J Antimicrob Chemother 2011; 66: 693 – 701

doi:10.1093/jac/dkr009 Advance Access publication 3 February 2011

The role of topical antibiotics used as prophylaxis in surgical site

infection prevention
S. M. McHugh 1,2*, C. J. Collins 3, M. A. Corrigan 1,2, A. D. K. Hill 1,2 and H. Humphreys 3,4
1
Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland; 2Department of Surgery, Beaumont Hospital, Dublin 9,

Downloaded from https://academic.oup.com/jac/article-abstract/66/4/693/726610 by guest on 14 September 2019

Ireland; 3Department of Microbiology, Beaumont Hospital, Dublin 9, Ireland; 4Department of Clinical Microbiology, Royal College
of Surgeons in Ireland, Dublin 2, Ireland

*Corresponding author. Department of Surgery, Beaumont Hospital, Dublin 9, Ireland. Tel: +353-18093000; E-mail: seamusmchugh@rcsi.ie

Compared with systemic antibiotic therapy, the topical or local delivery of an antibiotic has many potential
advantages. However, local antibiotics at the surgical site have received very limited approval in any of the sur-
gical prophylaxis consensus guidelines that we are aware of. A review of the literature was carried out through
searches of peer-reviewed publications in PubMed in the English language over a 30 year period between
January 1980 and May 2010. Both retrospective and prospective studies were included, as well as meta-ana-
lyses. With regard to defining ‘topical’ or ‘local’ antibiotic application, the application of an antibiotic solution to
the surgical site intraoperatively or immediately post-operatively was included. A number of surgical procedures
have been shown to significantly benefit from perioperative topical prophylaxis, e.g. joint arthroplasty, cataract
surgery and, possibly, breast augmentation. In obese patients undergoing abdominal surgery, topical surgical
prophylaxis is also proven to be beneficial. The selective use of topical antibiotics as surgical prophylaxis is jus-
tified for specific procedures, such as joint arthroplasty, cataract surgery and, possibly, breast augmentation. In
selective cases, such as obese patients undergoing abdominal surgery, topical surgical prophylaxis is also
proven to be beneficial. Apart from these specific indications, the evidence for use of topical antibiotics in
surgery is lacking in conclusive randomized controlled trials.

Keywords: perioperative antibiotics, healthcare-associated infections, abdominal surgery, cardiothoracic, orthopaedic

Background post-operative surgical infections, especially SSI. Compared

Surgical site infection (SSI) accounts for 20% of all healthcare-
associated infections.1 Approximately 5% of patients undergoing
surgery develop SSI.2 SSI results in failure of wound healing with
subsequent increased treatment costs,3 a greater likelihood of
admission to the intensive care unit, prolonged hospital stay
and higher post-operative mortality.4 In particular, studies have
demonstrated an extra 7 –10 days inpatient stay in those with
SSI.4 – 6 The associated hospital cost has been estimated at
US$3937 per infected patient.6 Therefore, there is interest in SSI
and its prevention amongst surgeons and amongst many other
healthcare professionals, because of the increased patient mor-
bidity and the associated financial burden.
There are many interventions advocated to reduce SSI, includ-
ing pre-operative assessment to optimize underlying disease
such as diabetes mellitus, aseptic techniques in the operating
theatre and the use of systemic prophylactic antibiotics.7 – 9
Amongst the many interventions advocated to prevent SSI, the
effectiveness of pre-operative intravenous administration of anti-
biotic prophylaxis has been extensively studied and has been
shown to be effective.10 – 15
Surgical practice often includes the use of topical or local
antimicrobial agents applied to the operative site to minimize
with systemic antibiotic therapy, topical or local delivery of an
antibiotic has many potential advantages, as well as some dis-
advantages, as outlined in a review by Lipsky and Hoey.16 The
benefits of local application include high and sustained concen-
trations at the site of infection where local physiological changes
may hinder the efficacy of systemic antibiotics.16 – 19 Other
benefits include the limited potential for systemic absorption
and toxicity, reduced volumes of antibiotic use, and, possibly,
less potential for the development of antibiotic resistance (as
there is likely to be less of an effect on, e.g. bowel flora).16 Novel
agents that are not available systemically may also be used.16
While local hypersensitivity or contact dermatitis reactions
and interference with local wound healing may be problematic,
a major disadvantage of local antibiotics is that there are no
specific efficacy criteria for agents in this setting that have
been standardized and approved by any official oversight
agency for evaluating their efficacy.16 Antibiotics may be deliv-
ered locally in the form of intraoperative washes or injections,
locally applied lotions, solutions, powders, gels, creams or oint-
ments, and antibiotic-impregnated beads or collagen implants.
The more commonly used antibiotics include cephalosporins,
aminoglycosides, glycopeptides, chloramphenicol and bacitracin.
The pharmacodynamic/pharmacokinetic profiles vary depending

# The Author 2011. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved.
For Permissions, please e-mail: journals.permissions@oup.com

