American Journal of Infection Control 41 (2013) 167-73

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

journal homepage: www.ajicjournal.org

Review article

Preoperative chlorhexidine shower or bath for prevention of surgical site

infection: A meta-analysis
Maciej Piotr Chlebicki MD a, Nasia Safdar MD, PhD b, c, d, *, John Charles OHoro MD e, Dennis G. Maki MD b, c
a
Department of Infectious Diseases, Singapore General Hospital, Singapore
b
Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, Madison, WI
c
Infection Control Department, University of Wisconsin Hospital and Clinics, Madison, WI
d
William S. Middleton Memorial Veterans Hospital, Madison, WI
e
Department of Graduate Medical Education, Aurora Healthcare, Milwaukee, WI

Key Words: Background: Chlorhexidine showering is frequently recommended as an important preoperative

Antiseptic measure to prevent surgical site infection (SSI). However, the efcacy of this approach is uncertain.
Systematic review Methods: A search of electronic databases was undertaken to identify prospective controlled trials
Clean
evaluating whole-body preoperative bathing with chlorhexidine versus placebo or no bath for preven-
Clean-contaminated
tion of SSI. Summary risk ratios were calculated using a DerSimonian-Laird random effects model and
a Mantel-Haenzel dichotomous effects model.
Results: Sixteen trials met inclusion criteria with a total of 17,932 patients: 7,952 patients received
a chlorhexidine bath, and 9,980 patients were allocated to various comparator groups. Overall, 6.8% of
patients developed SSI in the chlorhexidine group compared with 7.2% of patients in the comparator
groups. Chlorhexidine bathing did not signicantly reduce overall incidence of SSI when compared with
soap, placebo, or no shower or bath (relative risk, 0.90; 95% condence interval: 0.77-1.05, P .19).
Conclusions: Meta-analysis of available clinical trials suggests no appreciable benet of preoperative
whole-body chlorhexidine bathing for prevention of SSI. However, most studies omitted details of chlo-
rhexidine application. Better designed trials with a specied duration and frequency of exposure to chlo-
rhexidine are needed to determine whether preoperative whole-body chlorhexidine bathing reduces SSI.
Copyright 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.

Approximately 25.2 million inpatient surgical procedures were
performed in the United States in 2002.1 In the same year, almost
135,000 patients were discharged with a principal diagnosis of
postoperative surgical site infection (SSI). The mean length of
hospitalization for these patients was 7.5 days, and the mean
hospital charges were $24,346, resulting in aggregate charges of
almost $3.3 billion.2 Patients who develop SSI have longer and
costlier hospitalizations than patients who do not develop such
infections,3 are 60% more likely to spend time in an intensive care
unit and twice as likely to die, and more than 5 times more likely to
be readmitted to the hospital.4
SSIs following clean surgery are caused in nearly all cases by
endogenous organisms colonizing the patients skin and are
introduced into the surgical wound intraoperatively.5 Most proce-
dures for intraoperative surgical asepsis are designed to minimize
cutaneous colonization of the surgical site and intraoperative
contamination of the wound to prevent subsequent infection.
Whole-body bathing or showering with an antiseptic agent,
such as 2% to 4% chlorhexidine gluconate, has been shown to
reduce bacterial colonization of the skin.6 Studies have shown that
the antibacterial effect of chlorhexidine is cumulative7 and lasts
longer than that produced by other antiseptic agents.8 Whereas
some studies have shown that preoperative chlorhexidine showers
reduce the incidence of SSI,9,10 others have found minimal or no
clinically relevant benet.11-17 We have undertaken a meta-analysis
to systematically review published, controlled, clinical trials eval-
uating use of chlorhexidine baths or showers for prevention of SSI.

