Water for wound cleansing

  • Comment
  • Review
  • Intervention

Authors


Abstract

Background

Although various solutions have been recommended for cleansing wounds, normal saline is favoured as it is an isotonic solution and does not interfere with the normal healing process. Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost effective; however, there is an unresolved debate about its use.

Objectives

The objective of this review was to assess the effects of water compared with other solutions for wound cleansing.

Search methods

For this fourth update we searched the Cochrane Wounds Group Specialised Register (searched 9 November 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); Ovid MEDLINE (2010 to October Week 4 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, November 8, 2011); Ovid EMBASE (2010 to 2011 Week 44); and EBSCO CINAHL (2010 to 4 November 2011).

Selection criteria

Randomised and quasi randomised controlled trials that compared the use of water with other solutions for wound cleansing were eligible for inclusion. Additional criteria were outcomes that included objective or subjective measures of wound infection or healing.

Data collection and analysis

Two review authors independently carried out trial selection, data extraction and quality assessment. We settled differences in opinion by discussion. We pooled some data using a random-effects model.

Main results

We included 11 trials in this review. We identified seven trials that compared rates of infection and healing in wounds cleansed with water and normal saline; three trials compared cleansing with no cleansing and one trial compared procaine spirit with water. There were no standard criteria for assessing wound infection across the trials, which limited the ability to pool the data. The major comparisons were water with normal saline, and tap water with no cleansing. For chronic wounds, the risk of developing an infection when cleansed with tap water compared with normal saline was 0.16, (95% CI 0.01 to 2.96) demonstrating no difference between the two groups. The use of tap water to cleanse acute wounds in adults and children was not associated with a statistically significant difference in infection when compared to saline (adults: RR 0.66, 95% CI 0.42 to 1.04; children: RR 1.07, 95% CI 0.43 to 2.64). We identified no statistically significant differences in infection rates when wounds were cleansed with tap water or not cleansed at all (RR 1.06, 95% CI 0.07 to 16.50). Likewise, there was no difference in the infection rate in episiotomy wounds cleansed with water or procaine spirit. The use of isotonic saline, distilled water and boiled water for cleansing open fractures also did not demonstrate a statistically significant difference in the number of fractures that were infected.

Authors' conclusions

There is no evidence that using tap water to cleanse acute wounds in adults or children increases or reduces infection. There is not strong evidence that cleansing wounds per se increases healing or reduces infection. In the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents.

摘要

以水清洗傷口

背景

清水被頻繁的使用在清潔傷口以避免感染。這可以是自來水、蒸餾水、放涼的滾水或鹽水。成人身上使用自來水清潔急性傷口不會增加感染率;然而,沒有有力證據顯示清潔本身較不清潔好。審閱者結論是在自來水品質高(可飲用)之處,水之使用可能與其他方法一樣好,像是無菌水或鹽(鹹)水(且較具成本效益),但仍需要更多研究。

目的

本審閱目標是評估清水與其他溶劑在傷口清潔上的效果。

搜尋策略

就此第4次更新我們搜尋了考科藍創傷群組專業註冊(搜尋至2011年11月9日);考科藍對照試驗註冊(CENTRAL) (考科藍圖書館2011年第4期);Ovid MEDLINE (2010年到2011年10月第4周);Ovid MEDLINE (In-Process & Other Non-Indexed Citations,2011年11月8日);Ovid EMBASE (2010年到2011年第44周);與EBSCO CINAHL (2010 年到2011年11月4日)。

選擇標準

隨機與準隨機對照試驗中,採用比較了水與其他溶劑在傷口清潔上的使用。額外準則為包含有客觀與主觀傷口感染或癒合測量的果。

資料收集與分析

兩位審閱作者獨立執行試驗選擇、數據摘錄與品質評估。我們討論意見以平息差異。我們採用隨機效果模型集合一些數據。

主要結果

此審閱中我們採用了11個試驗。我們找出7個試驗,比較清水與生理鹽水清洗傷口的感染與癒合率;3個試驗比較有洗清與無洗清,而一個試驗比較procaine spirit與清水。沒有標準準則可在所有試驗評估傷口感染,這限制了集合數據的能力。主要比較是水與生理鹽水,以及自來水與無清潔。就慢性傷口而言,發展出感染的風險在自來水清潔與生理鹽水相比時為0.16,(95% CI 0.01 to 2.96)顯示兩群組間無差異。成人與兒童身上使用自來水來洗清急性傷口與生理鹽水比較時,並無發生感染的統計上顯著差異(成人:RR 0.66, 95% CI 0.42 to 1.04;兒童:RR 1.07, 95% CI 0.43 to 2.64)。自來水洗清與完全無洗清相比時我們在感染率中找出統計上顯著差異, (RR 1.06, 95% CI 0.07 to 16.50)。 同樣的,在外陰切開術中以清水或procaine spirit清潔傷口的感染率上無差異。使用等滲壓鹽水、蒸餾水、滾水在清潔開放性骨折上,也沒有在受感染的骨折數中顯示出統計上的顯著差異。

作者結論

沒有證據顯示在成人或兒童身上使用自來水清理急性傷口會增加或減少感染。沒有有力的證據顯示清潔傷口是否增加癒合或是減少感染。沒有自來水的地方、滾水與冷水以及蒸餾水當做傷口清潔劑的使用。

Abstrak

Air sebagai pembersih luka

Latar Belakang

Walaupun pelbagai cecair telah dicadangkan untuk pembersihan luka, salin normal digemari kerana ia merupakan cecair isotonik dan tidak mengganggu proses penyembuhan normal. Air paip biasa digunakan dalam masyarakat untuk pembersihan luka kerana ia mudah didapati, efisien dan kos efektif; walau bagaimana pun, terdapat satu perbahasan tentang penggunaannya yang belum diselesaikan lagi.

Matlamat

Objektif sorotan ini adalah untuk menilai kesan air berbanding cecair lain untuk pembersihan luka.

Kaedah Pencarian

Untuk kemaskini yang keempat ini, kami telah mencari Daftar Kepakaran Kumpulan Luka Cochrane (carian pada 9 November 2011); Daftar Pusat Kajian Klinikal Terkawal Cochrane (CENTRAL) (Perpustakaan Cochrane 2011, Isu 4); Ovid MEDLINE (2010 hingga Oktober 2011 Minggu 4); Ovid MEDLINE ( Dalam Proses & Petikan Index Lain, November 8, 2011); Ovid EMBASE (2010 hingga 2011 Minggu 44); dan EBSCO CINAHL (2010 hingga 4 November 2011).

Kriteria Pemilihan

Perbandingan antara kajian klinikal rawak terkawal dan separa rawak terkawal membandingkan air dan cecair lain layak dimasukkan. Kriteria tambahan adalah hasil yang memasukkan cara objektif atau subjektif bagi jangkitan luka atau penyembuhan.

Pengumpulan Data dan Analisis

Dua penulis sorotan menjalankan pemilihan kajian, pengekstrakan data dan penilaian kualiti secara berasingan. Kami menyelesaikan perbezaan pendapat melalui perbincangan. Kami mengumpulkan beberapa data dengan menggunakan model kesan secara rawak.

Keputusan Utama

Kami memasukkan 11 kajian dalam sorotan ini. Kami mengenal pasti tujuh kajian yang membandingkan kadar jangkitan dan penyembuhan luka yang dibersihkan dengan air dan salin normal; tiga kajian membandingkan pembersihan dengan tanpa pembersihan dan satu kajian lagi membandingkan spirit procain dengan air. Tiada kriteria umum untuk menilai jangkitan luka bagi semua kajian yang mana telah menghadkan keupayaan untuk mengumpulkan data. Perbandingan utama adalah air dengan normal salin dan air paip dengan tanpa pembersihan. Untuk luka kronik, risiko untuk mendapat jangkitan apabila dibersihkan dengan air paip berbanding salin normal adalah 0.16 (95% CI 0.01-2.96) menunjukkan tiada perbezaan antara dua kumpulan tersebut. Penggunaan air paip untuk membersihkan luka akut dalam kalangan orang dewasa dan kanak-kanak tidak dikaitkan dengan perbezaan statistik yang signifikan berbanding salin normal (dewasa: RR 0.66, 95% CI 0.42 hingga 1.04; kanak-kanak: RR 1.07, 95% CI 0.43 hingga 2.64) untuk jangkitan. Kami telah mengenal pasti tiada perbezaan statistik yang signifikan dalam kadar jangkitan apabila luka dibersihkan dengan air paip atau tidak dibersihkan langsung (RR 1.06, 95% CI 0.07 hingga 16.50). Begitu juga, tiada perbezaan dalam kadar jangkitan pada luka episiotomi yang dibersihkan dengan air atau spirit procain. Penggunaan salin isotonik, air suling dan air masak untuk membersihkan luka terbuka juga tidak menunjukkan perbezaan statistik yang signifikan dalam bilangan luka yang dijangkiti.

Kesimpulan Pengarang

Tiada bukti yang kukuh bahawa penggunaan air paip untuk membersihkan luka akut dalam kalangan orang dewasa atau kanak-kanak meningkat atau mengurangkan jangkitan. Tiada juga bukti mengenai pembersihan luka semata-mata meningkatkan penyembuhan atau mengurangkan jangkitan. Dalam ketiadaan air paip, air masak, air sejuk dan air suling boleh digunakan sebagai ejen pembersih luka.

