The choice of postoperative dressing and the risk of surgical site infections

An infection in a surgical wound can cause suffering for the patient and increased costs for the health care services. Due to this, surgical site infections should be prevented. After surgery, a sterile dressing is applied over the wound to shield the wound and promote wound healing. There are several types of dressings, with or without negative pressure therapy.

Reading time approx. 11 minutes Published: November 7, 2023 Publication type:

SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

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Published: November 7, 2023 Report no: ut202333 Registration no: SBU 2023/754

Question

What systematic reviews have been published regarding the choice of postoperative dressings and its effect on postoperative site infections?

Method

A systematic literature search was performed using the following databases: Medline (by Ovid), Scopus and Cinahl.

Two authors independently assessed the abstracts of all identified studies.
Risk of bias in relevant systematic reviews was assessed using an assessment tool based on AMSTAR.

Identified literature

Two relevant systematic reviews with low risk of bias were identified [1] [2]. The results and conclusions are presented in Table 1. Seven relevant systematic reviews with moderate risk of bias were also identified, but the results and conclusions are not presented due to large overlap in included studies, or an earlier publication date [3-9]. In 68 relevant systematic reviews, the risk of bias was considered to be high, therefore the results and conclusions are not reported.

Table 1 Systematic reviews with low risk of bias.
Included studies	Population, Intervention, Control	Outcome and Results
NPWT = negative pressure wound therapy; RCT = randomized controlled trial; RR = risk ratio; SSI = surgical site infection
Dumville et al, 2016 [74] Dressings for the prevention of surgical site infection
Relevant studies: 18 RCT Setting: Europe: 10 studies USA: 6 studies Australia: 1 study Japan: 1 study	Population: Studies involving adults or children (aged two years and over) who had undergone surgical procedures where healing of the surgical wound was planned by primary intention. Intervention:Application of wound dressing Control: Alternative dressings	SSI:Basic contact wound dressings vs film dressings Clean surgery: (4 studies, n=897)RR 1.34 (95% CI, 0.70 to 2.55)Very low certainty evidence Basic contact wound dressings vs hydrocolloid dressings Clean surgery: (2 studies, n=556)RR 0.91 (95% CI, 0.30 to 2.78) Very low certainty evidence Potentially contaminated surgery: (3 studies, n=268)RR 0.57 (95% CI, 0.22 to 1.51) Very low certainty evidence Basic wound contact dressings vs fibrous‐hydrocolloid (hydrofibre) dressings Clean surgery: (3 studies, n=364)RR 1.29 (95% CI, 0.50 to 3.28) Very low certainty evidence Basic wound contact dressings vs silver dressings Clean surgery: (2 studies, n=496)RR 1.11 (95% CI, 0.47 to 2.62) Very low certainty evidence Potentially contaminated surgery: (5 studies, n=1353)RR 0.83 (95% CI, 0.51 to 1.37) Very low certainty evidence
Authors' conclusion: ”…there was insufficient evidence on which to base solid conclusions regarding whether any single type of dressing reduces risk of SSIs in wounds resulting from surgery”
Norman et al, 2022 [75] Negative pressure wound therapy for surgical healing by primary closure
62 RCT6 economic studies Setting: North America: 28 studies Europe: 24 studies Australasia: 5 studies Israel: 1 study Japan: 1 study South Korea: 1 study Not reported: 2 studies	Population: Studies involving people of any age and in any care with uninfected surgical wounds healing by primary closure. Surgical procedure: Knee or hip arthroplasties: 8 studies Peripheral vascular procedures: 10 studies Caesarean section: 10 studies Abdominal procedures: 14 studies Limb fracture: 6 studies Cardiac surgery: 3 studies Hepatopancreatiobiliary procedures: 3 studies Breast surgery: 3 studies Mixed wound types: 2 studies Hand injuries: 1 study Inguinal lymph node dissection: 1 study Spinal surgery: 1 study Intervention: NPWT for closed surgical incisions delivered by any mode. Type of NPWT (brand) VAC: 7 studies PICO: 20 studies PREVENA: 24 studies CuraVac: 1 study NANOVA: 1 study Not specified: 9 studies Control: Standard dressing or advanced dressing	SSI: (Follow-up period 30 days to 12 months or unspecified) NPWT vs standard dressing Overall: (44 studies, n=11 403) RR 0.73 (95% CI, 0.63 to 0.85) Moderate certainty evidence ⊕⊕⊕⊝ Superficial SSI: (22 studies, n=5539) RR 0.70 (95% CI, 0.53 to 0.92) Deep SSI: (22 studies, n=8521) RR 0.95 (95% CI, 0.76 to 1.18) Clean surgery: (17 studies, n=2288) RR 0.58 (95% CI, 0.41 to 0.81) Clean-contaminated surgery: (21 studies, n=7282) RR 0.83 (95% CI, 0.72 to 0.96) Contaminated surgery: (3 studies, n=1649) RR (95% CI, 0.28 to 2.14) Dirty surgery: (3 studies, n=184) RR 0.27 (95% CI, 0.06 to 1.12)
Authors' conclusion: “People with primary closure of their surgical wound and treated prophylactically with NPWT following surgery probably experience fewer SSIs than people treated with standard dressings but there is probably no difference in wound dehiscence (moderate-certainty evidence). Assessments of cost-effectiveness of NPWT produced differing results in different indications. There is a large number of ongoing studies, the results of which may change the findings of this review.”