* Address correspondence to Nasia Safdar, MD, PhD, Section of Infectious

METHODS
Diseases, MFCB University of Wisconsin Madison, 1685 Highland Avenue, Madison,
WI 53705.
E-mail address: ns2@medicine.wisc.edu (N. Safdar). We performed a search of MEDLINE, including PUBMED, and the
Conicts of interest: None to report. COCHRANE NETWORK including the Cochrane Register of Clinical

0196-6553/$36.00 - Copyright 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ajic.2012.02.014
168 M.P. Chlebicki et al. / American Journal of Infection Control 41 (2013) 167-73

Trials from inception until July 30, 2011, using the following
keywords: chlorhexidine, bath, shower, wash, scrub, disinfection,
preoperative care, perioperative care, surgical site infection, and
surgical wound infection. No language restrictions were applied.
References from articles were reviewed to identify other potentially
relevant articles. Our search strategy and analysis complied with
the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) statement.18
Prospective randomized controlled trials and quasirandomized
trialsdthose that allocated treatment by day of the week or by
warddas well as before-after trials comparing a preoperative
whole-body chlorhexidine shower or bath with nonantiseptic soap
or no bath and reporting SSI as an outcome were included in our
review. We chose to include quasirandomized trials because these
are common study designs that may yield useful information. Case
reports, abstract-only, review articles, letters, and editorials were
excluded. All authors independently reviewed each report identi-
ed by the search strategy.

Study quality

We assessed study quality and assessed for potential bias using

the recommendations of the Cochrane collaboration.19 Selection
bias was assessed by evaluations of subject allocation and blinding,
especially relevant for nonrandomized studies. Performance
biasdsystematic differences in care provided apart from the
intervention being evaluateddwas evaluated by comparing the
different bathing protocols and other interventions employed to
reduce SSI in each study. Detection bias was evaluated by exam-
ining the operational denition for SSI. Reporting bias was analyzed
using Eggers statistical test and a funnel plot to specically
examine publication bias.19

Statistical analysis

Summary risk ratios (RR) and their 95% condence intervals (CI)
were calculated using the DerSimonian and Laird random-effects
model.20 Heterogeneity was assessed with an I2 statistic, where
0% indicates no heterogeneity, and 100% indicates the highest level
of heterogeneity.21 Sensitivity and subgroup analyses were
performed to analyze sources of heterogeneity. Data analysis was
performed using Cochrane Databases Review Manager 5.1.0
software.19

