Preoperative bathing with chlorhexidine reduces the incidence of surgical site infections after total knee arthroplasty

BACKGROUND Surgical site infection is a devastating postoperative complication, and the occurrence ranges from 1% to 2% after total knee arthroplasty (TKA). The efficacy of the preoperative use of chlorhexidine for reducing infection has been debated. This meta-analysis aimed to examine the efficacy of the use of chlorhexidine to prevent surgical site infections after TKA. METHODS In February 2017, a systematic literature review was conducted using the following electronic databases: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, and the Google database. Data from randomized controlled trials (RCTs) and retrospective comparative study (RCS) that compared the use of chlorhexidine versus control washes to prep patients for TKA were retrieved. The primary endpoint was to compare the total incidence of infection with and without the use of chlorhexidine. The secondary outcomes were the incidence of infection in low-risk category patients, moderate-risk category patients, and high-risk category patients. After testing for publication bias and heterogeneity between studies, data were aggregated for random-effects modeling when necessary. RESULTS Four clinical trials that included 8787 patients (chlorhexidine group: n = 2615, control group: n = 6172) were ultimately included in the meta-analysis. Chlorhexidine was associated with a reduced total incidence of infection, corresponding to a reduction of 1.69% [risk ratio (RR) = 0.22; 95% confidence interval (95% CI) = 0.12-0.40; P = .000]. Similarly, chlorhexidine was associated with a reduction in the incidence of infection among patients in the moderate-risk category (RR, 0.18; 95% CI, 0.05-0.63; P = .007) and the high-risk category (RR, 0.13; 95% CI, 0.03-0.67; P = .014). There was no significant difference between the incidence of infection in low-risk category patients with chlorhexidine use compared with the use of control washes (RR, 0.60; 95% CI, 0.22-1.60; P = .330). CONCLUSION The preoperative use of chlorhexidine could reduce the total incidence of infection and the incidence of infection in moderate-risk and high-risk category patients. The overall evidence and the number of included studies was limited; thus, a greater number of high-quality RCTs is still needed to further identify the effects of chlorhexidine on reducing the incidence of infection after TKA.