Catatan terjemahan

Diterjemahkan oleh Rajasunthari Thambiraja dan Norhayati Mohd Noor (Universiti Sains Malaysia). Untuk sebarang pertanyaan berkaitan terjemahan ini sila hubungi hayatikk@usm.my

アブストラクト

創洗浄に対する水

背景

創洗浄にはさまざまな洗浄液が推奨されてきたが、等張液で、正常な治癒過程を妨げない生理食塩水が好まれる。地域社会では、容易に手に入り、効果的で費用対効果に優れているため、水道水が創の洗浄に使用されることが多いが、その使用に関して未だ見解の相違がある。

目的

このレビューの目的は、創洗浄に対する水の効果を他の溶液と比較して評価することであった。

検索戦略

この4回目の更新では、Cochrane Wounds Group Specialised Register(2011年11月9日検索);Cochrane Central Register of Controlled Trials(CENTRAL)(コクラン・ライブラリ2011年第4号);Ovid MEDLINE(2010年~2011年10月第4週);Ovid MEDLINE(In-Process & Other Non-Indexed Citations、2011年11月8日);Ovid EMBASE(2010年~2011年第44週)およびEBSCO CINAHL(2010年~2011年11月4日)を検索した。

選択基準

創の洗浄に対して、水の使用を他の溶液と比較したランダム化および準ランダム化比較試験を適格とした。さらに、創傷感染または創傷治癒の客観的または主観的な指標を含むアウトカムも基準にした。

データ収集と分析

2名のレビューアが独立して、試験の選択、データの抽出および質評価を実施した。意見の相違点は話し合いによって解決した。ランダム効果モデルを用いてデータの一部を統合した。

主な結果

今回のレビューには11件の試験を採用した。同定した試験のうち、7件は水による洗浄と生理食塩水による洗浄で、創傷の感染率および治癒率を比較し、3件は洗浄した場合と無洗浄の場合を比較し、1件はプロカイン酒精剤と水を比較した。試験間に創傷感染症を評価する標準的な基準がなかったため、データの統合には限界があった。主な比較は、水と生理食塩水との比較および水道水と無洗浄との比較であった。慢性創傷では、水道水で洗浄した場合の感染症発症リスクが生理食塩水に比べて0.16(95%CI 0.01~2.96)と、両群に差は認められなかった。成人および小児の急性創傷の洗浄に水道水を使用した場合を生理食塩水と比べると、感染症に統計学的な有意差はなかった(成人:RR 0.66、95%CI 0.42~1.04;小児:RR 1.07、95%CI 0.43~2.64)。創傷を水道水で洗浄した場合と無洗浄の場合で、感染率に統計学的な有意差は認められなかった(RR 1.06、95%CI 0.07~16.50)。また、会陰切開創の感染率は、水による洗浄とプロカイン酒精剤による洗浄に有意差はなかった。解放骨折の洗浄に、等張食塩水、蒸留水および沸騰させた水の使用で、感染した骨折の数に統計学的な有意差は認められなかった。

著者の結論

成人や小児では、急性創傷の洗浄に対する水道水の使用が、感染を増加または減少させるとするエビデンスはない。創洗浄それ自体が治癒を促進したり、感染を抑制したりすることを示す強固なエビデンスがない。飲用水道水がない場合は、沸騰させて冷ました水や蒸留水を創洗浄液として用いることができる。

訳注

《実施組織》厚生労働省「「統合医療」に係る情報発信等推進事業」(eJIM:http://www.ejim.ncgg.go.jp/)[2015.12.29]《注意》この日本語訳は、臨床医、疫学研究者などによる翻訳のチェックを受けて公開していますが、訳語の間違いなどお気づきの点がございましたら、eJIM事務局までご連絡ください。なお、2013年6月からコクラン・ライブラリーのNew review, Updated reviewとも日単位で更新されています。eJIMでは最新版の日本語訳を掲載するよう努めておりますが、タイム・ラグが生じている場合もあります。ご利用に際しては、最新版(英語版)の内容をご確認ください。

Resumo

Água para limpeza de feridas

Introdução

Embora várias soluções sejam recomendadas para a limpeza de feridas, a solução salina é favorecida por ser isotônica e não interferir no processo normal de cicatrização. A água da torneira é comumente utilizada na comunidade para a limpeza de feridas porque é de fácil acesso, eficiente e de baixo custo-efetividade; entretanto existem controvérsias com relação ao seu uso.

Objetivos

O objetivo desta revisão foi avaliar os efeitos do uso da água, comparado com outras soluções, para a limpeza de feridas.

Métodos de busca

Para esta quarta atualização, pesquisamos o Cochrane Wounds Group Specialised Register (pesquisado em 9 de novembro de 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library: Issue 4, 2011); Ovid MEDLINE (2010 à 4ª semana de outubro de 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, 8 de novembro de 2011); Ovid EMBASE (2010 à 44ª semana de 2011); e EBSCO CINAHL (2010 a 4 de novembro de 2011).

Critério de seleção

Elegemos para inclusão ensaios controlados randomizados e quasi-randomizados que compararam o uso de água com outras soluções para limpeza de feridas. Os critérios adicionais de inclusão foram desfechos que incluíram medidas (objetivas ou subjetivas) de taxas de infecção da ferida ou cicatrização.

Coleta dos dados e análises

Dois autores da revisão, de forma independente, realizaram a seleção, extração dos dados e avaliação da qualidade dos estudos. Os autores discutiam as opiniões divergentes. Agrupamos alguns dados usando modelo de efeitos randomicos.

Principais resultados

Incluímos 11 estudos nesta revisão. Identificamos sete estudos que compararam as taxas de infecção e cicatrização em feridas que foram limpas com água e solução salina normal; três estudos que compararam feridas que foram limpas versus feridas que não foram limpas e um estudo que comparou o uso de solução procaína com água. Não houve critérios padronizados para avaliar a infecção da ferida nos estudos encontrados, o que limitou a capacidade de agrupar os dados. A maioria das comparações foram a utilização de água com solução salina e água da torneira com a não limpeza da ferida. Para feridas crônicas o risco de desenvolver infecção quando a limpeza é realizada com água de torneira comparada com o uso de solução salina foi de 0,16 (95% IC 0,01 a 2,96), demonstrando não haver diferença entre os dois grupos. O uso de água da torneira para limpeza de feridas agudas em adultos e crianças não foi associado à diferenças estatisticamente significativas para infecção quando comparada com o uso de solução salina (adultos: RR 0,66; 95% IC 0,42 a 1,04; crianças: RR 1,07; 95% IC 0,43 a 2,64). Identificamos que não há diferenças estatisticamente significativas nas taxas de infecção quando as feridas foram limpas com água de torneira ou não foram limpas (RR 1,06; 95% IC 0,07 a 16,50). Da mesma forma, não houve diferença na taxa de infecção nas feridas de episiotomias onde utilizaram para a limpeza água ou solução procaína. O uso de solução salina isotônica, água destilada e água fervida para limpeza de fraturas expostas também não demonstrou diferenças estatisticamente significativas quanto ao número de fraturas que infectaram.

Conclusão dos autores

Não há evidência de que o uso de água da torneira para limpeza de feridas agudas em adultos ou crianças aumente ou reduza infecções. Novos estudos de boa qualidade podem alterar as conclusões de que a limpeza de feridas por si só aumenta a cicatrização ou reduz infecção. Na ausência de água da torneira potável, a água fervida e resfriada, bem como a água destilada podem ser usadas como agentes para limpeza de feridas.

Notas de tradução

Tradução do Centro Cochrane do Brasil (Emanuela Cardoso da Silva). E-mail: tradutores@centrocochranedobrasil.org.br.

Résumé scientifique

L'eau pour le nettoyage des plaies

Contexte

Même si plusieurs solutions ont été recommandées pour nettoyer les plaies, une solution saline normale est préférée, car il s'agit d'une solution isotonique qui n'interfère pas avec le processus de guérison normal. L'eau du robinet est couramment utilisée dans la société pour nettoyer les plaies, car elle est facilement accessible, efficace et rentable ; cependant, le débat au sujet de son utilisation est encore en cours.

Objectifs

L'objectif de cette revue était d'évaluer les effets de l'eau comparés à d'autres solutions pour le nettoyage des plaies.

Stratégie de recherche documentaire

Pour cette quatrième mise à jour, nous avons effectué des recherches dans le registre spécialisé du groupe Cochrane sur les plaies et contusions (le 9 novembre 2011) ; le registre Cochrane des essais contrôlés (CENTRAL) (The Cochrane Library 2011, numéro 4) ; Ovid MEDLINE (de 2010 à la 4ème semaine d'octobre 2011) ; Ovid MEDLINE (In-Process & Other Non-Indexed Citations, 8 novembre 2011) ; Ovid EMBASE (de 2010 à la 2011 44ème semaine ) et EBSCO CINAHL (de 2010 au 4 novembre 2011).

Critères de sélection

Les essais contrôlés randomisés et quasi-randomisés qui comparaient l'utilisation de l'eau à d'autres solutions pour le nettoyage des plaies étaient éligibles pour l'inclusion. Des critères supplémentaires comprenaient les mesures objectives et subjectives de l'infection des plaies ou de la cicatrisation.

Recueil et analyse des données

Deux auteurs de la revue ont procédé à la sélection des essais, l'extraction des données et l'évaluation de la qualité. Nous avons résolu les différences d'opinion par la discussion. Nous avons regroupé certaines données à l'aide d'un modèle à effets aléatoires.

Résultats principaux

Nous avons inclus 11 essais dans cette revue. Nous avons identifié sept essais qui comparaient les taux d'infection et de la cicatrisation des plaies nettoyées avec de l'eau et une solution saline normale ; trois essais comparaient le nettoyage avec l'absence de nettoyage et un essai comparait l'essence de procaïne avec de l'eau. Il n'y avait pas de critères standard pour évaluer l'infection des plaies entre les essais, ce qui limitait la possibilité de regrouper les données. Les principales comparaisons concernaient l'eau avec une solution saline normale, et l'eau du robinet à l'absence de nettoyage. Pour les plaies chroniques, le risque de développer une infection en cas de nettoyage avec de l'eau du robinet par rapport à une solution saline normale était de 0,16 (IC à 95 % 0,01 à 2,96), ne révélant aucune différence entre les deux groupes. L'utilisation de l'eau du robinet pour nettoyer les plaies aiguës chez l'adulte et l'enfant n'était pas associée à une différence statistiquement significative concernant l'infection par rapport à une solution saline (les adultes : RR 0,66, IC à 95 % 0,42 à 1,04 ; les enfants : RR 1,07, IC à 95 % 0,43 à 2,64). Nous n'avons identifié aucune différence statistiquement significative dans les taux d'infection lorsque les plaies étaient nettoyées avec de l'eau du robinet ou pas nettoyées du tout (RR 1,06, IC à 95 % 0,07 à 16,50). De même, il n'y avait aucune différence dans les taux d'infection pour les plaies d'épisiotomie nettoyées avec de l'eau ou l'essence de procaïne. L'utilisation d'une solution saline isotonique, de l'eau distillée et de l'eau bouillie pour le nettoyage des fractures ouvertes n'a pas mis en évidence une différence statistiquement significative dans le nombre de fractures qui ont été infectées.

Conclusions des auteurs

Il n'existe pas de preuves indiquant que l'utilisation de l'eau du robinet pour nettoyer les plaies aiguës chez les adultes ou les enfants augmente ou réduit l'infection. Il n'existe pas de preuves solides indiquant que le nettoyage en lui-même améliore la guérison ou réduit l'infection. En l'absence d'eau du robinet potable, l'eau bouillie et refroidie ou l'eau distillée peuvent être utilisées pour le nettoyage des plaies.