RESULTS

Study selection

The literature search strategy yielded 857 potential articles.
After screening and reviewing articles, 16 studies met our inclusion
criteria.9,10,12-17,22-29 The search strategy and reasons for exclusion
are detailed in a PRISMA ow diagram in Figure 1.30
In one of these trials,26 the chlorhexidine group was compared
with 2 control groups: 1 group that received only a limited, partial
chlorhexidine body wash and another group that received no
shower. We only included the chlorhexidine treatment group and
the control group that received no shower in our statistical analysis.
Study characteristics
Eight randomized control trials and 8 quasiexperimental trials
were identied. The 16 included trials enrolled 17,932
patients6,10,12-17,22,24-29: 7,952 patients received a chlorhexidine
shower or bath, and 9,980 patients were allocated to various
comparator groups of a preoperative shower or bath with
Fig 1. PRISMA ow diagram of search strategy. Figure generated with Review Manager
5.19
nongermicidal soap (n 5,696) or placebo (n 2,207) or no
preoperative shower/noncompliance with regimen (n 2,077). Six
studies10,14,15,27-29 had patients bathe as outpatients prior to
procedure, nine11-13,16,17,22,24-26 had baths or showers as inpatients,
and one9 did not specify where the washes took place. There was
considerable interstudy variation in the volume, timing, and/or
number of applications as summarized in Table 1.
In 7 trials,12-14,16,17,22,26 patients had a single preoperative bath.
Two baths were used in 5 trials,10,15,27-29 and 3 trials9,11,24 evaluated
the effect of 3 or more preoperative chlorhexidine baths or
showers. One did not specify the regimen.25
In all trials using a liquid formulation of chlorhexidine, patients
were required to apply the chlorhexidine solution or comparator
 M.P. Chlebicki et al. / American Journal of Infection Control 41 (2013) 167-73
and then thoroughly rinse it off, without specifying the duration of
continuous exposure of the skin to 4% chlorhexidine. Trials using
chlorhexidine cloths instructed patients to use the product once the
night before and once the morning of surgery without rinsing the
wash off. Sponges or brushes were not used in any of the trials.
Preoperative antibiotic prophylaxis was routinely administered
in 6 trials12,16,17,27-29 but was given to only in 12% of patients in the
trial conducted by Rotter et al.15 Ayliffe et al22 and Lynch et al24
mention that the frequency of antimicrobial prophylaxis was
similar both in treatment and comparator groups, without
providing data. The use of preoperative antimicrobial prophylaxis
was not mentioned in the remaining 7 trials.
Details of randomization
The highest quality trials performed were a multicenter center,
prospective, randomized, double-blind, and placebo-controlled
trial by Rotter et al15 and a single center, randomized controlled
trial by Veiga et al.16 In both studies, randomization was carried out
in each participating surgical unit by means of computer-generated
patient trial numbers, which were attached by manufacturer to the
bottles containing either chlorhexidine or placebo.
The trial by Lynch et al24 was also prospective, randomized,
double-blind, and placebo controlled, but no details of the
randomization procedure were provided. Similarly, Randall et al14
and Earnshaw et al12 did not provide any details of the randomi-
zation scheme. Murray et al28 was randomized and used masked
allocation but did not use an identical placebo.
Wells et al17 used a quasirandomized design in which patients
were assigned to a chlorhexidine or soap bath by month. In a study
conducted by Wihlborg,26 participating patients were allocated to
different wards by the chief surgeon. Finally, the 3 remaining trials
used a design in which all patients admitted to selected surgical
wards were allocated to a chlorhexidine bath or shower group, and
patients admitted to other wards constituted the control group10,22
with the ward allocations reversed after a specied period of time.
Two studies27,29 used a prospective intervention and historical
controls.
Denitions of SSI
The investigators used varying denitions of SSI in their trials
(Table 1). Six studies10,14,15,22,27,29 used clinical criteria, such as
wound inammation, breakdown, or discharge, to dene SSI.
Although the trials did not explicitly state so, these criteria are
similar to the CDC denition for deep incisional SSI as follows:
Meet[ing] one of the following criteria: infection occurs . . . after
