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      A systematic review and meta-analysis including GRADE qualification of the risk of surgical site infections after prophylactic negative pressure wound therapy compared with conventional dressings in clean and contaminated surgery

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          Abstract

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          Abstract

          Objective:

          Systematically review and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) studies on prophylactic negative pressure wound therapy (pNPWT) to prevent surgical site infections (SSIs).

          Introduction:

          pNPWT has been suggested as a new method to prevent wound complications, specifically SSIs, by its application on closed incisional wounds.

          Methods:

          This review was conducted as part of the development of the Global Guidelines for prevention of SSIs commissioned by World Health Organization in Geneva. PubMed, Embase, CENTRAL, CINAHL, and the World Health Organization database between January 1, 1990 and October 7, 2015 were searched. Inclusion criteria were randomized controlled trials and observational studies comparing pNPWT with conventional wound dressings and reporting on the incidence of SSI. Meta-analyses were performed with a random effect model. GRADE Pro software was used to qualify the evidence.

          Results:

          Nineteen articles describing 21 studies (6 randomized controlled trials and 15 observational) were included in the review. Summary estimate showed a significant benefit of pNPWT over conventional wound dressings in reducing SSIs in both randomized controlled trials and observational studies, odds ratio of 0.56 (95% confidence interval, 0.32–0.96; P = 0.04) and odds ratio of 0.30 (95% confidence interval, 0.22–0.42; P < 0.00001), respectively. This translates into lowering the SSI rate from 140 to 83 (49–135) per 1000 patients and from 106 to 34 (25–47) per 1000 patients, respectively. In stratified analyses, these results were consistent in both clean and clean-contaminated procedures and in different types of surgery, however results were no longer significant for orthopaedic/trauma surgery. The level of evidence as qualified with GRADE was however low.

          Conclusions:

          Low-quality evidence indicates that prophylactic NPWT significantly reduces the risk of SSIs.

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          Most cited references23

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          Incisional negative pressure wound therapy after high-risk lower extremity fractures.

          Thomas Moore, Gerald McGwin, James Stannard … (2011)
          To investigate negative pressure wound therapy (NPWT) to prevent wound dehiscence and infection after high-risk lower extremity trauma. Prospective randomized multicenter clinical trial. Four Level I trauma centers. Blunt trauma patients with one of three high-risk fracture types (tibial plateau, pilon, calcaneus) requiring surgical stabilization. Incisional NPWT (Group B) was applied to the closed surgical incisions of patients randomized to the study arm of this trial, whereas standard postoperative dressings (Group A) were applied to the control patients. Acute and chronic wound dehiscence and infection. Two hundred forty-nine patients with 263 fractures have enrolled in this study with 122 randomized to Group A (controls) and 141 to Group B (NPWT). There was no difference between the groups in the distribution of calcaneus (39%), pilon (17%), or tibial plateau (44%) fractures. There were a total of 23 infections in Group A and 14 in Group B, which represented a significant difference in favor of NPWT (P = 0.049). The relative risk of developing an infection was 1.9 times higher in control patients than in patients treated with NPWT (95% confidence interval, 1.03-3.55). There have been no studies evaluating incisional NPWT as a prophylactic treatment to prevent infection and wound dehiscence of high-risk surgical incisions. Our data demonstrate that there is a decreased incidence of wound dehiscence and total infections after high-risk fractures when patients have NPWT applied to their surgical incisions after closure. There is also a strong trend for decreases in acute infections after NPWT. Based on our data in this multicenter prospective randomized clinical trial, NPWT should be considered for high-risk wounds after severe skeletal trauma.
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            Meta‐analysis of negative‐pressure wound therapy for closed surgical incisions