Notes de traduction

Traduction réalisée par Cochrane France

Plain language summary

The effects of water compared with other solutions for wound cleansing

Water is frequently used for cleaning wounds to prevent infection. This can be tap water, distilled water, cooled boiled water or saline (salty water). Using tap water to cleanse acute wounds in adults does not increase the infection rate; however, there is no strong evidence that cleansing per se is better than not cleansing. The reviewers concluded that where tap water is high quality (drinkable), it may be as good as other methods such as sterile water or saline (salty) water (and more cost-effective), but more research is needed.

Laički sažetak

Učinci vode u usporedbi s drugim otopinama za čišćenje rana

Kako bi se spriječila infekcija, voda se često koristi za čišćenje rana. To može biti voda iz slavine, destilirana voda, ohlađena flaširana voda ili fiziološka otopina (slana voda). Korištenje vode iz slavine za čišćenje akutnih rana u odraslih osoba ne povećava učestalost infekcija, međutim nema čvrstih dokaza da je čišćenje rana samo po sebi bolje od nikakvog čišćenja. Autori Cochrane sustavnog pregleda, nakon analiziranja 11 kliničkih pokusa, zaključuju da pitka voda može biti jednako dobra kao i druge metode za čišćenje rana, kao što su sterilna voda i fiziološka otopina (a uz to je i jeftinija). Ako nije dostupna pitka voda iz slavine, za čišćenje rana može se koristiti kuhana i flaširana voda, kao i destilirana voda.

Bilješke prijevoda

Prevoditelj:: Croatian Branch of the Italian Cochrane Centre

淺顯易懂的口語結論

清水與其他溶液比較,在傷口清潔上的效果

人們經常用水清洗傷口以避免感染──其型態可以是自來水、蒸餾水、開水或食鹽水(鹽水)。以自來水清洗成年人急性傷口的做法,不會提高感染率;然而,並未存在強力證據顯示傷口清洗本身比不清洗來得好。本回顧做出下列結論:在自來水水質較高(可飲用)的環境下,其效果可能和其他方法(如無菌水或食鹽水〔鹽水〕)一樣好(且成本效益較高),但仍需要更多的研究。

譯註

翻譯: East Asian Cochrane Alliance 14th December, 2011
翻譯補助: 台灣衛生福利部/台北醫學大學實證醫學研究中心

Ringkasan bahasa mudah

Kesan air berbanding cecair lain untuk pembersihan luka.

Air sering digunakan untuk membersih luka bagi mencegah jangkitan. Air paip, air suling, air masak yang telah disejukkan atau air masin telah digunakan. Penggunaan air paip untuk membersihkan luka akut dalam kalangan orang dewasa tidak meningkatkan kadar jangkitan. Walau bagaimana pun, tidak ada bukti yang kukuh bahawa pembersihan sebegini adalah lebih baik daripada tidak dibersihkan langsung. Pengulas membuat kesimpulan bahawa jika air paip berkualiti tinggi (boleh diminum), ia boleh menjadi sebaik kaedah lain seperti air suling atau air salin (yang lebih kos efektif) tetapi lebih banyak kajian diperlukan.

Catatan terjemahan

Diterjemahkan oleh Rajasunthari Thambiraja dan Norhayati Mohd Noor (Universiti Sains Malaysia). Untuk sebarang pertanyaan berkaitan terjemahan ini sila hubungi hayatikk@usm.my

平易な要約

創洗浄に対する水の効果と他の溶液との比較

創傷の感染を予防するために、水が洗浄に用いられることが多い。このような水には、水道水、蒸留水、沸騰させて冷ました水または生理食塩水がある。成人の急性創傷の洗浄に水道水を用いても、感染率は上昇しなかった。しかし、洗浄それ自体が無洗浄よりも有効であるという強固なエビデンスはない。レビューアは、水道水の質が高い(飲用に適している)地域では、水道水が、滅菌水や食塩水など他の方法とほぼ同等の効果があり、費用対効果はより高い可能性があるが、さらに研究を実施する必要があると結論づけた。

訳注

《実施組織》厚生労働省「「統合医療」に係る情報発信等推進事業」(eJIM:http://www.ejim.ncgg.go.jp/)[2015.12.29]《注意》この日本語訳は、臨床医、疫学研究者などによる翻訳のチェックを受けて公開していますが、訳語の間違いなどお気づきの点がございましたら、eJIM事務局までご連絡ください。なお、2013年6月からコクラン・ライブラリーのNew review, Updated reviewとも日単位で更新されています。eJIMでは最新版の日本語訳を掲載するよう努めておりますが、タイム・ラグが生じている場合もあります。ご利用に際しては、最新版(英語版)の内容をご確認ください。

எளியமொழிச் சுருக்கம்

பிற திரவங்களை ஒப்பிடுகையில், புண்களை சுத்தப்படுத்துவதில் தண்ணீரின் விளைவுகள்.

தொற்றுகளை தவிர்க்க, புண்களை சுத்தப்படுத்துவதற்கு அடிக்கடி தண்ணீர் பயன்படுத்தப்படுகிறது. இவை, குழாய் தண்ணீர், காய்ச்சி வடிக்கட்டிய தண்ணீர், குளிருட்டப்பட்ட கொதிக்க வைத்த தண்ணீர், அல்லது உப்பு தண்ணீர் என்று இருக்கலாம். குறுகிய-கால புண்களை சுத்தப்படுத்த குழாய் தண்ணீரை பயன்படுத்துதல் தொற்று நிகழ்வுகளை அதிகரிக்கவில்லை; எனினும், சுத்தப்படுத்தாமல் இருப்பதை விட, சுத்தப்படுத்துவது சிறப்பாக இருக்கும் என்பதற்கு உறுதியான ஆதாரம் இல்லை. குழாய் தண்ணீர் உயர்ந்த தரம் கொண்டது (குடிக்க தகுதி வாய்ந்தது) என்று திறனாய்வு ஆசிரியர்கள் முடிவு செய்தனர்; அது கிருமியற்ற தண்ணீர் அல்லது உப்பு தண்ணீர் போன்ற பிற முறைகளை போன்று சிறப்பாக இருக்கும் (மற்றும் செலவு-குறைந்ததாக), ஆனால் அதிக ஆராய்ச்சி தேவைப்படுகிறது.

மொழிபெயர்ப்பு குறிப்புகள்

மொழிபெயர்ப்பாளர்கள்: சிந்தியா ஸ்வர்ணலதா ஸ்ரீகேசவன், தங்கமணி ராமலிங்கம், ப்ளசிங்டா விஜய், ஸ்ரீகேசவன் சபாபதி.

Streszczenie prostym językiem

Skuteczność wody w porównaniu z innymi roztworami w oczyszczaniu ran

Woda jest często stosowana w oczyszczaniu ran celem zapobiegania zakażeniu. Może to być woda z kranu, woda destylowana, ochłodzona woda przegotowana lub sól fizjologiczna (słona woda). Korzystanie z wody z kranu do oczyszczenia świeżych ran u dorosłych nie zwiększa częstości zakażenia; jednakże, nie ma przekonujących danych naukowych, że oczyszczanie samo przez siebie jest lepsze niż nieoczyszczanie. Autorzy przeglądu stwierdzili, że gdy woda z kranu jest wysokiej jakości (zdatna do picia), to można ją uznać za równie dobrą jak inne metody, takie jak: sterylna woda lub sól fizjologiczna (a ponadto taka interwencja jest bardziej opłacalna ekonomicznie), jednak niezbędne są dalsze badania.

Uwagi do tłumaczenia

Tłumaczenie: Joanna Zając Redakcja: Magdalena Koperny

Resumo para leigos

Os efeitos da água comparada com outras soluções para limpeza de feridas

A água é frequentemente usada na limpeza de feridas com o objetivo de prevenir infecção. A água pode ser da torneira, água destilada, água fervida e resfriada ou solução salina (água salgada). O uso de água da torneira para limpeza de feridas agudas em adultos não aumenta as taxas de infecção; no entanto, novos estudos de boa qualidade podem alterar as conclusões de que a realização da limpeza da ferida por si só é melhor do que não limpar. Os revisores concluíram que o uso de água da torneira de alta qualidade (potável) pode ser tão bom quanto o uso de outras soluções, tais como água estéril ou solução salina, além de representar baixo custo. Porém, existe a necessidade de se realizar mais pesquisas.

Notas de tradução

Tradução do Centro Cochrane do Brasil (Emanuela Cardoso da Silva). E-mail: tradutores@centrocochranedobrasil.org.br.

Résumé simplifié

Les effets de l'eau comparés à d'autres solutions pour le nettoyage des plaies

L'eau est souvent utilisée pour le nettoyage des plaies afin de prévenir l'infection. Cela peut être de l'eau du robinet, de l'eau distillée, d'eau bouillie refroidie ou de sérum physiologique (eau salée). L'utilisation de l'eau du robinet pour nettoyer les plaies aiguës chez l'adulte n'augmente pas le taux d'infection ; cependant, il n'existe pas de preuves solides indiquant que le nettoyage en lui-même est plus efficace que l'absence de nettoyage. Les auteurs de la revue ont conclu que lorsque l'eau du robinet est de haute qualité (potable), il pourrait être aussi efficace que d'autres méthodes, telles que l'eau stérile ou le sérum physiologique (eau salée) (et plus rentable), mais des recherches supplémentaires sont nécessaires.

Notes de traduction

Traduction réalisée par Cochrane France

Background

Management of chronic and acute wounds has changed significantly in the last decade; however, minimal attention has been focused on the types of solutions used for wound cleansing.

The process of wound cleansing involves the application of a non-toxic fluid to remove debris, wound exudate and metabolic wastes to create an optimal environment for wound healing (Murphy 1995; Waspe 1996; Rodeheaver 1999). Clinicians and manufacturers have recommended various cleansing agents for their supposed therapeutic value. Preparations with antiseptic properties have been traditionally used, but published research using animal models has suggested that antiseptic solutions may hinder the healing process (Brennan 1985; Thomlinson 1987; Glide 1992; Bergstrom 1994; Hellewell 1997). The controversy surrounding the use of antiseptics prompted the development of guidelines for the use of antiseptics by wound care experts. These guidelines have resulted in changes in hospital practice.