the operative procedure . . . and infection appears to be related to
the operative procedure and involves deep soft tissues (eg, fascial
and muscle layers) of the incision and patient has at least 1 of the
following: (1) purulent drainage from the deep incision but not
from the organ/space component of the surgical site, (2) a deep
incision spontaneously dehisces or is deliberately opened by
a surgeon and is culture positive or not cultured and has 1 of the
following signs or symptoms: fever, or localized pain, or tender-
ness. A culture negative nding does not meet this criterion. (3) An
abscess or other evidence of infection involving the deep incision is
found on direct examination during reoperation or by histopatho-
logic or radiologic examination. (4) Diagnosis of a deep incisional
SSI by a surgeon or attending physician.31 Dimitrov et al,25 Wihl-
borg,26 Earnshaw et al,12 and Wells et al17 dened SSI as purulent
wound discharge. Lynch et al24 required the presence of purulent
discharge and an ASEPSIS (Additional treatment, presence of Serous
discharge, Erythema, Purulent exudate, Separation of the deep
tissues, the Isolation of bacteria and the duration of inpatient
169
Stay)32 score > 10 to dene SSI. Murray et al used clinical diagnosis
during surgical follow-up without a clear denition of what
constituted SSI.28
Ten studies specied the duration of hospital follow-up to
identify SSI. Four followed patients until discharge from the
hospital,12,13,17,22 1 followed patients for 7 days,14 1 for 3 weeks,15 1
for 1 month,16 1 for 2 months,28 and 2 for 6 weeks
postoperatively.10,11
Study quality
Nine of the included studies were determined to have a high risk
of bias stemming from lack of randomization, use of historical
controls, or lack of blinding when diagnosing SSI, and the
remaining 7 studies were classied as low risk. The risk assess-
ments of the individual studies are listed in Table 1.
All studies had patients shower or bathe at home or in the
hospital prior to surgery. Details of the protocols used are available
in Table 1. All provided some instruction about proper bathing
technique with chlorhexidine to subjects, but only one29 performed
an assessment of compliance, having patients remove stickers from
the chlorhexidine package and afx them to a sheet afrming that
the product was used.
Incidence of SSI
Three trials9,10,26 showed a signicant reduction in incidence of
SSI among patients randomized to receive a preoperative chlo-
rhexidine shower or bath. Table 2 shows the incidence of SSI in each
study. Figure 2 shows the relative risk of SSI in the 16 included
trials. Overall, 6.8% (543 of 7,952) of patients developed SSI in the
chlorhexidine group compared with 7.2% (715 of 9,980) of patients
in the comparator groups.
The summary RR estimate of patients randomized to preoper-
ative chlorhexidine showers/baths was 0.90 (95% CI: 0.77-1.05),
failing to reject the null hypothesis (P .19), shown in Figure 2. The
I2 test for heterogeneity showed low heterogeneity (28%).
Subgroup and sensitivity analysis
Sensitivity analysis was performed, excluding studies sequen-
tially to determine whether any individual study or subgroup had
a disproportional impact on the outcome. Sensitivity analyses did
not show signicant impact from any study or subgroup.
To determine whether there was a differential effect of chlo-
rhexidine in patients undergoing clean surgery, we analyzed the
ndings in the studies reporting the efcacy of preoperative chlo-
rhexidine showers or baths for prevention of SSI in patients
undergoing clean surgery. This subgroup failed to reach the
threshold for statistical signicance, with whole-body preoperative
chlorhexidine showering or shower demonstrating no clear benet
(RR, 0.88; 95% CI: 0.71-1.09, P .24). I2 value was 38%, indicating
moderate heterogeneity. The lack of benet was seen also in
contaminated and clean contaminated surgery (RR, 0.94; 95% CI:
0.76-1.16, P .55), with low heterogeneity (I2 0%).
We conducted an analysis restricted to the high-quality,
randomized controlled trials.11,12,14-16,24,28 In these, no benet of
perioperative chlorhexidine washing or showering could be
demonstrated (RR, 0.99; 95% CI: 0.85-1.16, P .90). Heterogeneity
of these results was low with I2 0%.
We also analyzed the 7 studies in which patients underwent 2 or
3 preoperative showers or baths.9-11,15,24,27,29 The use of multiple
chlorhexidine baths did not reach statistical signicance, although
there was a trend toward reduction of SSI (RR, 0.79; 95% CI: 0.60-
1.03, P .08).
Table 1