            N. Hyldig, H. Birke‐Sorensen, Elisabeth M. Kruse … (2016)
            Abstract Background Postoperative wound complications are common following surgical procedures. Negative‐pressure wound therapy (NPWT) is well recognized for the management of open wounds and has been applied recently to closed surgical incisions. The evidence base to support this intervention is limited. The aim of this study was to assess whether NPWT reduces postoperative wound complications when applied to closed surgical incisions. Methods This was a systematic review and meta‐analysis of randomized clinical trials of NPWT compared with standard postoperative dressings on closed surgical incisions. Results Ten studies met the inclusion criteria, reporting on 1311 incisions in 1089 patients. NPWT was associated with a significant reduction in wound infection (relative risk (RR) 0·54, 95 per cent c.i. 0·33 to 0·89) and seroma formation (RR 0·48, 0·27 to 0·84) compared with standard care. The reduction in wound dehiscence was not significant. The numbers needed to treat were three (seroma), 17 (dehiscence) and 25 (infection). Methodological heterogeneity across studies led to downgrading of the quality of evidence to moderate for infection and seroma, and low for dehiscence. Conclusion Compared with standard postoperative dressings, NPWT significantly reduced the rate of wound infection and seroma when applied to closed surgical wounds. Heterogeneity between the included studies means that no general recommendations can be made yet.
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              Negative pressure wound therapy after severe open fractures: a prospective randomized study.

              Bob R. Stewart, Jose Alonso, Gerald McGwin … (2009)
              To evaluate the impact of negative pressure wound therapy (NPWT) after severe open fractures on deep infection. Prospective randomized study. Academic level I trauma center. Fifty-nine patients with 63 severe high-energy open fractures were enrolled in this study, with data available on 58 patients with 62 open fractures. Twenty-three patients with 25 fractures randomized to the control group and underwent initial irrigation and debridement followed by standard fine mesh gauze dressing, with repeat irrigation and debridement every 48-72 hours until wound closure. Thirty-five patients randomized to the NPWT group and had identical treatment except that NPWT was applied to the wounds between irrigation and debridement procedures until closure. The presence or absence of deep wound infection or osteomyelitis, wound dehiscence, and fracture union were primary outcome measures. Control patients developed 2 acute infections (8%) and 5 delayed infections (20%), for a total of 7 deep infections (28%), whereas NPWT patients developed 0 acute infections, 2 delayed infections (5.4%), for a total of 2 deep infections (5.4%). There is a significant difference between the groups for total infections (P = 0.024). The relative risk ratio is 0.199 (95% confidence interval: 0.045-0.874), suggesting that patients treated with NPWT were only one-fifth as likely to have an infection compared with patients randomized to the control group. NPWT represents a promising new therapy for severe open fractures after high-energy trauma.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Medicine (Baltimore)
                Journal ID (iso-abbrev): Medicine (Baltimore)
                Journal ID (publisher-id): MEDI
                Title: Medicine
                Publisher: Wolters Kluwer Health
                ISSN (Print): 0025-7974
                ISSN (Electronic): 1536-5964
                Publication date Collection: September 2016
                Publication date (Electronic): 09 September 2016
                Volume: 95
                Issue: 36
                Electronic Location Identifier: e4673
                Affiliations
                [a ]Department of Surgery, Academic Medical Centre Amsterdam, The Netherlands
                [b ]Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
                [c ]Infection Prevention and Control Global Unit, Service Delivery and Safety, World Health Organization, Geneva, Switzerland
                [d ]Institute of Social and Preventive medicine, University of Bern, Switzerland
                [e ]Department of Surgery, University of Washington, Seattle, WA, USA.
                Author notes
                [∗ ]Correspondence: Fleur E.E. De Vries, Academic Medical Centre, PO Box 22660, Amsterdam 1100 DD, The Netherlands (e-mail: f.e.devries@ 123456amc.uva.nl ).
                Article
                Accession ID: 04673
                DOI: 10.1097/MD.0000000000004673
                PMC ID: 5023882
                PubMed ID: 27603360
                SO-VID: 1b77a8b3-6b64-491e-9329-ab6f71e4a72f
                Copyright © Copyright © 2016 the Author(s). Published by Wolters Kluwer Health, Inc. All rights reserved.
                License:

                This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

                History
                Date received : 22 June 2016
                Date revision received : 27 July 2016
                Date accepted : 30 July 2016
                Categories
                Subject: 7100
                Subject: Research Article
                Subject: Systematic Review and Meta-Analysis
                Custom metadata
                OPEN-ACCESS TRUE

                Keywords: incisional wound therapy,prevention,prophylactic negative pressure wound therapy,surgical site infection,wound infections
                Data availability:
                Keywords: incisional wound therapy, prevention, prophylactic negative pressure wound therapy, surgical site infection, wound infections

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