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Three Part Question

In [patients with lacerations] is [wound toilet with iodine solution or sterile saline more effective than wound toilet with tap water] at [reducing rate of infection]?

Clinical Scenario

A patient presents to the Emergency Department with a laceration to the right forearm. The wound will need cleaning and then closing. There appear to be many different cleaning solutions available - you wonder which is best.

Search Strategy

Medline 1966-10/03 using the OVID interface on ATHENS (including Medline in progress and non-indexed citations)
({[exp "wounds and injuries" OR exp wounds, penetrating OR laceration$.ti,ab,rw,sh OR wound$.ti,ab,rw,sh OR cut$.ti,ab,rw,sh] AND [exp iodine OR exp iodine compounds OR exp povidone-iodine OR iodine$.ti,ab,rw,sh OR exp sodium chloride OR saline.ti,ab,rw,sh OR anti-infective agents, local OR antiseptic$.ti,ab,rw,sh] AND [clean$.ti,ab,rw,sh OR exp decontamination OR exp sterilisation OR exp disinfection OR decontaminate$.ti,ab,rw,sh OR exp irrigation OR lavage.ti,ab,rw,sh]} AND [random$.af] LIMIT to human and english and abstracts)

Search Outcome

397 papers found. One citation is a cochrane review of tap water use. There are no individual published after the cochrane review. 4 other papers not included in the cochrane review of water are also included.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
fernandez r 2001 (updated April 2003) Australia	A variety of patients were included in the review. 5 of the 6 trials included in the review used emergency department patients.	Meta-analysis of trials of wound cleansing.	tap water vs normal saline (2 trials) - infection rates	OR 0.52 (CI 0.28 - 0.96) in favour of tap water	Only 6 trials were included in this well conducted review. There were concerns regarding the methodological quality of several of the included trials. No trials included children.
			distilled water or cool boiled water vs normal saline (1 trial) - infection rates	OR 0.55 (CI 0.18-1.6s NS) in favour of tap water
roberts ah 1985 UK	418 patients with hand lacerations. All wounds cleaned with savlodil. Experimental group sprayed with povidone-iodine	Randomised clinical trial.	Infection rate	4.6% (povidone-iodine) vs 5.3% (control) (NS)	Poor randomisation. No control. 96 lost to follow up.
			Imperfect healing	35.5% (povidone-iodine) vs 41.2% (control) (NS)
Gravett A, 1987. USA.	500 emergency department patients with lacerations requiring sutures. All wounds irrigated with normal saline. Experimental group irrigated and scrubbed with 1% povidone iodine.	Randomised clinical trial.	Infection rate	15.4% (control) vs 5.47% (povidone-iodine)	No control. 105 patients lost to follow up and 122 followed up by phone only. High control infection rate.
Dire DJ and Welsh AP. 1990. USA.	531 patients with minor, uncomplicated soft-tissue lacerations requiring suturing. Treated with either irrigation with normal saline, 1% povidone-iodine or F-68 (Shur-Clens).	Clinical trial	Infection rates	6.9% (normal saline) vs 4.3% (povidone-iodine) vs 5.6% (F-68). Non significant	Not randomised.
Lammers RL, 1990 USA	35 patients with 37 heavily contaminated wounds requiring debridement. Randomised to soaking for 10 min with either 1% povidone-iodine solution, normal saline or covering for 10 min with a dry dressing.	PRCT	Change in bacterial counts	No change povidone-iodine group or control. Increase in saline group	Small numbers.

Comment(s)

It is striking that the infection rate remains 5 - 10% whatever the intervention. In this case the cheapest and most easily obtained solution should be used. The meta-analysis shows that tap water may have a beneficial effect. Clearly the quality of water should be good (at least potable)

Editor Comment

This BET was updated in Nov 2003. The meta-analysis does not include other solutions hence the other papers in the table.

Clinical Bottom Line

Tap water is a safe and effective solution for cleaning recent wounds requiring closure and is the treatment of choice.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. fernandez r; griffiths t; ussia c water for wound cleaning cochrane database of systematic reviews vol 3 2003
2. Roberts AH, Roberts FE, Hall RI, Thomas IH A prospective trial of prophylactic povidone iodine in lacerations of the hand J Hand Surg 1985;10(3):370-374.
3. Gravett A, Sterner S, Clinton JE, Ruiz E. A trial of povidone-iodine in the prevention of infection in sutured lacerations. Ann Emerg Med 1987;16(2):167-171.
4. Dire DJ, Welsh AP. A comparison of wound irrigation solutions used in the emergency department. Ann Emerg Med 1990;19(6):704-708.
5. Lammers RL, Fourre M, Callaham ML, Boone T. Effect of povidone-iodine and saline soaking on bacterial counts in acute, traumatic, contaminated wounds. Ann Emerg Med 1990;19(6):709-714