170
Characteristics of the included studies

Chlorhexidine dosing
Authors, year Study design Type of surgery Exclusion criteria Denition of SSI schedule Comparator group (s) Risk of bias
Brandberg et al,9 1979 Prospective Clean (vascular surgery) Not specied Pus collection at surgical Three to 8 chlorhexidine Soap and water wash High
nonrandomized wound site shower-baths prior to
procedure
Ayliffe et al,22 1983 Before/after, two 30-week Clean, CL/CONT, Trauma and emergency Inammation, breakdown Single bath or shower with Nonmedicated bar soap High
periods contaminated surgery or discharge from wound undiluted 4%
chlorhexidine (25 mL) on
the day of or before
operation
Leigh et al,13 1983 Before/after, 2 wards, 4 Clean, CL/CONT, Not stated Not stated Single bath or shower with Non-medicated soap High
months contaminated undiluted 4%
chlorhexidine (supplied
in 250-mL bottle) a few
hours before operation.

M.P. Chlebicki et al. / American Journal of Infection Control 41 (2013) 167-73

Wells et al,17 1983 Quasirandomization (by
month)
Randall et al,14 1983 Randomized, (no details)
controlled trial, 3 groups
Hayek et al,10 1987 Before/after, 2-month
periods
Dimitrov et al,25 1984 Prospective study, method
of allocation not
specied
Wihlborg,26 1987 Quasirandomization (by
ward)
Rotter et al,15 1988 Randomized, multicenter,
double-blind, placebo
controlled
Earnshaw et al,12 1989 Randomized (no details),
controlled trial
Byrne et al,11 1991 Randomized controlled
trial
Lynch et al,24 1992 Randomized (no details),
double-blind, placebo
controlled
Clean (cardiothoracic
surgery)
Clean (vasectomy only)
Clean, CL/CONT,
contaminated
CL/CONT (gastrointestinal
and genitourinary
surgeries)
Clean, CL/CONT (only
biliary, hernia or breast
surgery)
Clean (various procedures)
Clean (vascular surgery)
Clean (hernia surgery)
Clean, CL/CONT,
contaminated
Emergency surgery Not stated Single scrub with undiluted Nonmedicated bar soap High
4% chlorhexidine (30 mL)
1 day before operation
Not stated Discharge or wound Single bath or shower 1 Two groups: nonmedicated Low
breakdown hour before surgery (no bar soap and no shower
other details provided)
Emergency surgery, Inammation, breakdown Two baths or showers with Two groups: placebo and High
concurrent infection or discharge from wound undiluted 4% nonmedicated bar soap
chlorhexidine (supplied
in two 25-mL sachets) 1
day before and on the
morning of operation
Not stated Suppuraton at surgical site Patients instructed to bath Bar soap High
with chlorhexidine prior
to surgery, regimen and
concentration not
specied
Not stated Denite collection of pus. Single shower (double No shower High
application) on the
afternoon of the day
before surgery.
Fever, concurrent infection, Inammation, or discharge Two baths or showers (2 Identical placebo Low
recent antibiotics (7 from wound applications each time)
days), incarcerated with undiluted 4%
inguinal hernia or radical chlorhexidine (supplied
mastectomy in one 100-mL bottle) 1
day before and on the
morning of operation
Not stated Purulent (but not serous) Single bath or shower with Nonmedicated soap Low
wound discharge 2 applications of
undiluted 4%
chlorhexidine (no other
details provided)
Not stated Not stated Three showers with 4% Identical placebo Low
chlorhexidine prior to
surgery
Not stated Purulent discharge or Three baths or showers Nonmedicated liquid soap Low
ASEPSIS score > 10 with undiluted 4%
chlorhexidine on
admission, before going
to bed and on the
morning of operation
 M.P. Chlebicki et al. / American Journal of Infection Control 41 (2013) 167-73 171

Three studies used a 2% chlorhexidine impregnated cloth

ASEPSIS, Additional treatment, presence of Serous discharge, Erythema, Purulent exudate, Separation of the deep tissues, Isolation of bacteria, and the duration of inpatient Stay; CL, Clean; CONT, contaminated; SSI, surgical site infection.
product rather than a liquid preparation used in the other studies.
Analysis restricted to studies that used the cloth product (n 3) did
High

High
Low

Low
not show a reduction (P .29) in incidence of SSI.