Normal saline (0.9%) is the favoured wound cleansing solution because it is an isotonic solution and does not interfere with the normal healing process, damage tissue, cause sensitisation or allergies or alter the normal bacterial flora of the skin (which would allow the growth of more virulent organisms) (Huxtable 1993; Lawrence 1997; Philips 1997; Joanna Briggs 1998). Tap water is also recommended and has the advantages of being efficient, cost-effective and accessible (Fowler 1985; Angeras 1992; Murphy 1995; Thompson 1999). However, clinicians have been cautioned against using tap water to cleanse wounds that have exposed bone or tendon, in which case normal saline is recommended (Lindholm 1999).

There has been much debate in clinical circles about the potential advantages and disadvantages of cleaning exudate from the wound, as the exudate itself may contain growth factors and chemokines which contribute to wound healing (Thomson 1998). However, the literature also suggests that large amounts of bacteria may inhibit wound healing because of the proteases secreted by the organisms (Robson 1988). Until further research has established its demerits, cleansing will continue to remain an integral part of the wound management process (Hellewell 1997).

Wounds cause considerable cost to individuals in terms of morbidity, and to the health services in terms of the personnel and consumables to perform wound care (Johnson 1997). The purpose of this systematic review was to investigate the effectiveness of water for cleansing wounds in clinical practice.

Objectives

The objective of this review was to compare the effects of water (tap or cool, boiled or distilled) and saline for wound cleansing.

The review will address the following questions.
What are the comparative effects on rates of healing and infection in acute and chronic wounds, of the following cleansing solutions:

  • tap water compared with no cleansing;

  • tap water compared with sterile normal saline;

  • water (distilled and/or cooled boiled water) compared with sterile normal saline;

  • tap water compared with cooled boiled tap water;

  • tap water compared with any other solution.

Methods

Criteria for considering studies for this review

Types of studies

We considered all randomised controlled trials (RCTs) and quasi RCTs comparing wound healing outcomes or infection rates in wounds cleaned with water and those cleaned with normal saline or any other solution eligible for inclusion in this review. A quasi RCT uses a method of allocating participants that is not truly random, e.g. according to date of birth (odd or even years) (Jadad 1998). We included trials if they reported an objective measure of infection such as wound culture or biopsy and objective measures of healing such as change in surface area and wound depth. We also included trials that included only subjective measures of infection such as redness, purulent discharge or swelling around the affected area in the review, but we analysed these separately. We included trials undertaken in any country, irrespective of the tap water quality, and there was no restriction on the basis of the language in which the trial reports were written.

Types of participants

Trials involving people of all ages with a wound of any aetiology, in any setting (hospital, community, nursing homes, general practice, wound clinics). For the purpose of the review a wound was defined as a break in the skin.

We excluded trials if they compared solutions for dental procedures or for patients with burns.

Types of interventions

We considered trials eligible for inclusion if the solutions compared were used specifically for wound cleansing. For the purpose of this review, wound cleansing is defined as: "the use of fluids to remove loosely adherent debris and necrotic tissue from the wound surface" (Hellewell 1997).
We considered all trials evaluating the following comparisons eligible for inclusion in the review:

  • tap water compared with no cleansing;

  • tap water compared with sterile normal saline;

  • water (distilled and/or cooled boiled water) compared with sterile normal saline;

  • tap water compared with cooled boiled water;

  • tap water compared with any other solution.

We excluded trials that:

  1. utilised solutions for pre-operative skin cleansing to prevent postoperative infections;

  2. assessed the effectiveness of solutions as part of the operative procedure (for example lavage with povidone-iodine or normal saline after fascia closure);

  3. compared dressings for patients with ulcers;

  4. used a solution, for example povidone-iodine as a prophylactic treatment.

Types of outcome measures

Primary outcomes

The primary outcome of interest was wound infection, as measured objectively by bacterial counts, wound cultures, wound biopsy and/or by subjective indicators of wound infection (e.g. presence of pus, discolouration, friable granulation tissue).

Secondary outcomes

The secondary outcomes of interest were:

  • proportion of wounds that healed;

  • the rate of wound healing expressed as percentage or absolute change in wound area;

  • costs;

  • pain and discomfort;

  • patient satisfaction;

  • staff satisfaction.

Search methods for identification of studies

The search methods section for the third update of this review can be found in Appendix 1.

Electronic searches

For this fourth update we searched the following databases:

  • The Cochrane Wounds Group Specialised Register (searched 9 November 2011);

  • The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4);

  • Ovid MEDLINE (2010 to October Week 4 2011);

  • Ovid MEDLINE (In-Process & Other Non-Indexed Citations, November 8, 2011);

  • Ovid EMBASE (2010 to 2011 Week 44);

  • EBSCO CINAHL (2010 to 4 November 2011).

We used the following search strategy to search CENTRAL:
#1 MeSH descriptor Wounds and Injuries explode all trees
#2 MeSH descriptor Skin Ulcer explode all trees
#3 MeSH descriptor Diabetic Foot explode all trees
#4 ("wound" or "wounds" or "ulcer" or "ulcers" or "bite" or "bites" or "abrasion" or "abrasions" or "laceration" or "lacerations" or "diabetic foot" or "diabetic feet"):ti,ab,kw
#5 (#1 OR #2 OR #3 OR #4)
#6 MeSH descriptor Water explode all trees
#7 "water":ti,ab,kw
#8 (#6 OR #7)
#9 (clean* or wash* or irrigat* or shower* or bath* or rins*):ti,ab,kw
#10 (#5 AND #8 AND #9)

We have provided the search strategies for Ovid MEDLINE, Ovid EMBASE and EBSCO CINAHL in; Appendix 2, Appendix 3 and Appendix 4 respectively. We combined the Ovid MEDLINE search with the Cochrane Highly Sensitive Search Strategy for identifying randomised trials in MEDLINE: sensitivity- and precision-maximising version (2008 revision) (Lefebvre 2011). We combined the Ovid EMBASE and EBSCO CINAHL searches with the trial filters developed by the Scottish Intercollegiate Guidelines Network (SIGN 2011). There were no restrictions on the basis of date or language of publication.

Searching other resources

We scrutinised the reference lists of relevant reviews and trials to identify additional studies.

Data collection and analysis

Selection of studies

Two review authors independently assessed the references and abstracts of the trials identified by the above search against the eligibility criteria, and obtained the full text of potentially relevant trials. We entered references identified from the search of electronic databases and other literature into a bibliographic software package (EndNote). Two review authors jointly made the decision to include or exclude a study against the eligibility criteria.

Data extraction and management

We extracted the following data for each trial:

  • characteristics of wounds and patients in the trials;

  • description of main interventions, including tap water quality;

  • description of concurrent interventions;

  • setting;

  • duration of follow up;

  • rates of wound infection;

  • number of wounds healed;

  • the number and reasons of withdrawals;

  • costs;

  • pain score/level of discomfort;

  • patient and staff satisfaction.

We included trials published in duplicate only once, but extracted maximum data from each publication. Two review authors independently extracted and summarised data from included trials using a data extraction sheet developed and piloted by the review team. We resolved differences in opinion between the authors by discussion. We excluded trials from the review if they made comparisons that did not include the use of tap water. We have listed these trials with their reasons for exclusion (Characteristics of excluded studies).

Assessment of risk of bias in included studies

The review authors independently evaluated reports of all included trials using the Jadad scale (Jadad 1996) plus the following criteria to assess the methodological quality:

  • detailed description of inclusion and exclusion criteria used to derive the sample from the target population;

  • appropriate random sequence generation (e.g. random number tables);

  • evidence of sample size calculation;

  • evidence of allocation concealment at randomisation (e.g. centralised or remote randomisation, sealed opaque envelopes);

  • description of baseline comparability of treatment groups;

  • description of methods used to assess adverse effects;

  • evidence of blinded outcome assessment;

  • description of the types of wounds (grades);

  • description of withdrawals and dropouts; and

  • description of the method of statistical analysis.

We resolved differences in opinion between the review authors by discussion.

Data synthesis

The main comparison of water with other wound cleansing solutions was stratified by whether the wounds were classified as acute or chronic (we pre-specified this subgroup analysis in the protocol). We calculated a weighted treatment effect across trials using the Cochrane statistical package, RevMan version 4.2. We assessed trials for clinical heterogeneity by considering the settings, populations, interventions and outcomes. Where two or more trials compared similar solutions and used the same outcome measures, we tested them for heterogeneity using the I2 statistic (Higgins 2003). This statistic examines the percentage of total variation across studies due to heterogeneity rather than to chance. Values of I2 over 75% indicate a high level of heterogeneity and in such cases we would carefully consider the appropriateness of pooling. We have expressed dichotomous outcomes (e.g. number of patients developing a wound infection) as relative risks (RR) with 95% confidence intervals (CI).

Results

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies.

The searches identified no new trials for this fourth update. We identified 11 trials that were eligible for inclusion in this review. We excluded 18 trials that either compared various types of dressings or used solutions for purposes other than cleansing (e.g. povidone-iodine for infection prophylaxis), or were available in abstract form only with no further data available. We have listed these trials in the Characteristics of excluded studies, with reasons for their exclusion. The included studies were conducted in Australia (Griffiths 2001), Germany (Riederer 1997; Neues 2000), Singapore (Tay 1999), Sweden (Angeras 1992), USA (Goldberg 1981; Bansal 2002; Godinez 2002; Valente 2003; Moscati 2007) and Tanzania (Museru 1989).

Trial design

Nine of the eleven trials were conducted in single centres (Goldberg 1981; Museru 1989; Angeras 1992; Riederer 1997; Tay 1999; Neues 2000; Bansal 2002; Godinez 2002; Valente 2003). All trials utilised a parallel group design and the studies by Museru 1989 and Neues 2000 had three comparison arms.

Participants

The age of the patients ranged from two to 95 years. Two trials were undertaken in children (Bansal 2002; Valente 2003). In five of the 11 trials (Angeras 1992; Tay 1999; Griffiths 2001; Bansal 2002; Valente 2003), the treatment groups in each individual trial were comparable at baseline. In the trial by Angeras 1992, there were significantly more males than females in both groups and half the patients were between 18 and 35 years. In eight trials the baseline data were not available. Of the included trials, five trials involved people with lacerations (Angeras 1992; Bansal 2002; Godinez 2002; Valente 2003; Moscati 2007); one trial each involved people with open fractures, (Museru 1989) and chronic wounds (Griffiths 2001); and four trials examined people with surgical wounds (Goldberg 1981; Riederer 1997; Tay 1999; Neues 2000).

