Invited Commentary 

February 21, 2024

Surgical Site Infections—Time to Test Cost-Effective Prevention Strategies?

Jeffrey S. Upperman, Eunice Y. Huang

JAMA Surg. 2024;159(5):492.

doi:10.1001/jamasurg.2023.7979

The recent randomized clinical trial by Mueller et al¹ assessing the effectiveness of polyhexanide 0.04% solution in surgical site infection (SSI) prevention following laparotomy presents findings that challenge established clinical practice. While the authors concluded that polyhexanide provides no significant benefit over saline, this commentary highlights critical omissions and suggests an avenue for future research.

In a 2016 review for the Surgical Infection Society, Edmiston and Leaper² recommended standardizing appropriate intraoperative irrigation practices in perioperative care. Previous trials and meta-analyses indicate a potential reduction in SSI with various irrigation solutions; however, methodological limitations and outdated practices need to be updated to maintain the usefulness of practice change. The 2020 trial (RECIPE) showed the benefit of polyhexanide in decreasing SSI and renewed interest in antiseptic irrigation.³ Nevertheless, patient selection and surgical management likely differed between the RECIPE trial and the current study,¹ as the baseline SSI showed a 2-fold difference. Notably, the current study reports wound edge protector devices used in more than 25% of patients.

Several studies have shown the benefits of wound-edge protector devices. Salgado-Nesme et al⁴ evaluated the impact of a circumferential wound. Among 41 randomized patients, those using the retractor experienced a significant reduction in SSIs compared with the nonretractor group, with statistical analysis supporting its effectiveness (odds ratio, 8.5; P = .03). A 2022 meta-analysis by Li et al,⁵ including 22 randomized clinical trials with 4492 patients, showed wound-edge protector devices effectively decreased SSI in clean-contaminated and contaminated surgical procedures.

With the benefit of wound-edge protector device use, the benefit of polyhexanide in the epifascial wound bed may be unnecessary. Future research should pivot to methodologically robust randomized trials that holistically evaluate SSI prevention strategies, including wound-edge protector devices. Such studies should explicitly control for different adjuncts, such as wound irrigation, to discern the true efficacy of each adjunct in reducing SSI. Other considerations may include costs associated with different SSI prevention modalities and the ease of implementation in low- to middle-income countries.