World Journal of Surgery

, Volume 43, Issue 2, pp 374–384 | Cite as

A Meta-analysis of Prophylaxis of Surgical Site Infections with Topical Application of Povidone Iodine Before Primary Closure

  • Manuel López-CanoEmail author
  • Miquel Kraft
  • Anna Curell
  • Mireia Puig-Asensio
  • José Balibrea
  • Manuel Armengol-Carrasco
  • Josep M. García-Alamino
Scientific Review



Povidone iodine (PVI) is a widely used antiseptic solution among surgeons. A meta-analysis based on randomized controlled trials (RCTs) was conducted to establish whether application of PVI before wound closure could reduce surgical site infection (SSI) rates.


Systematic review of MEDLINE/PubMed, Scopus, CINAHL, and Web of Science databases from inception to September 2017, with no language restrictions. Only RCTs were retrieved. The primary outcome was the SSI rate. Meta-analysis was complemented with trial sequential analysis (TSA).


A total of 7601 patients collected from 16 RCTs were analyzed. A reduction in overall SSI rate was found (RR 0.64, 95% CI 0.48–0.85, P = 0.002, I2 = 65%), which was attributed to patients undergoing elective operations (n = 2358) and mixed elective/urgent operations (n = 2019). When RCTs of uncertain quality (n = 9) were excluded, the use of PVI before wound closure (n = 4322 patients) was not associated with a significant reduction of SSI (RR 0.81, 95% CI 0.55–1.20, P = 0.29, I2 = 51%) and was only significant in clean wounds (RR 0.25, 95% CI 0.09–0.70, P = 0.008, I2 = 0%). For the primary outcome, the TSA calculation using a relative risk reduction of 19% and an 11% proportion of control event rate (CER) with 51% of I2, the accrued information size (n = 4322) was 32.8% of the estimated optimal information size (n = 13,148).


There is no conclusive evidence for a strong recommendation of topical PVI before wound closure to prevent SSI.



The authors are grateful to Marta Pulido, MD, PhD, for provision of editing services.

Compliance with ethical standards

Conflict of interest

The Authors declare that they have no conflict of interest.

Supplementary material

268_2018_4798_MOESM1_ESM.pdf (84 kb)
Supplementary material 1 (PDF 84 kb)
268_2018_4798_MOESM2_ESM.pdf (104 kb)
Supplementary material 2 (PDF 103 kb)