Interventions

Ten of the 11 trials evaluated patients in the hospital emergency departments and ward settings (Goldberg 1981; Museru 1989; Angeras 1992; Riederer 1997; Tay 1999; Neues 2000; Bansal 2002; Godinez 2002; Valente 2003; Moscati 2007) and only one trial (Griffiths 2001) was undertaken in the community. The cleansing process was undertaken by the medical or nursing staff (Museru 1989; Angeras 1992; Griffiths 2001; Bansal 2002; Godinez 2002; Valente 2003; Moscati 2007) or by the person themselves (Goldberg 1981; Riederer 1997; Tay 1999; Neues 2000; Moscati 2007). It was unclear if standard instructions were given to the patients or the health professionals about the cleansing process. Only one trial (Godinez 2002) specified the duration of the cleansing process and only four trials reported on the volume of the cleansing fluid used (Museru 1989; Griffiths 2001; Valente 2003; Moscati 2007). The solutions used for wound cleansing included tap water (Goldberg 1981; Angeras 1992; Riederer 1997; Tay 1999; Neues 2000; Griffiths 2001; Bansal 2002; Godinez 2002; Valente 2003; Moscati 2007), cooled boiled water (Museru 1989), distilled water (Museru 1989) and normal saline (Museru 1989; Angeras 1992; Griffiths 2001; Godinez 2002; Moscati 2007). The duration of follow up ranged from one to six weeks. The method used to contain the solution was reported in four trials and included bowls (Angeras 1992; Godinez 2002), clean washed bottles (Griffiths 2001), and sterile bottles or basins (Museru 1989; Bansal 2002). The method for cleansing included irrigation (Museru 1989; Angeras 1992; Griffiths 2001; Godinez 2002; Bansal 2002; Valente 2003; Moscati 2007) and showering (Goldberg 1981; Riederer 1997; Neues 2000).

Risk of bias in included studies

We used the eight-point Quality Scale Assessment tool developed by the Cochrane Collaboration (Mulrow 1996) to measure the quality of the RCTs; based on these criteria essential information was absent from five of the 11 trials (Goldberg 1981; Museru 1989; Tay 1999; Neues 2000; Godinez 2002). All trials stated that allocation to treatment was random; random number tables were used in three trials (Griffiths 2001; Bansal 2002; Moscati 2007); alternate allocation (in fact quasi-random) in six trials (Goldberg 1981; Angeras 1992; Riederer 1997; Tay 1999; Neues 2000; Valente 2003) and the allocation method used was not described in two trials (Museru 1989; Godinez 2002). Two trials (Griffiths 2001; Moscati 2007) clearly described concealed allocation, which was achieved by a computer generated randomisation process with the code held at a remote site.

Eight trials (Goldberg 1981; Museru 1989; Angeras 1992; Riederer 1997; Griffiths 2001; Bansal 2002; Valente 2003; Moscati 2007) provided a clear description of the inclusion/exclusion criteria; three trials (Angeras 1992; Griffiths 2001; Moscati 2007) provided information on whether the patients and the outcome assessors were blinded to the intervention.

A description of the baseline characteristics of the patients is essential to assess comparability between the groups (indicates if randomisation was successful). It also assists the reader in deciding if the results are applicable to their situation. The baseline characteristics for each treatment group were given in six of the nine trials (Angeras 1992; Tay 1999; Neues 2000; Griffiths 2001; Bansal 2002; Valente 2003). The sex of the patients in each group was stated in five trials (Angeras 1992; Tay 1999; Griffiths 2001; Bansal 2002; Valente 2003). The distribution of males and females was even in three trials (Angeras 1992; Griffiths 2001; Bansal 2002) and the Tay 1999 trial had recruited only females. There was no difference in the age of the patients in each treatment group in the six trials (Angeras 1992; Tay 1999; Neues 2000; Griffiths 2001; Bansal 2002; Valente 2003) in which age was reported. Comparability between types of wounds was reported in all but one trial (Godinez 2002).

A wide range of outcome measures was used in the included trials. With the exception of trials that compared tap water with no cleansing, other comparisons were represented within single studies. The patients were followed up for a maximum of six weeks after therapy (Griffiths 2001), thus it is difficult to determine the long-term effects of tap water on the wounds that had not healed. Six of the included trials commented on the attrition rates and described the number and reason for withdrawals (Angeras 1992; Riederer 1997; Griffiths 2001; Bansal 2002; Valente 2003; Moscati 2007). Sample sizes ranged between 35 and 770 patients (median 111). Two trials described a priori sample size calculation (Valente 2003; Moscati 2007). Cost analysis was reported in only two trials (Griffiths 2001; Moscati 2007).

Effects of interventions

We identified 11 trials that met the inclusion criteria. Three trials (Goldberg 1981; Riederer 1997; Neues 2000) compared wounds cleansed using tap water with those not cleansed and eight trials (Museru 1989; Angeras 1992; Tay 1999; Griffiths 2001; Bansal 2002; Godinez 2002; Valente 2003; Moscati 2007) compared wound cleansing with water and other solutions. There was significant heterogeneity in the types of the wounds, the cleansing solution used and the outcomes measures used in the trials. All trials used subjective measures to assess wound infection and two trials used blinded outcome assessment (Griffiths 2001; Moscati 2007).

1. Comparison of tap water with no cleansing (Analysis 1)

We identified three RCTs (Goldberg 1981; Riederer 1997; Neues 2000) that compared infection and healing rates in patients with surgical wounds who were allowed to bathe or shower their wounds and those who were not. The studies allowed patients assigned to the showering group to use cleansing agents.

Primary outcome (infection)

We pooled data for infection in a meta-analysis. Neues 2000 assigned participants to one of three groups: those assigned to the control group were required to keep the wounds dry for eight days following surgery; one intervention group used tap water only and the third group used tap water and shower gel for body cleansing. No wound infection was reported in any of the three groups. As the characteristics of the two groups that showered were comparable, we considered it appropriate to combine the data from those groups for comparison with data from the no cleansing group. Although this approach maintains the randomisation and avoids double counting, it results in unequally sized comparison groups. Overall pooling the results of these three trials (Goldberg 1981; Riederer 1997; Neues 2000) demonstrated no difference in infection rate between wounds that were cleansed using tap water compared with wounds not cleansed (RR 1.06, 95% CI 0.07 to 16.50)(Analysis 1.1).

Secondary outcomes
(i) Wound healing

Two trials reported on wound healing (Goldberg 1981; Neues 2000). Neues 2000 reported wound dehiscence as a measure of wound healing. Pooled data demonstrated no statistically significant difference in the number of wounds that did not heal between the groups (RR 1.26, 95% CI 0.18 to 8.66) (Analysis 1.2).

(ii) Patient satisfaction

The only secondary outcome for which there were data from both trials was patient satisfaction. Although an objective measurement scale was not used in either trial, a feeling of well being was reported in both studies among the patients who were allowed to shower their wounds.

2. Comparison of tap water with normal saline (Analysis 2)

Six trials (Angeras 1992; Griffiths 2001; Bansal 2002; Godinez 2002; Valente 2003; Moscati 2007) compared infection and healing rates in acute and chronic wounds irrigated with either tap water or normal saline.

Primary outcome (infection)
(a) Acute wounds

Three trials (Angeras 1992; Godinez 2002; Moscati 2007) compared infection rates in acute soft tissue wounds and lacerations that were sutured and pooled results demonstrated no reduction in infection rates in wounds cleaned with tap water compared with normal saline (RR 0.66, 95% CI 0.42 to 1.04; P = 0.16) (Analysis 02, Outcome 01). A significantly higher infection rate in the saline group was reported in one trial (Angeras 1992) which could be attributed to the difference in the temperature of the irrigant used (tap water was at 37ºC whilst normal saline was at room temperature). Two trials (Bansal 2002; Valente 2003) measured infection rates in children and the pooled results demonstrated no statistically significant difference in the infection rates in children whose wounds were cleansed with saline or tap water (RR 1.07, 95% CI 0.43 to 2.64; P = 0.88) (Analysis 2.1).

(b) Chronic wounds

Griffiths 2001 reported no statistically significant difference in infection rates in non sutured chronic wounds that were cleansed with either tap water or normal saline (RR 0.16, 95% CI 0.01 to 2.96; P = 0.22). The low power of this trial to detect a clinically important difference as statistically significant must be emphasised (49 wounds and only three infections) (Analysis 2.2).

Secondary outcomes
(i) Wound healing

Only one trial reported on wound healing (Griffiths 2001). There was no statistically significant difference in the number of wounds that healed after cleansing with either tap water or normal saline (RR 0.57, 95% CI 0.30 to 1.07) (Analysis 2.3).

(ii) Cost analysis

Two trials (Griffiths 2001; Moscati 2007) reported a cost analysis and demonstrated that the use of tap water was inexpensive compared with the use of normal saline. In the trial by Griffiths 2001, the estimated cost per dressing using normal saline was AUD$1.43 plus the cost of the dressing, compared with AUD$1.16 using tap water. If the wound was cleansed during showering, the only cost would be the dressing. Costs for the saline group included staff time, materials and equipment used for the dressings. In the second trial (Moscati 2007), costs were calculated to include supplies, saline and antibiotics if required. The costs were extrapolated to the eight million lacerations that occur in the USA each year. The results demonstrated an adjusted annual saving of US$65,600,000 if wounds were irrigated using tap water.

(iii) Patient satisfaction

Griffiths 2001 cleansed wounds using tap water and normal saline, both administered from a bottle. The authors reported that patients who had showered their wounds prior to participating in the trial preferred that method to irrigation with normal saline. This finding demonstrates that method of cleansing remains as important as the solution used for cleansing wounds.

3. Comparison of water (distilled water and/or cooled boiled water) with normal saline (Analysis 3)

Museru 1989 designed a three-arm study to compare the infection and healing rates as a consequence of cleansing by irrigation open fractures using distilled water; cooled boiled water; or isotonic saline. The study made the following comparisons.
(a) Distilled water compared with cooled boiled water.
(b) Distilled water compared with isotonic saline.
(c) Cooled boiled water compared with isotonic saline.
(d) Water (distilled water and/or cooled boiled water) compared with normal saline.

(a) Distilled water compared with cooled boiled water
Primary outcome (Infection)

Six out of 35 patients (17%) in the distilled water group and nine out of 31 (29%) in the cooled boiled water group developed a wound infection; this difference was not statistically significant. (RR 1.69, 95% CI 0.68 to 4.22). The small number of wounds cleansed using distilled water (n = 35) and cooled boiled water (n = 31) means that the study lacked power to detect clinically important differences (Museru 1989) Analysis 3.1.