693
Review
on the antibiotic, the dose and the method of delivery. Conse-
quently, it is difficult to establish which antibiotic to use, as
well as how much, for how long and in what form, for prophy-
laxis in a particular type of surgery. Comparisons of studies of
local antibiotics in certain surgical settings may also be difficult
given the variation in agent, dose and formulation. For this and
other reasons, local antibiotics at the surgical site have received
very limited approval in any of the surgical prophylaxis consensus
guidelines that we are aware of.
We reviewed the literature to determine what evidence exists
regarding the range of agents used, the indications for their use
and the efficacy of topical antibiotics in the prevention of SSI.
Methods
A detailed review of the literature was carried out through searches of
peer-reviewed publications in PubMed in the English language over a
30 year period between January 1980 and May 2010. Terms used in
the search included ‘topical antibiotics’, ‘local antibiotics’, ‘intra-operative
antibiotics’, ‘surgical prophylaxis’, ‘antibiotic prophylaxis’, ‘surgical site
infection’, ‘surgical infection’, ‘healthcare associated infection’, ‘surgical
infection prevention’ and ‘wound infection’. We focused on publications
dealing with the intraoperative or immediate post-operative application
of topical or local antibiotics for SSI prophylaxis. With regard to defining
‘topical’ or ‘local’ antibiotic application, the application of an antibiotic
solution to the surgical site intraoperatively or immediately post-
operatively was included. Studies in a setting of already infected surgical
wounds or the treatment of established infection were excluded. Both
retrospective and prospective studies were included, as well as meta-
analyses. Case reports and review articles were excluded.
The review was focused solely on the use of topical or local antibiotics
as surgical prophylaxis in SSI prevention only. In addition, studies asses-
sing antibiotic-impregnated cement, beads or gels for local application
were included. However, publications on studies of nasal mupirocin
(usually used to reduce post-operative infections due to Staphylococcus
aureus), antiseptics, antibiotic-impregnated devices (e.g. ventriculo-
peritoneal shunts), grafts or suture materials were excluded, as these
are specifically advocated and used to prevent device-related infections
and not just SSI.
Results
Abdominal surgery
There is good evidence that systemic antibiotic prophylaxis
reduces wound infection rates and major prophylaxis guidelines
recommend that it is given.20,21 The reported incidence of SSI
after abdominal surgery is 15%.22 Previously, studies of
topical cephalosporin use in gallbladder surgery reported that
topical antibiotics should not be used on their own as prophy-
laxis,23 especially in patients at high risk of SSI.24 In 1992, a
Japanese study confirmed that antibiotic concentrations in the
peritoneum were protective against those bacteria commonly
causing SSI in these patients. The study prospectively followed
two patient groups to observe SSI rates. One group received
local intraoperative application of latamoxef, ceftizoxime, cefo-
tiam or cefamandole to the surgical site alone, compared with
a control group receiving the same prophylaxis but intravenously.
On clinical follow-up, no significant differences were observed
between patients who were given topical antibiotics and those
administered intravenous prophylaxis. However, this study was
limited by sample size: only 80 patients were studied and,
694
therefore, the study was not powerful enough to detect a signifi-
cant difference.25
In 2009, a study comparing intravenous and local antibiotic
prophylaxis in inguinal hernia mesh repair reported that local
intraoperative administration of gentamicin had comparable effi-
cacy in preventing SSI to intravenous gentamicin adminis-
tration.26 However, the overall SSI rate in these two groups
was high (6.9%) and the patient number small, with only 202
study participants. A larger randomized controlled trial has ques-
tioned the need for any antibiotic prophylaxis in uncomplicated
Downloaded from https://academic.oup.com/jac/article-abstract/66/4/693/726610 by guest on 14 September 2019
inguinal hernia mesh repairs.27
More recently, two studies from the USA have reported on the
use of gentamicin/collagen sponges above the fascia at the time
of surgical closure in patients undergoing colorectal and cardiac
surgery.28,29 Counterintuitively, this randomized controlled trial in
602 colorectal patients observed an increase in SSI incidence
(30% versus 20.9%, P ¼ 0.01) in patients receiving the gentami-
cin/collagen sponges as compared with the control group. This
was explained as possibly being in part due to the mechanical
effects of the sponge and the inadequacy of a single local
bolus of gentamicin to prevent infection due to Gram-positive
cocci, such as S. aureus, compared with the efficacy of large con-
centrations of gentamicin to treat or prevent Gram-negative
bacillary infections. More importantly, these trials have contra-
dicted earlier findings on the efficacy of gentamicin sponges
used prophylactically, possibly because these were single-centre
studies. For example, one such single-centre, non-blinded study
involving 221 patients undergoing colorectal surgery had pre-
viously shown a 70% relative reduction in SSI through the use
of the sponge (18.4% versus 5.6%, P,0.01).30
Many recent publications on the topical use of antibiotics in
abdominal surgery focus on morbidly obese patients, as
obesity is an independent risk factor for SSI.22 A recent study
of 837 obese patients undergoing laparotomy with 6 weeks of
follow-up found that topical kanamycin applied to the subcu-
taneous space for 2 h led to a significant reduction in SSI in
the deep subcutaneous space.22 A similar study of 400 obese
patients undergoing laparotomy in whom topical subcutaneous
kanamycin was used significantly reduced SSI.31 However, both
of these studies were observational rather than a comparison
between a study group and a control group, and further random-
ized controlled trials are needed to investigate the potential
benefit of topical administration of kanamycin in this selective
cohort.
A recent prospective trial examined the use of topical fusidic
acid in addition to routine systemic antibiotics applied immedi-
ately after surgical closure in patients undergoing emergency
Caesarean section.32 Here, a decrease in SSI was noted from
17.1% to 2.8% (P ¼ 0.046) through topical antibiotic use.
However, this was a small trial (only 70 patients in total), with
a high baseline rate of SSI in control patients.
Overall, in abdominal surgery the evidence would suggest
that the application of topical antibiotics should only be
considered in morbidly obese patients undergoing laparotomy
where the local application of kanamycin has been shown to
be of potential benefit. Furthermore, the use of
antibiotic-impregnated sponges has been shown to increase
wound complication rates in colorectal surgery patients in a well-
conducted trial and this intervention should now be seriously
questioned.
Review
Orthopaedic surgery
Intravenous administration of surgical prophylaxis is rec-
ommended by practice guidelines as an effective measure in
SSI prevention.33 In addition, a recent US study reported that
56% of orthopaedic surgeons used topical antibiotics during
