematic review and network meta-analysis. JAMA Surg 2024 Jul 1; 159(7): 792–800. doi: 10.1001/jamasurg.2024.0775

22. Carballo Cuello CM, Fernández-de Thomas RJ, De Jesus O, De Jesús Espinosa A, Pastrana EA. Prevention of surgical site infection in lumbar instrumented fusion using a sterile povidone-iodine solution. World Neurosurg 2021 Jul; 151: e700–6. doi: 10.1016/j.wneu.2021.04.094

23. Cochrane handbook for systematic reviews of interventions [Internet]. Available from: https://training.cochrane.org/handbook [cited 27 February 2025].

24. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews | The BMJ [Internet]. [cited 2025 Feb 27]. Available from: https://www.bmj.com/content/372/bmj.n71

25. Schünemann HJ, Cuello C, Akl EA, Mustafa RA, Meerpohl JJ, Thayer K, et al. GRADE guidelines: 18. How ROBINS-I and other tools to assess risk of bias in nonrandomized studies should be used to rate the certainty of a body of evidence. J Clin Epidemiol 2019 Jul; 111: 105–14. doi: 10.1016/j.jclinepi.2018.01.012

26. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019 Aug 28; 366: l4898. doi: 10.1136/bmj.l4898

27. Abdallah DY, Jadaan MM, McCabe JP. Body mass index and risk of surgical site infection following spine surgery: a meta-analysis. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc 2013 Dec; 22(12): 2800–9. doi: 10.1007/s00586-013-2890-6

Copyright (c) 2025 Thiago de Albuquerque Farias Camarotti, Victoria Zecchin Ferrara, Vitória Ritter Maldaner, Augusto Graziani e Sousa, Enrico Prajiante Bertolino, Maria Camarotti, Marcelo Averbach

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