(b) Distilled water with isotonic saline
Primary outcome (infection)

Outcomes from the distilled water group were also compared with the isotonic saline group. In this comparison 7/20 (35%) patients whose fractures were cleansed with isotonic saline developed an infection compared with 6/35 (17%) in the distilled water group (RR 0.49, 95% CI 0.19 to 1.26) (Analysis 3.1) (Museru 1989).

(c) Cooled boiled water with isotonic saline
Primary outcome (infection)

Outcomes from the isotonic saline group were also compared with the cooled boiled water group. In this comparison 9/31 (29%) patients whose fractures were cleansed with cooled boiled water developed an infection compared with 7/20 (35%) cleansed with isotonic saline (RR 0.83, 95% CI 0.37 to 1.87) (Analysis 3.1) (Museru 1989).

(d) Water (distilled water and/or cooled boiled water) with normal saline
Primary outcome (infection)

When the results for the distilled and cooled boiled water were pooled and compared with isotonic saline, there was no statistically significant difference in the number of infections (RR 0.65, 95% CI 0.31 to 1.37) (Analysis 3.1). However this comparison was severely under-powered (86 participants, 22 infections) (Museru 1989).

Secondary outcomes

No secondary outcomes were reported for any of the comparisons.

4. Comparison of tap water with cooled boiled tap water

No trials were identified that made these comparisons.

5. Comparison of tap water with procaine spirit

Procaine spirit is a preparation of procaine HCL 2% with spirit 70%, that is commonly prescribed as a wound cleansing agent following surgery. One trial compared the use of procaine spirit with tap water for washing postoperative wounds (Tay 1999). Women who had undergone a normal vaginal delivery with an episiotomy were randomised to have the incision site cleaned with either tap water or procaine spirit.

Primary outcomes

The authors reported that there were no statistically significant differences in the number of infections. As actual data were unavailable the analysis could not be replicated.

Secondary outcomes

No statistically significant difference in wound complications was reported and by the 14th day all the wounds had healed well.

Another outcome reported was pain, and the findings indicated that there were no statistically significant differences in pain scores between women cleansing with procaine and tap water.

Quality of the tap water

Two trials reported on the quality of the water used. Griffiths 2001 reported that the quality of the tap water met the requirements of the Australian National Health and Medical Research Council and Angeras 1992 undertook microbiological cultures of samples of the water used and reported that the bacterial counts were fewer than 5 bacteria/ml except in two instances, when gram negative rods 103/ml and antheroid rods 106/ml were isolated. However none of the bacteria isolated from the tap water were identified in the cultures taken from the wound.

Discussion

This systematic review of the effectiveness of water for wound cleansing has summarised the best available evidence at the time of the report. Following an extensive literature search, we identified 11 trials that met the inclusion criteria and we have presented them in this review. With the exception of one trial (Angeras 1992), there was no evidence of a benefit of cleansing, nor of any particular type of cleansing solution. However the trial by Angeras 1992 has some methodological flaws; for example the solutions were administered at different temperatures, therefore the evidence needs to be interpreted with caution and more rigorous research is needed. Furthermore the Angeras trial was conducted in Sweden, where high-quality drinking water is readily available. The use of tap water as a cleanser would not be recommended in a country where a constant supply of potable drinking water is not available.

The fundamental feature of RCTs is the ability to eliminate selection bias through the method of allocation. In three of the included trials, details of the method of randomisation of patients to treatment groups were absent (Museru 1989; Neues 2000; Godinez 2002) and in six the methods were susceptible to selection bias (Goldberg 1981; Angeras 1992; Tay 1999; Riederer 1997; Neues 2000; Valente 2003), which reduces the strength of the evidence. The ability to extract definitive conclusions from the trials detailed in this review is reduced by the overall poor quality of the trials and the lack of replication of most comparisons. Although three trials (Goldberg 1981; Museru 1989; Angeras 1992) were completed before the CONSORT guidelines were published (Begg 1996) when recommendations for trial reporting were formalised, the trial by Angeras 1992 was well reported.

It is essential that the eligibility criteria are well defined in order to understand the type of population treated. The eligibility criteria should also define the severity of the patients eligible to participate. For example the description of the type of wound should accord with a standard criteria. This would allow the findings and recommendations to be generalised to other clinical settings.

Data analysis regarding wound infection was complicated by a lack of consistency in the criteria used to assess wound infection. In addition, variance data for the healing outcomes were not reported in the study that compared tap water with procaine spirit (Tay 1999). The use of a standardised and validated tool for the measurement of wound infection and healing and an assessor blinded to the intervention would have enhanced the rigour of the trials and strengthened the evidence. Other outcomes such as patient comfort and satisfaction should be measured.

Meta-analysis was restricted to trials of the same intervention that assessed the same outcome and was consequently limited by the lack of replication studies. As a result, this report is mainly in the narrative form with figures utilised to highlight particular findings.

The lack of an apparent effect of cleansing on the infection and healing rates in wounds that were not cleansed and those that were cleansed with either tap water or other solutions is important for the clinicians and the health services. The current practice in wound management is to cleanse the wound while showering the patient and in many instances these patients include those who are bedfast (AWMA Inc 2002). In this review although all trials used some type of water, only three trials (Goldberg 1981; Riederer 1997; Neues 2000) used showering as a method to cleanse wounds. While the findings of this review do not indicate adverse effects from the use of tap water, practitioners and health service managers should interpret the findings with caution as most of the comparisons were based on single trials, some of which do not report the methodology in sufficient detail to enable assessment of quality.

The availability and cost of resources may also determine which solution is used for cleansing wounds in different settings. One trial reported that in countries with limited resources, distilled or boiled water is used for wound cleansing without complications.

Prospective trials in this subject need to be more robust in order to assist clinicians and policy makers in making informed decisions about the appropriate use of solutions for cleansing wounds.

Limitations of the review

Inadequate reporting of the trials made it difficult for the authors to critically appraise the validity of the trials. Although we attempted made to contact the authors to obtain additional data, we received no response and this lack of information is reflected in the report.

Authors' conclusions

Implications for practice

Tap water is a wound cleansing agent commonly used in the community and hospitals; however published data on patient outcomes from tap water cleansing have not previously been reviewed. Based on the randomised trials undertaken to date, evidence suggests that tap water is unlikely to be harmful if used for wound cleansing. The decision to use tap water to cleanse wounds should take into account the quality of water, nature of wounds and the patient's general condition, including the presence of comorbid conditions.

This update includes two trials undertaken in patients with acute lacerations which, together with the trial included in the previous review, demonstrate no reduction in the infection rates in wounds that were cleansed using tap water compared with those cleansed with normal saline. There is evidence that the use of tap water is cost-effective when it is undertaken as part of the patient's personal hygiene, as it limits the use of other equipment. The meta-analysis indicated no significant difference in the infection and healing rates in postoperative wounds that were cleansed with tap water (showered) and those that were not cleansed. Clinicians should consider the relative benefits of cleansing clean surgical wounds.

Implications for research

Properly designed multicentre trials are needed to compare the clinical benefits and cost effectiveness of different solutions for wound cleansing in different groups of patients, different types of wounds and in a wide range of settings.

Trials comparing cleansing with no cleansing are required to determine the extent to which cleansing contributes to the healing and infection of acute and chronic wounds.

The strongest evidence for whether tap water is an effective wound cleansing solution is likely to be provided by trials in which the volume and the temperature of the comparison solution are the same as the tap water.

Future research should have well defined inclusion and exclusion criteria, adequate sample size, methods to ensure baseline comparability of the groups, use of true randomisation with allocation concealment, use of an objective outcome measurement of wound infection and healing (e.g. percentage and absolute change in wound area), blinded outcome assessment, adequate follow-up period and appropriate statistical analysis.

The trials should be reported according to the guidelines set out in the CONSORT statement (Begg 1996) to enable readers to determine the validity and reliability of the results.

Given the purchasing costs of equipment, economic evaluations should be undertaken in future trials.

Acknowledgements

We are grateful to the Nursing Director of the South Western Sydney Area Health Service (Australia) for funding this review. In addition we would like to acknowledge the assistance of the librarians and library staff of the Liverpool Health Service library for their assistance with the development of the search strategy and the timely retrieval of articles for the first version of this review; Rachel Langdon and Soufiane Bofous for their assistance with the statistical analysis; Venita Devi for secretarial support; Jeff Rowland, Brenda Ramstadius and Annette Hodgkinson for reading drafts and commenting on the clinical and policy perspective of the review. Thanks to Associate Professor Rosemary Chester for her support throughout the project and to Adrian Bauman, Bin Jalaludin, Maureen McIlwrath, Claire Matthews and Jenny Morris who peer reviewed the review for methodological rigour, readability and clinical relevance. We also acknowledge the assistance of Heidi Otten and Dr Hashi with interpretation of studies in German. We would like to thank Cheryl Ussia, a community nurse who identified the need for a systematic review as a basis for the development of evidence-based practice guidelines for community nurses. Cheryl was seconded to work with the review team as a clinical expert in wound care and was responsible for organising the retrieval of papers and obtaining data on unpublished studies for the initial version of this review. Thanks also to Joanne Cummings who assisted with retrieving the publications for the third update.

The authors would like to thank Cochrane Wounds Group referees (Brian Gilchrist, Carol Dealey, Fuijan Song, Ruth Lewis, Mary Harrison, Raj Mani, Seokyung Hahn) and Editors (Nicky Cullum, Mieke Flour) for their comments to improve the review. In addition the authors would like to thank Ruth Foxlee (Trials Search Co-ordinator) for updating the search strategy and running the searches for this update, Sally Bell-Syer (Managing Editor) for checking the manuscript, editorial advice and general copy editing and Sally Stapley for support during the third update. The authors would also like to thank Nancy Owens for copy editing the latest updated version of the review.

Data and analyses

Download statistical data

Comparison 1. Tap water versus no cleansing
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Infection3873Risk Ratio (M-H, Fixed, 95% CI)1.06 [0.07, 16.50]
2 2. Wounds not healed2772Risk Ratio (M-H, Fixed, 95% CI)1.26 [0.18, 8.66]
Analysis 1.1.

Comparison 1 Tap water versus no cleansing, Outcome 1 Infection.

Analysis 1.2.

Comparison 1 Tap water versus no cleansing, Outcome 2 2. Wounds not healed.