intraoperative irrigation to decrease SSI rates.34 Previous animal
studies have suggested that a combination of compounds, includ-
ing antibiotics, in irrigation fluid during orthopaedic surgery
reduce SSI rates.35,36 A more recent study assessing the injection
of gentamicin solution into surgical wounds in rats resulted in sig-
nificantly lower levels of bacteria compared with systemic genta-
micin treatment.17 However, subsequent in vitro studies have
reported that antibiotic solutions are no more effective in remov-
ing staphylococci from stainless steel screws than saline alone.37
Similarly, neomycin and bacitracin solutions were found to offer
no advantage over saline in the removal of bacteria from bone,
titanium and stainless steel.37 In a review, Anglen38 has commen-
ted on the absence of evidence for the efficacy of intraoperative
irrigation of antibiotics. A recent prospective randomized con-
trolled trial of 400 patients with and without bacitracin irrigation
of open fractures showed no difference in infection rates.39
Another randomized study of 100 patients undergoing hip
surgery assessed the efficacy of topical chloramphenicol applied
to the surgical site and found no statistically significant differ-
ences in infection rates.40
Based on initial animal studies, antibiotic-impregnated cement
has been used prophylactically for total joint arthroplasties or as
part of treatment when an infected arthroplasty is removed
and replaced in a single operation.41 Gentamicin-impregnated
cement has been shown to prevent S. aureus, streptococcal
and Gram-negative infections in rat tibias.42 In addition,
erythromycin- and colistin-impregnated cement prevented infec-
tion within 7 days of surgery when Escherichia coli was inoculated
into joints.43 Over the last two decades, the use of bone cement
impregnated with antibiotic agents has been common practice
in joint arthroplasty both in Europe44,45 and in the USA.42 A
recent meta-analysis was published examining the effectiveness
of antibiotic-impregnated cement as infection prophylaxis.46
Reporting on 19 studies, a total of 35659 patients undergoing
hip replacement were analysed and a significant decrease in SSI
rates was noted (2.3% to 1.2%) when antibiotic-impregnated
cement was used compared with antibiotic-free cement.
Antibiotic-impregnated beads are also used in orthopaedic
surgery prophylactically when repairing open fractures, as well
as in the treatment of infected arthroplasties or chronic osteo-
myelitis.41 The introduction of local antibiotics in the form of
beads fills the dead space and helps to reduce bacterial contami-
nation, thereby preventing infection. A review of 1085 consecutive
cases of compound limb fractures undergoing debridement and
stabilization demonstrated a significantly decreased rate of
infection (from 12% to 3.7%) amongst patients who not
only received systemic antibiotics but also had gentamicin-
impregnated beads applied locally.47 A further study compared
antibiotic beads with systemic antibiotics in open fractures.48
The study was randomized and prospective, but found no signifi-
cant differences between the two prophylactic measures in terms
of SSI incidence. However, the study was limited by the small
number of patients (67) recruited. Given the lack of adequate
randomized controlled trials, recent guidelines from the Surgical
JAC
Infection Society stated that there was insufficient evidence to
support the routine use of antibiotic-impregnated beads as pro-
phylaxis in open fracture surgery.49
In summary, considerable evidence exists to support the use
of antibiotic-impregnated bone cement as prophylaxis in joint
arthroplasty. However, further randomized prospective trials are
needed to fully delineate the efficacy of local irrigation with anti-
biotic solutions of the surgical site or the use of antibiotic beads
in the surgical treatment of open fractures.
Downloaded from https://academic.oup.com/jac/article-abstract/66/4/693/726610 by guest on 14 September 2019
Cardiothoracic surgery
Systemic prophylaxis is recommended as best practice for SSI
prevention in patients undergoing cardiothoracic surgery.50
In cardiac surgery, post-operative SSI is associated with very sig-
nificant morbidity and mortality.51 – 55 Previous randomized con-
trolled trials have demonstrated that perioperative intravenous
prophylaxis reduces sternal SSI rates by 80%.56 However,
coagulase-negative staphylococci, which are the most common
cause,52,57 – 59 may be resistant in vitro to the routinely used
b-lactam antibiotics. Vancomycin for intravenous prophylaxis is
discouraged because of the potential for the emergence of
vancomycin-resistant enterococci, the additional cost and
because of poor penetration to tissues.60 Despite this, the intrao-
perative administration of vancomycin has been shown to be
effective in reducing sternal SSI.61 In a prospective randomized
study of 416 patients, the use of topical vancomycin applied to
the cut sternotomy edges reduced SSI rates from 3.6% to
0.45% (P ¼ 0.02). In addition, in 2005, a larger randomized con-
trolled trial of 2000 patients found that the intraoperative local
application of gentamicin/collagen sponges to the sternum
resulted in a decrease of SSI incidence from 9% in the control
group treated with routine intravenous prophylaxis alone to
4.3% in the group also receiving local prophylaxis (P,0.001).55
Despite such earlier studies showing a potential benefit, a more
recent randomized controlled trial of .1500 patients demon-
strated no significant differences in sternal wound infections in
patients treated with gentamicin/collagen sponges as well as
systemic prophylaxis compared with a control group receiving
systemic prophylaxis alone.28
Of 504 thoracotomies for lung resection carried out in Greece,
local intraoperative instillation of fusidic acid into the pleural
space in addition to systemic prophylaxis was used in 290,
with the remainder receiving systemic prophylaxis alone.62 The
authors noted a significant decrease in the post-operative rates
of SSI, from 6.4% to 1% (P ¼ 0.003) in patients receiving instilla-
tion of fusidic acid. A further study examining the benefit of local
antibiotic prophylaxis in patients undergoing pneumonectomy
was carried out in 2001.63 Here, 93 patients were retrospectively
reviewed, with 47 receiving intraoperative intracavitary instilla-
tion of an antibiotic solution containing penicillin G, bacitracin
and gentamicin. There were statistically fewer cases of
empyema in patients receiving the local antibiotics (P ¼ 0.012).
However, as well as being retrospective, this study also had
small numbers and failed to show any difference in overall mor-
tality between the two groups.
Therefore, in patients undergoing sternotomy, controversy
exists as to whether application of gentamicin/collagen sponges
to the sternum is effective in reducing SSI. In thoracic surgery
695
Review
involving lung resection, limited evidence exists to support the use
of local antibiotics to prevent SSI. Although small retrospective
studies raise the possibility of intrapleural or intracavitatory
lavage with antibiotic solutions, larger randomized prospective
trials are necessary.
Dermatological surgery
Currently, patients undergoing simple skin lesion excisions do not
routinely receive systemic prophylaxis and it is thought to be
reserved for high-risk patients.21,64 Chloramphenicol ophthalmic
ointment is widely used by plastic surgeons as topical surgical