Publication bias

Soap and water shower

Shower with identical

Noncompliance with

Noncompliance with
Publication bias was assessed with a funnel plot (Fig 3).33 This is
consistent with some degree of publication bias.
regimen

regimen
placebo

Adverse effects of chlorhexidine

In only 1 trial15 were adverse effects of preoperative showering

or bathing with chlorhexidine reported. In that trial, itching or
within 2 hours of surgery
detergent 2 hours before

Patients were instructed to

Patients were instructed to

Patients were instructed to

and morning of surgery

and morning of surgery

and morning of surgery

chlorhexidine 4% liquid

apply 2% chlorhexidine

apply 2% chlorhexidine

apply 2% chlorhexidine
reddening of skin occurred in 5 patients (0.36%) of the placebo
to the surgical site and
cloths the night before

cloths the night before

cloths the night before

to the head and trunk,
each arm and leg, and

ipsilateral arm, axilla,

abdomen, neck, each

group and 5 (0.36%) in chlorhexidine group. No adverse effects

for the neck, chest,

extremity, and the

Shower with liquid

the surgical site.

attributed to the chlorhexidine shower or bath were mentioned in

detergent based

chest and back.

the remaining 15 trials.

surgical site.
surgery

DISCUSSION

Our analyses show that preoperative whole-body showering or

bathing with chlorhexidine, in its current nonspecied manner, is
space as dened by CDC

space as dened by CDC

of no benet for prevention of postoperative SSI. Our ndings agree

Deep infection of joint

Deep infection of joint

with and extend those of a Cochrane systematic review that

included data from 9 trials from 1983 through 2005 and failed to
show a benet for chlorhexidine bathing or showering.34 Our
CDC denition

review extends the literature search to July 2011 and identied 4

Not stated

additional trials since the Cochrane review, thus increasing the

statistical power of the analysis to detect a clinically relevant
reduction in SSI if one exists. Our study also included quasiexper-
imental designs that were excluded in Cochranes methodology.
and immunosuppression
diabetes, heavy smoking
skin lesions, antibiotics

Given the known efcacy of chlorhexidine in reducing bacterial

Chlorhexidine allergies,

Current infection, open

immunosuppressive

infection at time of
at time of surgery,

burden, it is somewhat surprising that this meta-analysis demon-

Known active joint
wound, chronic

strated no clinical benet. Several factors may have contributed to

this. Many of the trials studied patients undergoing clean-
condition

contaminated or contaminated types of surgery, where the

Not stated

surgery

patients cutaneous ora contributes negligibly if at all to the

incidence of SSI.35,36 Also, the authors of most of the studies did not
provide specic data on the proportion of patients in each group
that received perioperative antimicrobial prophylaxis.35,37 Major
Clean (knee arthrosplasty
surgical procedures of

Clean (shoulder surgery)

disparities between study groups in frequency of antimicrobial

Elective clean plastic

prophylaxis are unlikely in randomized studies; however, it is very

possible that signicant disparities in the use of antimicrobial
and revision)
arthroplasty)
Clean (total hip

prophylaxis could have occurred in studies using a time-sequence,

the trunk

before-after design and masked a true benecial effect of preop-

erative chlorhexidine showering or bathing.
It is also worth noting that chlorhexidine may have been
employed in a less than optimal fashion in several studies. In all the
trials, patients were simply instructed to bathe or shower with the
Randomized control trial

Single blind randomized

study agent in the usual fashion, not specically instructed to keep

prospective cohort

prospective cohort

the 4% chlorhexidine on their skin for several minutes before

controlled trial
Nonrandomized

Nonrandomized

rinsing. Moreover, the application of chlorhexidine was not

supervised in the majority of trials. It is possible that the duration of
chlorhexidine application was considerably less than adequate,
effective cutaneous antisepsis.
Studies evaluating the optimal duration of chlorhexidine hand
scrubs provide insights into this potentially very important issue.
Johnson et al,27 2010

Pereira et al showed that a 5-minute initial hand scrub followed by

Murray et al,28 2011

Zywiel et al,29 2011

Veiga et al,16 2009

consecutive 3-minute scrubs resulted in far lower bacterial counts

on hands than a 3-minute initial scrub followed by consecutive 30-
second scrubs,38 suggesting that application of 4% chlorhexidine to
the skin for 3 to 5 minutes provides optimal antibacterial effect on
the cutaneous microora. It is very plausible that the patients
enrolled in the analyzed trials received far too brief application of
172 M.P. Chlebicki et al. / American Journal of Infection Control 41 (2013) 167-73