  1. 1.
    Abbas M, Pittet D (2016) Surgical site infection prevention: a global priority. J Hosp Infect. Google Scholar
  2. 2.
    Mangram AJ, Horan TC, Pearson ML et al (1999) Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 20:250e278 (quiz 79e80) CrossRefGoogle Scholar
  3. 3.
    Heal CF, Banks JL, Lepper PD et al (2016) Topical antibiotics for preventing surgical site infection in wounds healing by primary intention. Cochrane Database Syst Rev. Google Scholar
  4. 4.
    Allegranzi B, Bischoff P, de Jonge S et al (2016) New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis 16:e276–e287CrossRefGoogle Scholar
  5. 5.
    Allegranzi B, Zayed B, Bischoff P et al (2016) WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis 16:e288–e303CrossRefGoogle Scholar
  6. 6.
    Berríos-Torres SI, Umscheid CA, Bratzler DW et al (2017) Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. Google Scholar
  7. 7.
    National Institute for Health and Care Excellence (2008) Surgical site infection: prevention and treatment of surgical site infection. Clinical guideline 74. London: National Institute for Health and Care Excellence. Accessed Feb 2017
  8. 8.
    Lachapelle JM, Castel O, Fueyo Casado A et al (2013) Antiseptics in the era of bacterial resistance: a focus on povidone iodine. Clin Pract 10:579–592CrossRefGoogle Scholar
  9. 9.
    Liberati A, Altman DG, Tetzlaff J et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 62:e1–e34CrossRefGoogle Scholar
  10. 10.
    Stone PW (2002) Popping the (PICO) question in research and evidence-based practice. Appl Nurs Res 15:197–198CrossRefGoogle Scholar
  11. 11.
    Higgins JP, Altman DG, Gotzsche PC et al (2011) The Cochrane Collaboration´s tool for assessing risk of bias in randomized trials. BMJ 343:d5928CrossRefGoogle Scholar
  12. 12.
    Higgins JPT, Thompson SG, Deeks JJ et al (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560CrossRefGoogle Scholar
  13. 13.
    Thorlund K, Imberger G, Walsh M (2011) The number of patients and events required to limit the risk of overestimation of intervention effects in meta-analysis-a simulation study. PLoS ONE 6:e25491CrossRefGoogle Scholar
  14. 14.
    Thorlund K, Engstrøm J, Wetterslev J, et al (2011) User manual for trial sequential analysis (TSA). Copenhagen, Denmark: Copenhagen Trial Unit, Centre for Clinical Intervention Research 1–115. Accessed Feb 2018
  15. 15.
    Tanphiphat C, Sangsubhan C, Vongvaravipatr V et al (1978) Wound infection in emergency appendicectomy: a prospective trial with tropical ampicillin and antiseptic solution irrigation. Br J Surg 65:89–91CrossRefGoogle Scholar
  16. 16.
    Lau WY, Wong SH (1981) Randomized, prospective trial of topical hydrogen peroxide in appendectomy wound infection. High risk factors. Am J Surg 142:393–397Google Scholar
  17. 17.
    Czarnecki D, Meehan C, Nash C (1992) Prevention of post-excisional wound infections: a comparison of oral cephalexin with topical mupirocin and topical cetrimide–chlorhexidine cream. Int J Dermatol 31:359–360CrossRefGoogle Scholar
  18. 18.
    Anglen JO (2005) Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds. A prospective, randomized study. J Bone Joint Surg Am 87:1415–1422Google Scholar
  19. 19.
    Tijerina J, Velasco-Rodríguez R, Vásquez C et al (2010) Effectiveness of a systemic antibiotic followed by topical ionized solution as surgical site infection prophylaxis. J Int Med Res 38:1287–1293CrossRefGoogle Scholar
  20. 20.
    Pollock AV, Evans M (1975) Povidone-iodine for the control of surgical wound infection: a controlled clinical trial against topical cephaloridine. Br J Surg 62:292–294CrossRefGoogle Scholar
  21. 21.
    Kiff RS, Lomax J, Fowler L et al (1988) Ceftriaxone versus povidone iodine in preventing wound infections following biliary surgery. Ann R Coll Surg Engl 70:313–316Google Scholar
  22. 22.
    Ko W, Lazenby WD, Zelano JA et al (1992) Effects of shaving methods and intraoperative irrigation on suppurative mediastinitis after bypass operations. Ann Thorac Surg 53:301–305CrossRefGoogle Scholar
  23. 23.
    Harihara Y, Konishi T, Kobayashi H et al (2006) Effects of applying povidone-iodine just before skin closure. Dermatology 212(Suppl 1):53–57CrossRefGoogle Scholar
  24. 24.
    Ghafouri HB, Zare M, Bazrafshan A et al (2016) Randomized, controlled trial of povidone-iodine to reduce simple traumatic wound infections in the emergency department. Injury 47:1913–1918CrossRefGoogle Scholar
  25. 25.
    Tighe B, Anderson M, Dooley C et al (1982) Betadine irrigation following appendicectomy—a randomized prospective trial. Ir Med J 75:96Google Scholar
  26. 26.
    Sindelar WF, Brower ST, Merkel AB et al (1985) Randomised trial of intraperitoneal irrigation with low molecular weight povidone-iodine solution to reduce intra-abdominal infectious complications. J Hosp Infect 6(Supp A):103–114CrossRefGoogle Scholar
  27. 27.
    Sindelar WF, Mason GR (1979) Irrigation of subcutaneous tissue with povidone-iodine solution for prevention of surgical wound infections. Surg Gynecol Obstet 148:227–231Google Scholar