prophylaxis post-operatively: 66% in a recent UK and Ireland
survey.65 The acceptable rate of SSI after clean dermatological
surgery should be ,5%.66 – 68 A prospective randomized placebo-
controlled double-blind trial of 1014 patients carried out in
Queensland, Australia, in primary care assessed whether a
single post-operative application of topical chloramphenicol as
surgical prophylaxis reduced SSI rates in minor dermatological
surgery.69 SSI rates were reduced by 4.4% in those treated
with topical prophylaxis. Despite the result being statistically sig-
nificant, the authors considered the results disappointing, having
set themselves a target of a 5% reduction. In addition, the SSI
rate in the control group was high at 11.1%.
A prospective multicentre study published in 2007 reported
no link between the post-operative infection rate in dermatologi-
cal procedures and surgical prophylaxis.70 A total of 3491 der-
matological procedures were assessed, but no statistically
significant differences were noted between the type of surgical
prophylaxis used and the SSI rates. However, the primary
outcome for this study was an assessment of overall infection
control practices in dermatological surgery, rather than a study
examining the efficacy of topical antibiotics in these patients.
A recent meta-analysis assessed the value of topical anti-
biotic prophylaxis in the setting of skin grafting for burns
patients.71 A total of 1113 patients were included in the analysis
spanning 40 years (1968– 2008). Although the study reported
that systemic antibiotics reduced overall mortality, the results
were of borderline significance in the actual prevention of SSI.
However, this meta-analysis also reported no statistical advan-
tage through the application of topical antibiotics.
In summary, controversy exists as to whether topical anti-
biotic prophylaxis is of benefit in patients undergoing clean der-
matological surgery. In patients undergoing skin grafting for
burns, topical antibiotics are not indicated.
Breast surgery
The CDC recommend a first-generation cephalosporin for sys-
temic perioperative prophylaxis only in breast surgery involving
implants.21 The frequency of SSI following aesthetic breast aug-
mentation is 1.1% –2.5%.72 – 74 In patients undergoing breast
augmentation procedures, the topical delivery of cefazolin
through intraoperative irrigation results in equivalent concen-
trations in the wound comparable to intravenous delivery.75
However, this study consisted of only 24 patients, with the
primary outcome measured being serum and wound drainage
antibiotic concentrations rather than SSI rates.
A recent retrospective study of 436 patients assessed the
effectiveness of adding cefalotin to the irrigation of the breast
696
implant pocket versus normal saline alone and found that SSI
rates were significantly reduced from 12.8% to 6.7% in those
in whom a topical antibiotic was used.76 However, this was a ret-
rospective study and, consequently, the impact of topical cefalo-
tin may have been overestimated.
Overall, further randomized controlled trials are required to
fully investigate whether the topical application of surgical pro-
phylaxis is effective in the prevention of SSI in certain categories
of breast surgery.
Downloaded from https://academic.oup.com/jac/article-abstract/66/4/693/726610 by guest on 14 September 2019
Ocular surgery
Endophthalmitis is a devastating complication that may follow
intraocular surgery.77 Although various measures have been
suggested to reduce the risk of post-operative bacterial
endophthalmitis, current guidelines recommend pre-operative
conjunctival irrigation with 5% povidone iodine as prophylaxis
against infection.78 In addition, the Endophthalmitis Study Group
of the European Society of Cataract and Refractive Surgeons
reported reductions in post-operative endophthalmitis incidence
following cataract surgery in patients receiving intracameral cefur-
oxime injection in addition to povidone iodine.79 The penetration
of systemically administered antibiotics into the eye is uniquely
restricted by the presence of blood–ocular barriers: the blood–
aqueous barrier and the blood–retina barrier.80 Achieving thera-
peutic drug levels, particularly with hydrophilic antibiotics, such
as aminoglycosides, b-lactams and glycopeptides, may be diffi-
cult.81 Other forms of drug administration, such as topical or intra-
vitreal, may be used in an attempt to overcome these issues.
Concentrations of vancomycin in the irrigating solution used in
cataract surgery have been shown to be adequate for bacterial
inhibition in the anterior chamber of the eye at the end of cataract
surgery.82 Furthermore, a study in 2001 demonstrated a
decreased rate of positive bacterial cultures in patients who had
vancomycin (20 mg/L) in the intraoperative irrigating fluid com-
pared with those patients who did not receive local vancomycin.83
The efficacy of topical antibiotics has also been shown in clinical
settings. Intracameral (i.e. administration into the anterior
chamber of the eye) injection of cefazolin as surgical prophylaxis
at the end of cataract surgery has been shown to reduce the
rate of post-operative endophthalmitis. In 2002, a retrospective
observational study observed a post-operative infection rate of
only 0.06% following post-cataract surgery administration of
intracameral cefuroxime in a single-centre study. However, this
study did not describe a before-and-after analysis of the use of
intracameral cefuroxime; rather, it described low rates of infection
with its use.84 A further retrospective observational study of
.7000 patients noted a significantly reduced rate of post-
operative endophthalmitis in cases who received intracameral
cefazolin at the end of surgery (0.055%) compared with
those who did not (0.63%).85 Similarly, prophylactic subconjunc-
tival antimicrobial prophylaxis administered post-operatively
decreased the incidence of endophthalmitis as the antibiotic con-
centrations in the anterior chamber were shown to inhibit/kill
intraoperative bacteria. One such study demonstrated a decrease
in post-operative endophthalmitis from 0.179% to 0.011%.
Although this study was a retrospective chart review, it included
13 886 consecutive cataract operations.86
In summary, given the difficulty in achieving effective
antibiotic levels at the surgical site in ophthalmological surgery,
Review
intracameral or subconjunctival administration of surgical pro-
phylaxis has been reported as being effective in the prevention
of SSI. Although retrospective, these studies consist of large
numbers of patients demonstrating statistically significant
results, making the possibility of future blinded prospective ran-
domized trials less likely and less compelling.
Discussion
Compared with systemic antibiotic prophylaxis, the topical appli-
JAC
determining the dose,16 as the rigorous trials to determine this
are not available, unlike with the use of antibiotics for systemic
use. In addition, concern remains about the overuse of topical
antibiotics resulting in antibiotic resistance.69 Previous guidelines
suggest that use of topical antibiotics should be restricted,
because of the capacity of most topical drugs to select resistant
microorganisms and to cause sensitization.87,88
Surveys have shown high levels of topical antibiotic use for
prophylaxis34,65 and some surgical procedures have been
shown to significantly benefit from perioperative topical prophy-