References

Dumville JC, Gray TA, Walter CJ, Sharp CA, Page T, Macefield R, et al. Dressings for the prevention of surgical site infection. Cochrane Database Syst Rev. 2016;12(12):CD003091. Available from: https://doi.org/10.1002/14651858.CD003091.pub4.
Norman G, Shi C, Goh EL, Murphy EM, Reid A, Chiverton L, et al. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev. 2022;4(4):CD009261. Available from: https://doi.org/10.1002/14651858.CD009261.pub7.
Gillespie BM, Thalib L, Ellwood D, Kang E, Mahomed K, Kumar S, et al. Effect of negative-pressure wound therapy on wound complications in obese women after caesarean birth: a systematic review and meta-analysis. Bjog. 2022;129(2):196-207. Available from: https://doi.org/10.1111/1471-0528.16963.
Kirkham AM, Candeliere J, McIsaac DI, Stelfox HT, Dubois L, Gill HL, et al. Efficacy of Strategies Intended to Prevent Surgical Site Infection After Lower Limb Revascularization Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Ann Surg. 2023;278(3):e447-e56. Available from: https://doi.org/10.1097/SLA.0000000000005867.
Meyer J, Roos E, Davies RJ, Buchs NC, Ris F, Toso C. Does Prophylactic Negative-Pressure Wound Therapy Prevent Surgical Site Infection After Laparotomy? A Systematic Review and Meta-analysis of Randomized Controlled trials. World J Surg. 2023;47(6):1464-74. Available from: https://doi.org/10.1007/s00268-023-06908-7.
Sandy-Hodgetts K, Watts R. Effectiveness of negative pressure wound therapy/closed incision management in the prevention of post-surgical wound complications: a systematic review and meta-analysis. JBI Database System Rev Implement Rep. 2015;13(1):253-303. Available from: https://doi.org/10.11124/jbisrir-2015-1687.
Svensson-Bjork R, Zarrouk M, Asciutto G, Hasselmann J, Acosta S. Meta-analysis of negative pressure wound therapy of closed groin incisions in arterial surgery. Br J Surg. 2019;106(4):310-8. Available from: https://doi.org/10.1002/bjs.11100.
Wee IJY, Syn N, Choong A. Closed Incision Negative Pressure Wound Therapy in Vascular Surgery: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg. 2019;58(3):446-54. Available from: https://doi.org/10.1016/j.ejvs.2018.12.021.
Zwanenburg PR, Tol BT, Obdeijn MC, Lapid O, Gans SL, Boermeester MA. Meta-analysis, Meta-regression, and GRADE Assessment of Randomized and Nonrandomized Studies of Incisional Negative Pressure Wound Therapy Versus Control Dressings for the Prevention of Postoperative Wound Complications. Ann Surg. 2020;272(1):81-91. Available from: https://doi.org/10.1097/SLA.0000000000003644.

Search Strategies

Medline via OvidSP 20 July 23

Title: Postoperative dressings
Search terms		Items found
/ = Term from the MeSH controlled vocabulary; .sh = Term from the MeSH controlled vocabulary; exp = Term from MeSH including terms found below this term in the MeSH hierarchy; .ti,ab = Title or abstract; .tw = Title or abstract; .kf = Keywords; .kw = Keywords, exact; .bt = Book title. NLM Bookshelf.; .pt = Publication type; .ja = Journal abbreviation; .af = All fields; adjn = Adjacent. Proximity operator retrieving adjacent words, adj3 retrieves records with search terms within two terms from each other.; * or $ = Truncation; “ “ = Citation Marks; searches for an exact phrase ^a. Cochrane Highly Sensitive Search Strategy for identifying randomized trials in MEDLINE: sensitivity- and precision-maximizing version (2008 revision); Ovid format. The Cochrane Collaboration; 2008. Available from: https://training.cochrane.org/handbook/current/chapter-04-technical-supplement-searching-and-selecting-studies#section-3-6-1. with modifications: the following terms are added: clinical trial, phase iii.pt. ; randomised.ab. ; ("Phase 3" or "phase3" or "phase III" or P3 or "PIII").ti,ab,kw.
Population:
1.	exp Surgical Wound/ or ((exp Surgical Procedures, Operative/ or exp Perioperative Period/ or exp Perioperative Care/ or surger.ti,ab,bt,kw. or surgical.ti,ab,bt,kw. or operation.ti,ab,bt,kw. or operative.ti,ab,bt,kw. or perioperati.ti,ab,bt,kw. or extracti.ti,ab,bt,kw. or restorati.ti,ab,bt,kw.) and (wound or incisi* or excisi*).ti,ab,bt,kw.)	271 698
Intervention:
2.	exp Bandages/ or dressing.ti,ab,bt,kw. or bandage.ti,ab,bt,kw. or “Negative Pressure”.ti,ab,bt,kw or “Vacuum Assisted”.ti,ab,bt,kw or NWPT.ti,ab,bt,kw or exp Negative-Pressure Wound Therapy/	64 362
Study types: systematic reviews and meta-analysis / randomized controlled trials^a
3.	((Systematic Review/ or Meta-Analysis/ or Cochrane Database Syst Rev.ja. or ((systematic adj4 review) or "meta analys" or metaanalys).ti,bt,ab.) not (editorial/ or letter/ or case reports/))	439 505
Combined sets:
4.	1 AND 2	12 813
5.	3 AND 4	570
Final result
6.	5	570