  28. 28.
    Gilmore OJ, Sanderson PJ (1975) Prophylactic interparietal povidone-iodine in abdominal surgery. Br J Surg 62:792–799CrossRefGoogle Scholar
  29. 29.
    Sindelar WF, Mason GR (1977) Efficacy of povidone-iodine irrigation in prevention of surgical wound infections. Surg Forum 28:48–51Google Scholar
  30. 30.
    Morgan WJ (1978) Povidone-iodine spray for wounds sutured in the accident department. Lancet 1:769CrossRefGoogle Scholar
  31. 31.
    Naunton Morgan TC, Firmin R, Mason B et al (1980) Prophylactic povidone iodine in minor wounds. Injury 12:104–106CrossRefGoogle Scholar
  32. 32.
    Walsh JA, Watts JM, McDonald PJ et al (1981) The effect of topical povidone-iodine on the incidence of infection in surgical wounds. Br J Surg 68:185–189CrossRefGoogle Scholar
  33. 33.
    Gray JG, Lee MJ (1981) The effect of topical povidone iodine on wound infection following abdominal surgery. Br J Surg 68:310–313CrossRefGoogle Scholar
  34. 34.
    de Jong TE, Vierhout RJ, van Vroonhoven TJ (1982) Povidone-iodine irrigation of the subcutaneous tissue to prevent surgical wound infections. Surg Gynecol Obstet 155:221–224Google Scholar
  35. 35.
    Rogers DM, Blouin GS, O’Leary JP (1983) Povidone-iodine wound irrigation and wound sepsis. Surg Gynecol Obstet 157:426–430Google Scholar
  36. 36.
    Galland RB, Karlowski T, Midwood CJ et al (1983) Topical antiseptics in addition to peroperative antibiotics in preventing post-appendicectomy wound infections. Ann R Coll Surg Engl 65:397–399Google Scholar
  37. 37.
    Lau WY, Fan ST, Chu KW et al (1986) Combined topical povidone-iodine and systemic antibiotics in postappendicectomy wound sepsis. Br J Surg 73:958–960CrossRefGoogle Scholar
  38. 38.
    Cheng MT, Chang MC, Wang ST et al (2005) Efficacy of dilute betadine solution irrigation in the prevention of postoperative infection of spinal surgery. Spine (Phila Pa 1976) 30:1689–1693CrossRefGoogle Scholar
  39. 39.
    Chang FY, Chang MC, Wang ST et al (2006) Can povidone-iodine solution be used safely in a spinal surgery? Eur Spine J 15:1005–1014CrossRefGoogle Scholar
  40. 40.
    Kokavec M, Fristáková M (2008) Efficacy of antiseptics in the prevention of post-operative infections of the proximal femur, hip and pelvis regions in orthopedic pediatric patients. Analysis of the first results. Acta Chir Orthop Traumatol Cech 75:106–109Google Scholar
  41. 41.
    Walker SR, Smith A (2013) Randomized, blinded study to assess the effect of povidone-iodine on the groin wound of patients undergoing primary varicose vein surgery. ANZ J Surg 83:844–846CrossRefGoogle Scholar
  42. 42.
    Mahomed K, Ibiebele I, Buchanan J et al (2016) The Betadine trial—antiseptic wound irrigation prior to skin closure at caesarean section to prevent surgical site infection: a randomised controlled trial. Aust N Z J Obstet Gynaecol 56:301–306CrossRefGoogle Scholar
  43. 43.
    Ghafouri HB, Zavareh M, Jalili F et al (2016) Is 1% povidone-iodine solution superior to normal saline for simple traumatic wound irrigation? Wound Medicine 15:1–5CrossRefGoogle Scholar
  44. 44.
    de Jonge SW, Boldingh QJJ, Solomkin JS et al (2017) Systematic review and meta-analysis of randomized controlled trials evaluating prophylactic intra-operative wound irrigation for the prevention of surgical site infections. Surg Infect (Larchmt) 18:508–519CrossRefGoogle Scholar
  45. 45.
    Roberts I, Ker K, Edwards P et al (2015) The knowledge system underpinning healthcare is not fit for purpose and must change. BMJ 350:h2463CrossRefGoogle Scholar
  46. 46.
    Cruse PJ, Foord R (1980) The epidemiology of wound infection. A 10-year prospective study of 62 939 wounds. Surg Clin North Am 60:27–40CrossRefGoogle Scholar
  47. 47.
    Culver DH, Horan TC, Gaynes RP et al (1991) Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med 91:152S–157SCrossRefGoogle Scholar
  48. 48.
    Pivot D, Tiv M, Luu M et al (2011) Survey of intraoperative povidone-iodine application to prevent surgical site infection in a French region. J Hosp Infect 77:363–364CrossRefGoogle Scholar
  49. 49.
    BusinessWire (2013) Survey conducted at AORN congress reveals need for new and better surgical site infection prevention strategies. Accessed June 2018
  50. 50.
    Grady D, Redberg RF (2010) Less is more: how less health care can result in better health. Arch Intern Med 170:749–750CrossRefGoogle Scholar
  51. 51.
    Prasad V, Vandross A, Toomey C et al (2013) A decade of reversal: an analysis of 146 contradicted medical practices. Mayo Clin Proc 88:790–798CrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  1. 1.Department of General Surgery, Abdominal Wall Surgery Unit and General and Digestive Surgery Research Group, Institut de Recerca Vall d’Hebron (VHIR), Hospital Universitari Vall d’HebronUniversitat Autónoma de BarcelonaBarcelonaSpain
  2. 2.Department of Infectious Diseases, Hospital Universitari Vall d’HebronUniversitat Autónoma de BarcelonaBarcelonaSpain
  3. 3.Evidence-Based HealthcareUniversity of OxfordOxfordUK

Personalised recommendations