Downloaded from https://academic.oup.com/jac/article-abstract/66/4/693/726610 by guest on 14 September 2019

cation of antimicrobial agents has many potential advantages,
including limiting the possibility of systemic toxicity and allowing
for high concentrations of antimicrobials at the surgical site. Fur-
thermore, the avoidance of systemic antibiotics reduces the
potential development of antibiotic resistance.16 However,
there are also a number of disadvantages, including interference
with the surgical site healing process,16,34 local hypersensitivity
or contact dermatitis reactions and difficulties in accurately
laxis (Table 1). This is evident in joint arthroplasty, where the use
of antibiotic-impregnated cement has been shown to be effec-
tive in SSI prevention. Further examples include ocular surgery,
where the perioperative intracameral or subconjunctival admin-
istration of antibiotics has been shown to decrease post-
operative rates of endophthalmitis in trials, which, although
retrospective, consist of large cohorts of patients with statisti-
cally and clinically significant results.

Table 1. Comparative studies showing a statistically significant reduction in SSI rates through prophylactic use of topical of local antibiotics

Surgical
specialty Operation Study type Intervention Significant finding Reference

Abdominal colorectal randomized controlled gentamicin/collagen sponge reduction from 30

surgery trial of 221 patients 18.4% to 5.6%
emergency Caesarean non-randomized fusidic acid reduction from 32
section prospective study of 70 17.1% to 2.8%
patients

Orthopaedic hip arthroplasty meta-analysis of 35659 antibiotic-impregnated bone reduction from 2.3% to 1.2% 46
surgery patients cement
debridement and retrospective observational gentamicin-impregnated reduction from 12% to 3.7% 47
stabilization of study of 1085 patients beads
compound limb
fractures

Cardiothoracic patients undergoing randomized controlled vancomycin reduction from 61

surgery sternotomy trial of 416 patients 3.6% to 0.45%
randomized controlled gentamicin/collagen sponges reduction from 9% to 4.3% 55
trial of 2000 patients
patients undergoing lung retrospective observational irrigation of the pleural space reduction in empyema from 62
resection study of 504 with fusidic acid 6.4% to 1%
thoracotomies
retrospective observational intracavitary irrigation with reduction in empyema from 63
study of 93 penicillin, gentamicin and 13% to 0%
thoracotomies bacitracin

Dermatological patients undergoing clean randomized controlled chloramphenicol ointment reduction from 11% to 6.6% 69
surgery skin lesion excision trial of 1014 patients applied to the surgical site

Breast surgery patients undergoing breast retrospective observational irrigation of the implant reduction from 76
augmentation study of 436 patients pocket with cefalotin 12.8% to 6.7%
solution

Ocular surgery post-cataract surgery retrospective observational intracameral cefazolin reduction in endophthalmitis 85
study of 7260 patients from 0.63% to 0.055%
retrospective observational administration of differing reduction in endophthalmitis 86
study of 13886 cases subconjunctival antibiotics from 0.179% to 0.011%