Comparison 2. Tap water versus normal saline
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Infection (acute wounds only)5 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
1.1 Adults31328Risk Ratio (M-H, Fixed, 95% CI)0.66 [0.42, 1.04]
1.2 Children2535Risk Ratio (M-H, Fixed, 95% CI)1.07 [0.43, 2.64]
2 Infection (chronic wounds only)149Risk Ratio (M-H, Fixed, 95% CI)0.16 [0.01, 2.96]
3 Healing1 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
Analysis 2.1.

Comparison 2 Tap water versus normal saline, Outcome 1 Infection (acute wounds only).

Analysis 2.2.

Comparison 2 Tap water versus normal saline, Outcome 2 Infection (chronic wounds only).

Analysis 2.3.

Comparison 2 Tap water versus normal saline, Outcome 3 Healing.

Comparison 3. Water (distilled water and/or cool boiled water ) versus normal saline
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 1. Infection1 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
1.1 Distilled water versus cool boiled water1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
1.2 Distilled water versus isotonic saline1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
1.3 Cool boiled water versus isotonic saline1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
1.4 Water (distilled and boiled ) vs isotonic saline1 Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]
Analysis 3.1.

Comparison 3 Water (distilled water and/or cool boiled water ) versus normal saline, Outcome 1 1. Infection.

Appendices

Appendix 1. Search methods for the third update - 2010

For this third update we searched the following databases:

  • Cochrane Wounds Group Specialised Register (Searched 22/2/10)

  • The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010 Issue 1);

  • Ovid MEDLINE - 2007 to February Week 2 2010;

  • Ovid MEDLINE - In-Process & Other Non-Indexed Citations (Searched 19/2/10);

  • Ovid EMBASE - 2007 to 2010 Week 06;

  • EBSCO CINAHL - 2007 to February 22 2010.

We used the following search strategy to search CENTRAL:
#1 MeSH descriptor Wounds and Injuries explode all trees
#2 MeSH descriptor Skin Ulcer explode all trees
#3 MeSH descriptor Diabetic Foot explode all trees
#4 ("wound" or "wounds" or "ulcer" or "ulcers" or "bite" or "bites" or "abrasion" or "abrasions" or "laceration" or "lacerations" or "diabetic foot" or "diabetic feet"):ti,ab,kw
#5 (#1 OR #2 OR #3 OR #4)
#6 MeSH descriptor Water explode all trees
#7 "water":ti,ab,kw
#8 (#6 OR #7)
#9 (clean* or wash* or irrigat* or shower* or bath* or rins*):ti,ab,kw
#10 (#5 AND #8 AND #9)

We have provided the search strategies for Ovid MEDLINE, Ovid EMBASE and EBSCO CINAHL in; Appendix 2, Appendix 3 and Appendix 4 respectively. We combined the Ovid MEDLINE search with the Cochrane Highly Sensitive Search Strategy for identifying randomised trials in MEDLINE: sensitivity- and precision-maximising version (2008 revision). We combined the Ovid EMBASE and EBSCO CINAHL searches with the trial filters developed by the Scottish Intercollegiate Guidelines Network. There were no restrictions on the basis of date or language of publication.

Appendix 2. Search strategy Ovid MEDLINE

1 exp "Wounds and Injuries"/
2 exp Skin Ulcer/
3 (wound*1 or ulcer*1 or laceration*1 or bite*1 or abrasion* or tear*1 or diabetic foot or diabetic feet).ti,ab,hw.
4 or/1-3
5 exp Water/
6 water.ti,ab,hw.
7 or/5-6 (458407)
8 (clean* or wash* or irrigat* or shower* or bath* or rins*).ti,ab,hw.
9 and/4,7-8

Appendix 3. Search strategy Ovid EMBASE

1 exp Wound/
2 exp Skin Ulcer/
3 (wound*1 or ulcer*1 or laceration*1 or bite*1 or abrasion* or tear*1 or diabetic foot or diabetic feet).ti,ab,hw.
4 or/1-3
5 exp Water/
6 water.ti,ab,hw.
7 or/5-6
8 (clean* or wash* or irrigat* or shower* or bath* or rins*).ti,ab,hw.
9 and/4,7-8

Appendix 4. Search strategy EBSCO CINAHL

S9 S4 and S7 and S8
S8 TI (clean* or wash* or irrigat* or shower* or bath* or rins*) or AB (clean* or wash* or irrigat* or shower* or bath* or rins*)
S7 S5 or S6
S6 TI water or AB water
S5 (MH "Water+")
S4 S1 or S2 or S3
S3 TI (wound* or ulcer* or laceration* or bite* or abrasion* or tear* or diabetic foot or diabetic feet) or AB (wound* or ulcer* or laceration* or bite* or abrasion* or tear* or diabetic foot or diabetic feet)
S2 (MH "Skin Ulcer+")
S1 (MH "Wounds and Injuries+")

Feedback

Data and Conclusions

Summary

The abstract data needs correcting. The first OR given is not the OR it is the RR. The second estimate is also confused as the RevMan graph on this occasion is set to RR and the figures are different. The last estimate in the abstract doesn't seem to connect to anything, or maybe the first comparison in the relevant graph. The conclusions about the quality of tap water are not conclusions from the data provided.

Reply

We have replied to each of the points raised as follows:
1. The first OR given is not the OR it is the RR.
Author's reply: This was amended when the review was updated and RR is now used.
2. The second estimate is also confused as the RevMan graph on this occasion is set to RR and the figures are different.
Author's reply: This was amended when the review was updated. RR is now used and the figures are now consistent between abstract and graph.
3. The last estimate in the abstract doesn't seem to connect to anything, or maybe the first comparison in the relevant graph.
Author's reply: This estimate was quoted in error. The correct estimate has now been inserted.
4. The conclusions about the quality of tap water are not conclusions from the data provided.
Author's reply: The conclusions of the review have been amended in the light of this comment.

Contributors

Feedback received: Professor Paul Garner, International Health Research Group, Liverpool School of Tropical Medicine.
Responses: Author, Ritin Fernandez.

Data queries, 26 May 2008

Summary

I have two comprehension questions concerning the review Water for wound cleansing 2008, Issue 1.

  1. Under description of studies/intervention: Doesn`t it mean Ten of the eleven studies instead of eight of the nine?

  2. Under results/3. Comparison of water (...) with normal saline/ (A): Are it nine out of 31 patients (29%) in the distilled water group and 6/35 (17%) in the cooled boiled water group who developed a wound infection or vice versa like described in paragraph (B) and (C) respectively?

Reply

Thanks for bringing the correction to my attention. Please note the following changes which have been made to the text of the review:

  1. Ten of the eleven studies is correct

  2. Comparison 3: (A) Distilled water compared with cooled boiled water (Analysis 03, Outcome 01)

Primary outcome (Infection)
Six out of 35 patients (17%) in the distilled water group and 9/31(29%) in the cooled boiled water group developed a wound infection; this difference was not statistically significant. (RR 1.69, 95% CI 0.68 to 4.22). The small number of wounds cleansed using distilled water (n = 35) and cooled boiled water (n = 31) means that the study lacked power to detect clinically important differences (Museru 1989).

Contributors

Feedback received: Sibylle Wenzler, Occupation medical scientist. Freiburgh.
Responses: Author, Ritin Fernandez.

Possible data entry errors, 9 January 2013

Summary

I recently had the opportunity to read your excellent Cochrane review on the topic of tap water for cleansing wounds (2012 update).
As an emergency physician I was particularly interested on the subsection of acute wounds but I seem to have found a possible error in your analysis. The error is likely to be due to accidental data entry while doing the meta-analysis and pertains to the numbers of patients included in the studies done on acute wounds in adults (analysis 2.1 in your review).
The study by Moscati et al had 300 patients in the tap water group and 334 in the saline group, you seem to have got it the other way round. This changes the relative risk to 1.21 (95% CI 0.54-2.71). This figure is in agreement with Moscati's own paper where he has calculated this (see page 406, 3rd para in his paper).
Another minor error is the number of patients in the saline group of Angeras' trial, he had 322, not 332 patients in that group. This of course does not change the relative risk of the individual study significantly.
When corrected, this changes the overall risk ratio for adults to 0.67 (95%CI 0.43-1.06), I used M-H fixed effects model for the calculation. It also increases the chi square to 3.48 and the I square to 43%. Put together, this would change the results significantly and the overall conclusion.

Reply

Thank you for bringing the data entry errors to my attention. I have corrected the errors in both the Moscati and Angeras trial and have adjusted the text and conclusions. Please note that the new calculation by RevMan produced a RR = 0.66, 95% CI 0.42 to 1.04; P = 0.16, I2 = 45%, Chi2 = 3.66

Contributors

Feedback received: Dr. Arun George, Registrar in Emergency Medicine, Broomfield Hospital, Chelmsford, Essex, UK
Responses: Author, Ritin Fernandez.

What's new

DateEventDescription
11 January 2013Feedback has been incorporatedFeedback received 10 January 2013. Data entry errors have been corrected and the conclusions of the review have been amended.

History

Protocol first published: Issue 4, 2000
Review first published: Issue 4, 2002

DateEventDescription
5 January 2012New citation required but conclusions have not changedFourth update.
5 January 2012New search has been performedWe carried out new searches in November 2011. We identified no new studies for inclusion.
18 March 2010New search has been performedFor this third update we carried out new searches in February 2010. We identified no new studies for inclusion. We assigned four studies in awaiting assessment as either duplicate publications of an included trial or as excluded from the review.
13 May 2009AmendedContact details updated.
18 June 2008AmendedConverted to new review format.
18 June 2008Feedback has been incorporatedFeedback queries received and answered
2 November 2007New citation required and conclusions have changedSubstantive amendment. For this second update, new searches were carried out in November 2007. Four studies were identified, of which 2 (Godinez 2002; Moscati 2007) were included and two studies were excluded.
18 June 2004New search has been performedFor the first update new searches were carried out in June 2004. Five studies were identified, of which 3 (Bansal 2002; Goldberg 1981; Valente 2003) were included and 2 were excluded.

Contributions of authors

Both authors designed the review.
Ritin Fernandez co-ordinated the review. In addition she was responsible for writing to study authors for additional information, data management and data entry into RevMan.
Ritin Fernandez and Rhonda Griffiths undertook data collection, developed the search strategy, searched the literature, screened search results, retrieved papers, appraised trial quality, analysed and interpreted data and wrote the review.
Funding for the review was obtained by Rhonda Griffiths from the South Western Sydney Area Health Service.

Contributions of editorial base:

Nicky Cullum: edited the review, advised on methodology, interpretation and review content. Approved the final review and review update prior to submission.
Sally Bell-Syer: coordinated the editorial process. Advised on methodology, interpretation and content. Edited the review and the updated review.
Ruth Foxlee: designed the search strategy, ran the searches and edited the search methods section for the update.