Table 2
Results of the included studies

Duration of follow up Number of patients in Number of SSI in Number of patients in Number of SSI in
Authors, year for determination of SSI chlorhexidine arm chlorhexidine arm (%) comparator arm comparator arm (%)
Brandberg et al,9 1979 Not specied 171 13 (7.6) 170 30 (17.6)
Ayliffe et al,22 1983 Through hospital 2,703 147 (5.4) 2,833 140 (4.9)
discharge
Leigh et al,13 1983 Through hospital 109 12 (11.0) 115 13 (11.3)
discharge
Wells et al,17 1983 Through postoperative 209 11 (5.3) 245 14 (6.7)
day 10 or hospital
discharge
Randall et al,14 1983 Seven days 32 12 (37.5) 62 19 (30.6)
Hayek et al,10 1987 Six-week follow-up 689 62 (9.0) 1,326 163 (12.3)
Dimitrov et al,25 1984 Not specied 57 0 (0) 46 0 (0)
Wihlborg,26 1987 Not specied 541 9 (1.7) 437 20 (4.6)
Rotter et al,15 1988 Three weeks 1,413 37 (2.6) 1,400 33 (2.4)
Earnshaw et al,12 1989 Through hospital 31 8 (25.8) 35 4 (11.4)
discharge
Byrne et al,11 1991 Six-week follow-up 29 2 (6.9) 27 2 (7.4)
Lynch et al,24 1992 Not specied 1,575 225 (14.3) 1,576 241 (15.3)
Veiga et al,16 2009 Thirty days follow-up 50 1 (2) 50 1 (2)
Johnson et al,27 2010 Not specied 157 0 (0) 897 14 (1.6)
Murray et al,28 2011 Two months 50 0 (0) 50 0 (0)
Zywiel et al,29 2011 Not specied 136 0 (0) 711 21 (3.0)

4% chlorhexidine, which might well explain the failure to detect any effect of chlorhexidine showers daily over 5 days and found that, as
benet in the pooled data. the study progressed, ever greater microbial reductions from the
The antibacterial effect of chlorhexidine is cumulative and baseline were achieved vis--vis a cumulative effect. It is very
greatly enhanced by repeated applications. Paulson39 evaluated the plausible that multiple applications of chlorhexidine over several

Fig 2. Number of infections in clean surgery and clean contaminated/contaminated subgroups. When excluding higher risk of bias studies, OR, 0.98 (95% CI: 0.83-1.16)
Figure generated with Review Manager 5 software.19
 M.P. Chlebicki et al. / American Journal of Infection Control 41 (2013) 167-73
Fig 3. Funnel plot. Figure generated with Review Manager 5 software. The funnel plot
functions as a measure of publication bias, graphing the effect size from relative risk
versus the standard error of the log of the relative risk. Because large studies should
have a smaller SE(log)OR, nding studies falling outside the funnel, as is the case here,
makes publication bias more probable.19
days prior to anticipated surgery may be far more efcacious than
a single preoperative chlorhexidine shower or bath. There was
a trend toward fewer infections in individuals receiving multiple
applications compared with single applications in our study,
although this failed to reach statistical signicance.
In conclusion, our analysis does not support routine use of
preoperative, whole-body chlorhexidine showering or bathing for
prevention of SSI. However, many of the trials done were suboptimal
in design, and the manner in which the chlorhexidine solutions
were used in the trials was not clearly described. Although chlo-
rhexidine bathing preoperatively is a low risk and relatively low cost
intervention that may be employed even if the magnitude of benet
is marginal, it is nonetheless important to denitively answer this
question, given constrained resources for infection control. A cluster
randomized trial to provide adequate statistical power in patients
undergoing clean surgery that employs standardized application
techniques and a prolonged duration of chlorhexidine with rigorous
blinded assessment of SSI outcomes is needed.
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