697
Review
Randomized controlled trials in cardiac surgery patients after
sternotomy have demonstrated a decrease in SSI of up to 80%
through the local application of both vancomycin and gentami-
cin to the cut sternotomy wound edges. However, given the
reluctance to widely use vancomycin because of fears of vanco-
mycin resistance developing, there remains the potential of local
application of gentamicin/collagen sponges as standard prophy-
laxis in SSI prevention. However, previous randomized trials
noting a decreased SSI rate through their use have not been con-
firmed by a recent multicentre trial.
In patients undergoing abdominal surgery, there is limited
evidence to support the routine use of topical antibiotics as
prophylaxis. Older studies examining the efficacy of the local
application of antibiotics as prophylaxis in gallbladder surgery
failed to demonstrate a clinical benefit.25 Similarly, a more
recent study in patients undergoing inguinal hernia mesh
repair also failed to demonstrate an advantage conferred by
topical antimicrobials.26 Worryingly, a randomized controlled
trial from 2010 has demonstrated an increased SSI incidence
in colorectal surgery patients receiving local application of
gentamicin/collagen sponges.29 Despite this, topical intraopera-
tive antibiotics to minimize SSI may be indicated in morbidly
obese patients.22,31 When we consider that in 2030 it is
expected that .85% of adults will be obese,89 it is clear that
the role of topical antibiotics in surgical prophylaxis may
increase if these findings are confirmed by prospective
randomized studies.
This review highlights a number of areas wherein the wide-
spread use of topical antibiotics is not supported by sufficient
evidence. For example, despite the lack of prospective clinical
data demonstrating the effectiveness of intraoperative irrigation
with antibiotics, the majority of those performing orthopaedic
surgery continue its use.34 Similarly, antibiotic-impregnated
beads continue to be widely used in open fracture surgery,
despite a need for blinded prospective randomized trials to
justify their use. In addition, breast augmentation involving
implants has been shown to have a reduced SSI rate when
topical antibiotics are used. A similar trend is also noted in a
retrospective study of patients undergoing Caesarean section,
but prospective studies are required to fully determine
whether local antibiotics are of benefit in this patient cohort.
The topical administration of antibiotic prophylaxis to the surgi-
cal site is common amongst plastic surgeons, but its effective-
ness is not borne out in clinical studies; notwithstanding a
recent large trial demonstrating a reduction in SSI rates after
dermatological surgery.69 However, given the low rates of SSI
in clean dermatological procedures, it is evident that trials
with larger numbers will be necessary to ascertain whether
topical prophylaxis would be truly effective.
Any adjunct to surgery that can reduce SSI is welcome and
interventions aside from antibiotic use have also been investi-
gated previously. A recent Cochrane review regarding surgical
hand antisepsis has suggested that chlorhexidine gluconate-
based aqueous scrubs are more effective than povidone iodine-
based aqueous scrubs in terms of the numbers of colony forming
units on surgeons hands.90 Hair removal from the surgical site
pre-operatively has also been investigated, with no differences
in SSI rates reported among patients who have had hair
removed prior to surgery and those who have not.91 Similarly,
a further Cochrane review has also shown that the use of
698
chlorhexidine bathing or showering pre-operatively is ineffective
in SSI prevention.92
Surgical practices are based on a combination of knowledge
gained during training and the evidence.34 The use of antibiotics
in the prevention of SSI is widespread with good evidence report-
ing the benefits of systemic prophylaxis.10 – 12,14,15,20 However, in
many cases, topical antibiotic use is based on behaviour and
ritual, rather than familiarity with the published evidence.34 As
previously outlined, evidence does exist to support the use of
topical antibiotics in orthopaedic and eye surgery. However, as
Downloaded from https://academic.oup.com/jac/article-abstract/66/4/693/726610 by guest on 14 September 2019
we have demonstrated, the use of topical antibiotics as prophy-
laxis in a number of surgical procedures is not evidence-based.
This is important in light of the increasing problem of bacterial
resistance to antibiotics; topical antibiotics as prophylaxis
should only be routinely administered where there is a clear
evidence base to support their use.
Conclusions
The selective use of topical antibiotics as surgical prophylaxis is
justified for specific procedures, such as joint arthroplasty, catar-
act surgery and, possibly, breast augmentation. In obese
patients undergoing abdominal surgery, topical surgical prophy-
laxis is also proven to be potentially beneficial. This is likely to be
of increased importance in the future, given the increasing
obesity rates in Western populations. The local intraoperative
administration of antibiotic prophylaxis commonly performed
in other orthopaedic procedures, plastic/dermatological surgery
and abdominal surgical procedures in non-obese patients
remains underevaluated and, to date, unproven. Topical anti-
biotics as surgical prophylaxis can only be recommended
where there are prospective randomized trials demonstrating
clear efficacy.
Transparency declarations
S. M. M. has received travelling grants from AstraZeneca and Pfizer. H. H.
has recently been in receipt of research funding from Steris Corporation,
3M, Inov8 Science, Pfizer/Wyeth and Cepheid, and has also recently
received lecture or consulting fees from 3M, Novartis and Astellas.
Other authors: none to declare.
References
1 de Lissovoy G, Fraeman K, Hutchins V et al. Surgical site infection:
incidence and impact on hospital utilization and treatment costs. Am J
Infect Control 2009; 37: 387– 97.
2 Gottrup F. Prevention of surgical-wound infections. N Engl J Med 2000;
342: 202–4.
3 Bowler PG, Duerden BI, Armstrong DG. Wound microbiology and
associated approaches to wound management. Clin Microbiol Rev 2001;
14: 244–69.
4 Kirkland KB, Briggs JP, Trivette SL et al. The impact of surgical-site
infections in the 1990s: attributable mortality, excess length of
hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999; 20:
725–30.
5 Johnson JT, Yu VL. Role of anaerobic bacteria in postoperative wound
infections following oncologic surgery of the head and neck. Ann Otol
Rhinol Laryngol Suppl 1991; 154: 46– 8.
Review
6 Zoutman D, McDonald S, Vethanayagan D. Total and attributable costs
of surgical-wound infections at a Canadian tertiary-care center. Infect
Control Hosp Epidemiol 1998; 19: 254– 9.
7 Leaper D, Burman-Roy S, Palanca A et al. Prevention and treatment of
surgical site infection: summary of NICE guidance. BMJ 2008; 337: a1924.
8 Humphreys H. Preventing surgical site infection. Where now? J Hosp
Infect 2009; 73: 316–22.
9 Mishriki SF. Surgical site infection. NICE forgot surgical skill. BMJ 2008;