Scopus via scopus.com 20 July 23

Title: Postoperative dressings
Search terms		Items found
TITLE-ABS-KEY = Title, abstract or keywords (including indexed keywords and author keywords); ALL = All fields; W/n = Within. Proximity operator retrieving terms within n words from each other.; PRE/n = Precedes by. Proximity operator, the first term in the search must precede the second by n words.; LIMIT-TO (X) = Includes only results of specified type, e.g., publication type or time range.; DOCTYPE = Publication type; “re” = review; “le” = letter; “ed” = editorial; “ch” = book chapter; “cp” = conference proceedings; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
Population:
1.	TITLE-ABS-KEY ( "Surgical wound" ) OR ( TITLE-ABS-KEY ( "Surgical procedure" OR "Perioperative period" OR "perioperative car" OR surger* OR surgical* OR operation* OR operative* OR perioperati* OR extracti* OR restorati* ) AND TITLE-ABS-KEY ( wound* OR incisi* OR excisi* ) )	477 990
Intervention:
2.	TITLE-ABS-KEY ( bandage* OR dressing* OR "negative pressure" OR "vacuum assisted" OR nwpt )	120 887
Study types: systematic reviews and meta-analysis / randomized controlled trials
3.	TITLE-ABS-KEY ( ( systematic W/2 review ) OR "meta analy" OR metaanaly ) AND (EXCLUDE (DOCTYPE, “le”) OR EXCLUDE (DOCTYPE, “ed”) OR EXCLUDE (DOCTYPE, “ch”) OR EXCLUDE (DOCTYPE, “cp”))	642 079
Combined sets:
4.	1 AND 2	20 028
5.	3 AND 4	790
Final result
6.	5	790

CINAHL via EBSCO 20 July 23

Title: Postoperative dressings
Search terms		Items found
TI = Title; AB = Abstract; SU = Keyword, exact or part (including all other fields for indexed and author keywords); MH = Exact subject heading, indexed keywords; TX = All text; PT = Publication type; Nn = Near. Proximity operator retrieving terms within n words from each other.; * = Truncation; “ “ = Citation Marks; searches for an exact phrase ^b. Glanville J, Dooley G, Wisniewski S, Foxlee R, Noel-Storr A. Development of a search filter to identify reports of controlled clinical trials within CINAHL Plus. Health Info Libr J. 2019;36(1):73-90. Available from: https://doi.org/10.1111/hir.12251.
Population:
1.	(MH Surgical Wound) or (MH Surgical Wound Care+) or (MH Perioperative Nursing+) or (((TI surg* or AB surg) or (TI operat or AB operat)) and ((TI wound or AB wound) or (TI incisi or AB incis) or (TI excisi or AB excisi*)))	57 795
Intervention:
2.	(MH "Negative Pressure Wound Therapy") or (MH “Bandages and Dressings”+) or (TI bandage* or AB bandage* or “Negative Pressure” or “Vacuum Assisted” or NWPT) or (TI dressing* or AB dressing* or “Negative Pressure” or “Vacuum Assisted” or NWPT)	18 397
Study types: systematic reviews and meta-analysis / randomized controlled trials^b
3.	((TI((systematic N3 review) OR "meta analys" OR metaanalys) OR AB((systematic N3 review) OR "meta analys" OR metaanalys) OR SU((systematic N3 review) OR "meta analys" OR metaanalys)) OR (PT "Systematic Review" OR PT "meta analysis")) NOT (MH "Case Studies" OR PT "Commentary" OR PT "Editorial" OR PT "Letter")	239 209
Combined sets:
4.	1 AND 2	3352
5.	3 AND 4	228
Final result
6.	5	228

Citation Search

Scopus via Elsevier (citation search) 29 September 2023

Title: Postoperative dressings
Search terms		Items found
LIMIT-TO (SRCTYPE, "j" = Limit to source type journal; LIMIT-TO (DOCTYPE, "ar" = Limit to document type article; LIMIT-TO (DOCTYPE, "re" = Limit to document type review LIMIT-TO (PUBYEAR, X = Limit to publication year
Cited articles
1.	DOI("10.1002/14651858.cd009261.pub7")	29
2.	DOI("10.1002/14651858.CD003091.pub4")	32
Citing articles
3.	#1 View cited by

Page published November 7, 2023

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