Declarations of interest

The authors of the review conducted one of the trials included in the review, however the authors did not receive from any commercial entity any payments or pecuniary, in-kind or other professional or personal benefits that were related in any way to the subject of the work. This trial was also subject to the same rigorous quality assessment as other trials included in the review.

Sources of support

Internal sources

  • University of Western Sydney Macarthur, Australia.

  • South Western Sydney Area Health Service, Australia.

External sources

  • NIHR/Department of Health (England), (Cochrane Wounds Group), UK.

Differences between protocol and review

The published protocol was titled: 'Normal saline vs tap water for wound cleansing'. This has been changed at the review stage to: 'Water for wound cleansing' to reflect the different types of water used in the studies.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Angeras 1992

MethodsQuasi-randomised controlled trial (allocation by alternation).
Baseline characteristics comparable.
Participants705 patients with soft tissue wounds less than 6 hours old, requiring sutures.
Exclusion criteria:
wounds that had connection with the thoracic cavity, abdominal cavity or the joints.
Interventions1) Wounds irrigated with tap water (n = 295).
2) Wounds irrigated with sterile normal saline (n = 322).
Outcomes1) Wound infection (defined as pus visible in the wound and prolonged healing time as judged by the nurse).
Notes88 patients evenly distributed between the two groups were lost to follow up. Follow up was undertaken 1 to 2 weeks after wound closure. Bacterial cultures taken every week from the tap water. Temperature of the tap water was 37 degrees C while the saline was delivered at room temperature.
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment (selection bias)High riskInadequate

Bansal 2002

MethodsRandomised controlled trial.
Allocation using randomisation schedule.
Baseline characteristics comparable.
Participants46 children with simple lacerations.
Interventions1) Cleansing with tap water (n = 21).
2) Cleansing with saline (n = 24).
OutcomesWound infection - criteria for wound complications (one or more of the following).
1. Cellulitis or erythema of the wound margin of more than 4 mm with tenderness.
2. Purulent discharge from the wound.
3. Ascending lymphangitis.
4. Dehiscence of the wound with wound separation of > 2mm.
NotesPerson performing the wound irrigation was blinded to the solution used. Wound irrigated with 35 ml syringe attached to an irrigation shield ( 25-40 psi).
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment (selection bias)Low riskAdequate, allocation using randomisation schedule.

Godinez 2002

MethodsRandomised controlled trial.
Method of allocation not stated.
Baseline comparability not stated.
Participants94 participants with minor extremity lacerations.
Interventions1) Irrigation with tap water (n = 36).
2) Irrigation with saline (n = 41).
Outcomes1) Wound infection.
NotesWounds were irrigated with tap water at a flow rate of 7 litres/minute. Saline was poured in a basin and aspirated using a syringe and irrigation was done using a pulsatile motion.
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment (selection bias)Unclear riskUnclear

Goldberg 1981

MethodsQuasi randomised controlled trial.
Method of allocation by alternation. Consecutive patients allocated to each group.
Does not state if the assessor was blinded.
Participants200 patients with lacerations or incisions who were operated.
Interventions1) Patients allowed to rinse all over with soap and water after 24 hours (n = 100).
2) Patients kept their wounds dry (n = 100).
Outcomes1) Wound infection.
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment (selection bias)High riskMethod of allocation by alternation. Consecutive patients allocated to each group.

Griffiths 2001

MethodsRandomised controlled trial.
Allocation was by a list of random numbers nominated by person not entering patients into the trial (closed list).
Both patients and outcome assessors were blinded to the treatment.
Baseline characteristics comparable.
Participants35 patients with 49 chronic wounds.
Exclusion criteria:
Grade 1 & 4 wounds, patients receiving antibiotics or who were immuno suppressed due to therapy, and wounds with a sinus where the base was not visible.
Interventions1) Wounds irrigated with tap water (n = 23).
2) Wounds irrigated with normal saline (n = 26).
Outcomes1) Wound infection (defined as presence of pus, discolouration, friable granulation tissue, pain tenderness, pocketing or bridging at base of the wound, abnormal smell and wound breakdown).
2) Number of wounds that healed.
3) Cost effectiveness.
4) Patient satisfaction.
5) Variance in wound size.
Notes4 patients in each group withdrew from the study.
Wounds were assessed at the end of 6 weeks. Quality of tap water reported to meet Australian National Health and Medical Research Council requirements.
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment (selection bias)Low riskAdequate - allocation was by a list of random numbers nominated by person not entering patients into the trial (closed list).

Moscati 2007

MethodsRandomised controlled trial.
Allocation using computer based random numbers generator.
Baseline comparability between groups not stated.
Person performing the assessment was blinded to the solution used.
Participants715 subjects with uncomplicated skin lacerations requiring staple or suture repair.
Interventions1) Irrigation with tap water (n = 300).
2) Irrigation with minimum 200 mls of sterile saline (n = 334).
Irrigation with tap water undertaken by patient while irrigation with sterile saline was undertaken by the provider. Wounds were irrigated with a 35 ml syringe using a splash guard.
Outcomes1) Wound infection
(defined as wounds that required a significant change in their course of treatment such as surgical debridement, antibiotics or early removal of sutures).
2) Costs.
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment (selection bias)Low riskAdequate - allocation using computer based random numbers generator

Museru 1989

MethodsRandomised controlled trial.
No information on the method of randomisation.
Blinding not mentioned. No loss to follow up.
Baseline characteristics of patient not stated however baseline description of wounds comparable.
Participants86 patients with open fractures. No exclusion criteria stated.
Interventions1) Wounds irrigated with distilled water (n = 35).
2) Wounds irrigated with boiled water (n = 31).
3) Wounds irrigated with isotonic saline (n = 20).
Outcomes1) Wound infections (no definition for wound infection).
2) Chronic osteomyelitis.
3) Tetanus.
4) Gangrene.
NotesLength of follow up not stated.
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment (selection bias)Unclear riskUnclear

Neues 2000

MethodsQuasi-randomised controlled trial (allocation by the month).
Blinding not mentioned.
Both groups comparable for age however comparability for gender not stated.
Participants817 patients having surgery for varicose veins. Exclusion criteria not specified.
Interventions1) Wounds showered on day two (water only) (n = 274).
2) Wounds showered on day two (water + shower gel) (n = 268).
3) Wounds kept dry for 8 to 10 days (not cleansed) (n = 302).
Outcomes1) Wound infections (not defined).
Notes94 patients in the non showered group, 130 in the group that used only water and 40 patients in the group that used water and shower gel were lost to follow up.
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment (selection bias)High riskInadequate - allocation by the month

Riederer 1997

MethodsQuasi-randomised controlled trial (allocation by alternation).
Blinding not mentioned.
Patient demographics not stated.
Participants121 patients having surgery for inguinal hernia.
Exclusion criteria not stated.
Interventions1) Wounds showered on day one (n = 49).
2) Wounds kept dry for 14 days (not cleansed) (n = 52).
Outcomes1) Wound infection (defined as irritation, slight redness of skin and stitch abscess).
2) Patient satisfaction.
NotesWounds assessed after 14 days.
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment (selection bias)High riskInadequate - allocation by alternation

Tay 1999

MethodsQuasi-randomised controlled trial (allocation by the month).
Blinding of outcome assessors not mentioned.
Participants in both groups comparable for age, parity, educational level and duration of first and second stage of labour.
Participants100 women having an episiotomy for a normal vaginal delivery.
No loss to follow up.
No exclusion criteria specified.
Interventions1) Perineal toilet using water and procaine spirit (n = 50).
2) Perineal toilet using water only (n = 50).
Outcomes1) Wound infection (not defined).
2) Wound healing (assessed for the degree of edema, bruising, erythema, wound union and wound discharge with a score of 0-2 for each parameter).
3) Pain score assessed using a verbal analogue scale between 0-10.
NotesWounds assessed on day 14.
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment (selection bias)High riskInadequate - allocation by the month

Valente 2003

MethodsQuasi randomised controlled trial.
Method of allocation was by alternation.
Participants530 children with simple lacerations.
Interventions1) Cleansing with tap water (n = 259).
2) Cleansing with saline (n = 271).
Wounds assigned to the normal saline group were irrigated using a 30-60 ml syringe and a 18G angiocatheter or splash guard. Wounds assigned to the tap water group were irrigated under running tap water for 10 seconds.
OutcomesWound infection.
Criteria for wound infection not stated.
NotesTap water pressure and flow rates were measured prior to the study.
Risk of bias
BiasAuthors' judgementSupport for judgement
Allocation concealment (selection bias)High riskInadequate - method of allocation was by alternation

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Bansal 1993This study compared the effects of topical phenytoin powder and normal saline on the healing of trophic leprosy ulcers.
Bulstrode 1988This study compared the addition of dilute and concentrated amino acids to saline on the rate of healing of chronic leg ulcers.
Burke 1998Study was excluded because the intervention was combined with saline dressings and whirlpool therapy (water). It is therefore not possible to attribute any effect to whirlpool therapy (water).
Chisholm 1992This study compared two devices used for irrigation of wounds. Irrigating solution used with both devices was normal saline.
Fraser 1976The purpose of the trial was not to assess the cleansing of the wound.
Greenway 1999Study excluded because it evaluates the effect of insulin and normal saline on the healing rate of wounds.
Johnson 1985Study excluded because it compares irrigation of perineal wounds with either 1% povidone-iodine or normal saline.
King 1984Wound cleansing in this study was part of the operative procedure.
Manhold 1976The study compared normal saline and glycoside for irrigation during dental procedures.
Medves 1997The study evaluates solution used to cleanse umbilical cord. A systematic review focusing on umbilical cord care has been undertaken.
Patterson 2005This study used antibacterial soap along with water for cleansing which could influence the findings.
Scondotto 1999This study evaluates the efficacy of sulodexide compared to cleansing with physiological solution and the application of elastic compression on the healing of venous ulcers.
Selim 2000Review.
Selim 2001No data reported.
Svedman 1983Compares two different methods of wound irrigation. Isotonic saline was the irrigant used in both groups.
Sweet 1976Not relevant to the review. This study compares two different devices for the irrigation of third molar surgical sites with high volumes of normal saline.
Voorhees 1982The purpose of the trial was not to assess the cleansing of the wound.
Weiss 2007Abstract only. The authors were contacted but did not respond, therefore there was insufficient information to include the trial in the update.

Ancillary