337: a2579.
10 Bratzler DW, Houck PM, Richards C et al. Use of antimicrobial
prophylaxis for major surgery: baseline results from the National
Surgical Infection Prevention Project. Arch Surg 2005; 140: 174– 82.
11 Nelson RL, Glenny AM, Song F. Antimicrobial prophylaxis for colorectal
surgery. Cochrane Database Syst Rev 2009; issue 1: CD001181.
12 Page CP, Bohnen JM, Fletcher JR et al. Antimicrobial prophylaxis for
surgical wounds. Guidelines for clinical care. Arch Surg 1993; 128: 79 –88.
13 Glenny A, Song F. Antimicrobial prophylaxis in total hip replacement: a
systematic review. Health Technol Assess 1999; 3: 1– 57.
14 Glenny AM, Song F. Antimicrobial prophylaxis in colorectal surgery.
Qual Health Care 1999; 8: 132–6.
15 Song F, Glenny AM. Antimicrobial prophylaxis in colorectal surgery: a
systematic review of randomized controlled trials. Br J Surg 1998; 85:
1232– 41.
16 Lipsky BA, Hoey C. Topical antimicrobial therapy for treating chronic
wounds. Clin Infect Dis 2009; 49: 1541 –9.
17 Yarboro SR, Baum EJ, Dahners LE. Locally administered antibiotics for
prophylaxis against surgical wound infection. An in vivo study. J Bone
Joint Surg Am 2007; 89: 929– 33.
18 Cavanaugh DL, Berry J, Yarboro SR et al. Better prophylaxis against
surgical site infection with local as well as systemic antibiotics. An in
vivo study. J Bone Joint Surg Am 2009; 91: 1907– 12.
19 Robson MC, Edstrom LE, Krizek TJ et al. The efficacy of systemic
antibiotics in the treatment of granulating wounds. J Surg Res 1974;
16: 299–306.
20 Bowater RJ, Stirling SA, Lilford RJ. Is antibiotic prophylaxis in surgery a
generally effective intervention? Testing a generic hypothesis over a set of
meta-analyses. Ann Surg 2009; 249: 551– 6.
21 Mangram AJ, Horan TC, Pearson ML et al. 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; 27: 97–132; quiz 133–4; discussion 96.
22 Alexander JW, Rahn R, Goodman HR. Prevention of surgical site
infections by an infusion of topical antibiotics in morbidly obese
patients. Surg Infect (Larchmt) 2009; 10: 53– 7.
23 Freischlag J, McGrattan M, Busuttil RW. Topical versus systemic
cephalosporin administration in elective biliary operations. Surgery
1984; 96: 686–93.
24 Pitt HA, Postier RG, Gadacz TR et al. The role of topical antibiotics in
‘high-risk’ biliary surgery. Surgery 1982; 91: 518–24.
25 Aoki Y, Tanimura H, Ohkohchi N. Topical antibiotics in cholecystectomy
for gallstone diseases. Nippon Geka Hokan 1992; 61: 387–95.
26 Praveen S, Rohaizak M. Local antibiotics are equivalent to intravenous
antibiotics in the prevention of superficial wound infection in inguinal
hernioplasty. Asian J Surg 2009; 32: 59– 63.
27 Aufenacker TJ, van Geldere D, van Mesdag T et al. The role of antibiotic
prophylaxis in prevention of wound infection after Lichtenstein open mesh
repair of primary inguinal hernia: a multicenter double-blind randomized
controlled trial. Ann Surg 2004; 240: 955– 60; discussion 60– 1.
JAC
28 Bennett-Guerrero E, Ferguson TB Jr, Lin M et al. Effect of an
implantable gentamicin-collagen sponge on sternal wound infections
following cardiac surgery: a randomized trial. JAMA 2010; 304: 755–62.
29 Bennett-Guerrero E, Pappas TN, Koltun WA et al. Gentamicin-collagen
sponge for infection prophylaxis in colorectal surgery. N Engl J Med 2010;
363: 1038– 49.
30 Rutten HJ, Nijhuis PH. Prevention of wound infection in elective
colorectal surgery by local application of a gentamicin-containing
collagen sponge. Eur J Surg 1997; Suppl 578: 31– 5.
31 Alexander JW, Rahn R. Prevention of deep wound infection in
Downloaded from https://academic.oup.com/jac/article-abstract/66/4/693/726610 by guest on 14 September 2019
morbidly obese patients by infusion of an antibiotic into the
subcutaneous space at the time of wound closure. Obes Surg 2004; 14:
970–4.
32 Pradhan GB, Agrawal J. Comparative study of post operative wound
infection following emergency lower segment caesarean section with
and without the topical use of fusidic acid. Nepal Med Coll J 2009; 11:
189–91.
33 National Institute for Health and Clinical Excellence (NICE). Prevention
and Treatment of Surgical Site Infection, Clinical Guideline, October 2008.
http://www.nice.org.uk/nicemedia/live/11743/42379/42379.pdf (2 January
2011, date last accessed).
34 Tejwani NC, Immerman I. Myths and legends in orthopaedic practice:
are we all guilty? Clin Orthop Relat Res 2008; 466: 2861 –72.
35 Rosenstein BD, Wilson FC, Funderburk CH. The use of bacitracin
irrigation to prevent infection in postoperative skeletal wounds. An
experimental study. J Bone Joint Surg Am 1989; 71: 427–30.
36 Dirschl DR, Wilson FC. Topical antibiotic irrigation in the prophylaxis of
operative wound infections in orthopedic surgery. Orthop Clin North Am
1991; 22: 419–26.
37 Anglen J, Apostoles PS, Christensen G et al. Removal of surface
bacteria by irrigation. J Orthop Res 1996; 14: 251–4.
38 Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad
Orthop Surg 2001; 9: 219–26.
39 Anglen JO. Comparison of soap and antibiotic solutions for irrigation
of lower-limb open fracture wounds. A prospective, randomized study.
J Bone Joint Surg Am 2005; 87: 1415 –22.
40 Kamath S, Sinha S, Shaari E et al. Role of topical antibiotics in hip
surgery. A prospective randomised study. Injury 2005; 36: 783–7.
41 Wininger DA, Fass RJ. Antibiotic-impregnated cement and beads for
orthopedic infections. Antimicrob Agents Chemother 1996; 40: 2675 –9.
42 Fish DN, Hoffman HM, Danziger LH. Antibiotic-impregnated cement
use in U.S. hospitals. Am J Hosp Pharm 1992; 49: 2469– 74.
43 Nelson CL, Evans RP, Blaha JD et al. A comparison of
gentamicin-impregnated polymethylmethacrylate bead implantation to
conventional parenteral antibiotic therapy in infected total hip and
knee arthroplasty. Clin Orthop Relat Res 1993; 295: 96 –101.
44 Josefsson G, Gudmundsson G, Kolmert L et al. Prophylaxis with
systemic antibiotics versus gentamicin bone cement in total hip
arthroplasty. A five-year survey of 1688 hips. Clin Orthop Relat Res
1990; 253: 173–8.
45 Espehaug B, Engesaeter LB, Vollset SE et al. Antibiotic prophylaxis in
total hip arthroplasty. Review of 10,905 primary cemented total hip
replacements reported to the Norwegian arthroplasty register, 1987 to
1995. J Bone Joint Surg Br 1997; 79: 590–5.
46 Parvizi J, Saleh KJ, Ragland PS et al. Efficacy of antibiotic-impregnated
cement in total hip replacement. Acta Orthop 2008; 79: 335– 41.
47 Ostermann PA, Seligson D, Henry SL. Local antibiotic therapy for
severe open fractures. A review of 1085 consecutive cases. J Bone Joint
Surg Br 1995; 77: 93–7.
699
Review
48 Moehring HD, Gravel C, Chapman MW et al. Comparison of antibiotic
beads and intravenous antibiotics in open fractures. Clin Orthop Relat
Res 2000; 372: 254–61.
49 Hauser CJ, Adams CA Jr, Eachempati SR. Surgical Infection Society
guideline: prophylactic antibiotic use in open fractures: an
evidence-based guideline. Surg Infect (Larchmt) 2006; 7: 379– 405.
50 Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an
advisory statement from the National Surgical Infection Prevention
Project. Clin Infect Dis 2004; 38: 1706–15.
51 Mossad SB, Serkey JM, Longworth DL et al. Coagulase-negative
staphylococcal sternal wound infections after open heart operations.
Ann Thorac Surg 1997; 63: 395–401.
52 Tegnell A, Aren C, Ohman L. Coagulase-negative staphylococci and
sternal infections after cardiac operation. Ann Thorac Surg 2000; 69:
1104– 9.
53 Hall RE, Ash AS, Ghali WA et al. Hospital cost of complications
associated with coronary artery bypass graft surgery. Am J Cardiol
1997; 79: 1680– 2.
54 Taylor GJ, Mikell FL, Moses HW et al. Determinants of hospital charges
for coronary artery bypass surgery: the economic consequences of
postoperative complications. Am J Cardiol 1990; 65: 309– 13.
55 Friberg O, Svedjeholm R, Soderquist B et al. Local gentamicin reduces
sternal wound infections after cardiac surgery: a randomized controlled
trial. Ann Thorac Surg 2005; 79: 153–61; discussion 61– 2.
56 Kreter B, Woods M. Antibiotic prophylaxis for cardiothoracic
operations. Meta-analysis of thirty years of clinical trials. J Thorac
Cardiovasc Surg 1992; 104: 590–9.
57 Pryor KO, Fahey TJ III, Lien CA et al. Surgical site infection and the
routine use of perioperative hyperoxia in a general surgical population:
a randomized controlled trial. JAMA 2004; 291: 79– 87.
58 Gardlund B, Bitkover CY, Vaage J. Postoperative mediastinitis in
cardiac surgery - microbiology and pathogenesis. Eur J Cardiothorac
Surg 2002; 21: 825–30.
59 Wilson AP, Gruneberg RN, Treasure T et al. Staphylococcus epidermidis
as a cause of postoperative wound infection after cardiac surgery:
assessment of pathogenicity by a wound-scoring method. Br J Surg
1988; 75: 168–70.
60 Friberg O. Local collagen-gentamicin for prevention of sternal wound
infections: the LOGIP trial. APMIS 2007; 115: 1016– 21.
61 Vander Salm TJ, Okike ON, Pasque MK et al. Reduction of sternal
infection by application of topical vancomycin. J Thorac Cardiovasc Surg
1989; 98: 618–22.
62 Baltayiannis N, Markogiannakis A, Sfyridis P et al. The influence of
local instillation of fusidic acid on the development of microbial
complications after lung resection. J Chemother 2006; 18: 285– 92.
63 Miller JD, Nemni J, Simone C et al. Prophylactic intracavitary
(pneumonectomy space) antibiotic instillation: a comparative study.
Ann Thorac Cardiovasc Surg 2001; 7: 14–6.
64 Messingham MJ, Arpey CJ. Update on the use of antibiotics in
cutaneous surgery. Dermatol Surg 2005; 31: 1068 –78.
65 Erel E, Platt AJ, Ramakrishnan V. Chloramphenicol use in plastic
surgery. Br J Plast Surg 1999; 52: 326– 7.
66 Culver DH, Horan TC, Gaynes RP et al. Surgical wound infection rates
by wound class, operative procedure, and patient risk index. National
Nosocomial Infections Surveillance System. Am J Med 1991; 91:
152S–7S.
67 Haas AF, Grekin RC. Antibiotic prophylaxis in dermatologic surgery.
J Am Acad Dermatol 1995; 32: 155– 76; quiz 77–80.
700
68 Cruse PJ, Foord R. The epidemiology of wound infection. A 10-year
prospective study of 62,939 wounds. Surg Clin North Am 1980; 60:
27– 40.
69 Heal CF, Buettner PG, Cruickshank R et al. Does single application of
topical chloramphenicol to high risk sutured wounds reduce incidence
of wound infection after minor surgery? Prospective randomised
placebo controlled double blind trial. BMJ 2009; 338: a2812.
70 Rogues AM, Lasheras A, Amici JM et al. Infection control practices and
infectious complications in dermatological surgery. J Hosp Infect 2007;
65: 258–63.
Downloaded from https://academic.oup.com/jac/article-abstract/66/4/693/726610 by guest on 14 September 2019
71 Avni T, Levcovich A, Ad-El DD et al. Prophylactic antibiotics for burns
patients: systematic review and meta-analysis. BMJ 2010; 340: c241.
72 Kjoller K, Holmich LR, Jacobsen PH et al. Epidemiological investigation
of local complications after cosmetic breast implant surgery in Denmark.
Ann Plast Surg 2002; 48: 229–37.
73 Gabriel SE, Woods JE, O’Fallon WM et al. Complications leading to
surgery after breast implantation. N Engl J Med 1997; 336: 677– 82.
74 Araco A, Gravante G, Araco F et al. Infections of breast implants in
aesthetic breast augmentations: a single-center review of 3,002
patients. Aesthetic Plast Surg 2007; 31: 325– 9.
75 White RR IV, Pitzer KD, Fader RC et al. Pharmacokinetics of topical and
intravenous cefazolin in patients with clean surgical wounds. Plast
Reconstr Surg 2008; 122: 1773 –9.
76 Pfeiffer P, Jorgensen S, Kristiansen TB et al. Protective effect of topical
antibiotics in breast augmentation. Plast Reconstr Surg 2009; 124:
629–34.
77 Kelkar A, Kelkar J, Amuaku W et al. How to prevent endophthalmitis in
cataract surgeries? Indian J Ophthalmol 2008; 56: 403–7.
78 Royal College of Ophthalmologists. Cataract Surgery Guidelines.
London: Royal College of Ophthalmologists, 2004.
79 ESCRS Endophthalmitis Study Group. Prophylaxis of postoperative
endophthalmitis following cataract surgery: results of the ESCRS
multicentre study and identification of risk factors. J Cataract Refract
Surg 2007; 33: 978–88.
80 Urtti A. Challenges and obstacles of ocular pharmacokinetics and
drug delivery. Adv Drug Deliv Rev 2006; 58: 1131 –5.
81 Lopez-Cabezas C, Muner DS, Massa MR et al. Antibiotics in
endophthalmitis: microbiological and pharmacokinetic considerations.
Curr Clin Pharmacol 2010; 5: 47– 54.
82 Adenis JP, Robert PY, Mounier M et al. Anterior chamber
concentrations of vancomycin in the irrigating solution at the end of
cataract surgery. J Cataract Refract Surg 1997; 23: 111– 4.
83 Mendivil Soto A, Mendivil MP. The effect of topical povidone-iodine,
intraocular vancomycin, or both on aqueous humor cultures at the
time of cataract surgery. Am J Ophthalmol 2001; 131: 293–300.
84 Montan PG, Wejde G, Koranyi G et al. Prophylactic intracameral
cefuroxime. Efficacy in preventing endophthalmitis after cataract
surgery. J Cataract Refract Surg 2002; 28: 977–81.
85 Romero P, Mendez I, Salvat M et al. Intracameral cefazolin as
prophylaxis against endophthalmitis in cataract surgery. J Cataract
Refract Surg 2006; 32: 438–41.
86 Colleaux KM, Hamilton WK. Effect of prophylactic antibiotics and
incision type on the incidence of endophthalmitis after cataract
surgery. Can J Ophthalmol 2000; 35: 373– 8.
87 Antibiotic Expert Group. Therapeutic Guidelines: Antibiotic. Version 13.
Melbourne: Therapeutic Guidelines Limited, 2006.
88 British Medical Association RPSoGB. British National Formulary.
London: BMA/RPSGB, 2006.
Review
89 Wang Y, Beydoun MA, Liang L et al. Will all Americans become
overweight or obese? Estimating the progression and cost of the US
obesity epidemic. Obesity (Silver Spring) 2008; 16: 2323– 30.
90 Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce
surgical site infection. Cochrane Database Syst Rev 2008; issue 1:
CD004288.
JAC
91 Tanner J, Woodings D, Moncaster K. Preoperative hair removal to
reduce surgical site infection. Cochrane Database Syst Rev 2006; issue
2: CD004122.
92 Webster J, Osborne S. Preoperative bathing or showering with skin
antiseptics to prevent surgical site infection. Cochrane Database Syst
Rev 2007; issue 2: CD004985.
Downloaded from https://academic.oup.com/jac/article-abstract/66/4/693/726610 by guest on 14 September 2019
701