Do dressings prevent infection of closed primary wounds after surgery?
BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2270 (Published 24 May 2016) Cite this as: BMJ 2016;353:i2270
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We thank Professor Heal for drawing attention to her well designed and conducted pragmatic trial. It examined the effectiveness in terms of surgical site infection (SSI) of keeping primary surgical wounds dry with a simple dressing for 48 hours, or, covering them with a dressing that was removed within 12 hours. In the latter group patients were allowed to bathe and wet the wound after early dressing removal. This trial, therefore, was not included in our review because both groups had early application of a dressing. Our review focused on trials comparing the immediate postoperative application of wound dressings with no wound dressing at all.
It is interesting to note that the Heal trial reported no untoward effects related to early dressing removal. We think that this and findings from our review support the need for a definitive trial that asks the question of whether dressings are needed at all.
Competing interests: No competing interests
Blazeby has correctly identified the dearth of evidence in support of dressings to minimise post-operative infection following closed primary wounds for surgery. However, there are many intended uses for dressings, other than prevention of surgical site infection, such as comfort, compressive support and reduction in anxiety.
Plastic surgery is perhaps uniquely placed to comment on these other intended consequences of a dressing due to the variety of operations, the anatomical location, the age range and gender of patients. For instance, when a pinnaplasty is performed for prominent ear correction, the intended benefits of a head bandage may be to reduce infection, minimise haematoma formation, improve comfort and reduce the long-term lateral ear projection. However, provided the result is good at the end of the surgical procedure, there is reasonable evidence to suggest that head bandages have no effect any of these complications or patient outcome scores. Indeed, there is very little evidence to support the use of dressings after 24 hours post-operatively (Norris, et al. 2012). The physical drawback of a dressing may actually outweigh any benefit. Following an open reduction and internal fixation with implanted metal-work to a closed metacarpal fracture, a bulky dressing may be applied to aid comfort (such as reducing the impact when knocking the affected area), whilst allowing early mobilisation without loading the hand in order to reduce stiffness. There is little evidence for this beyond anecdotal expert opinion. On the other hand, when implant-based breast augmentation or reconstruction is performed, the use of an adhesive film dressing as a “nipple-shield” to the nipple-areolar complex intra-operatively until the wound has been closed and covered has been shown to prevent bacteria harbouring in the mammary ducts from contaminating the operative field and the underlying implant (Collis, et al. 1999).
With such a lack of evidence for dressings to be used to cover closed primary surgical wounds, perhaps a pragmatic approach would be to discuss this with the patient. A simple statement and question such as “There is no evidence for dressings to the wound resulting from your surgery reducing infection, aiding healing or reducing pain/improving comfort. In fact, in operations involving children, it is common place not to use dressings. Would you prefer for your wound to be dressed or not?” may reduce how often we apply dressings to such wounds. Regardless, in an evidence-based healthcare system with limited funding where dressings are used the cheapest dressing should be utilised to achieve the surgeons’ intention for its usage.
References
1. Norris JM, Mabvuure NT, Cumberworth A, Watts SJ. Are head bandages required post-pinnaplasty? International Journal of Surgery. 2012;10(7):330-3
2. Collis N, Mirza S, Stanley PR, Campbell L, Sharpe DT. Reduction of potential contamination of breast implants by the use of 'nipple shields'. British Journal of Plastic Surgery. 1999 Sep;52(6):445-7
Competing interests: No competing interests
We , as a large community of physicians , have a long experience of treating surgical - sites , yet long for a clear solution. Medical devices - specifically implants, put up anywhere in a human - body pose a threat for infection , as that may provide a nidus for the bacterial - growth. This aspect , combined with poor understanding of the theory of microbial - contamination of surgical - sites to a patient due to illiteracy ( 1) , combined with overcrowding in medical - wards in public hospitals in general , and in Metros specifically ( 2 ) , and presence of numerous relatives at bedside , who ostensibly pose as well wishers of the patient , as well as sultry weather conditions get together to create an environment that increases risk of local infection.
In Cardiology Department , where 2 of us work , we regularly put pacemaker - implants to poor patients. It's our routine practice to regularly put dressing , preferably transparent one , as shown in image C of the figure 1 of the Practice article , and also prescribe one full course of an antibiotic to the recipients to prevent superinfection of the surgical - site , as that may be quite resistant to treat in the presence of the foreign - body ( the implant ) . Our colleagues in Orthopaedics department , who also regularly put implants , too adopt similar practice.
References -
( 1 ) School system fails students , The Hindu , Jan 19 , 2015 , available at http://www.thehindu.com/opinion/editorial/school-system-fails-students/a...
( 2 ) Haydon ME , To be poor and sick in India , in New York Times , Mar 31 , 2014 , available at http://india.blogs.nytimes.com/2014/03/31/to-be-poor-and-sick-in-india/
Both the webpages are accessed at the time of submission of this rapid response.
Competing interests: No competing interests
Dear Authors
We published a prospective randomised controlled trial 10 years ago which examined the effects of uncovering and wetting wounds healing by primary intention in the first 48hrs after skin cancer surgery, compared with the conventional treatment of covering and keeping wounds dry and covered for the first 48hrs. We had decided that methodologically we could not separate uncovering and wetting, so we measured the two factors together
A total of 857 patients were randomised to either keep their wound dry and covered (n = 442) or remove the dressing and wet the wound (n = 415). Our findings were that the incidence of infection in the intervention group (8.4%) was not inferior to the incidence in the control group (8.9%) (P < 0.05), and our conclusion was that wounds could be both uncovered and allowed to get wet in the first 48 hours after minor skin excision without increasing the incidence of infection.
I don't think this study has been cited in your review, possibly because it took place in primary care, but I think these results are important to inform your current systematic review and recommendations.
www.bmj.com/content/332/7549/1053
Competing interests: No competing interests
In General Practice, we too have questioned the value of applying dressings to wounds.
Reviewing the literature, we found the repeated phrase “moist wound care is the cornerstone of modern wound management”(1). This is also frequently written on over-the -counter proprietary dressings, leaving us wondering at the origins of this statement.
Tracking through several decades of guidelines revealed that it could be traced back to one paper published in Nature in 1962 by George Winter (2). Large surgical wounds were made on the backs of two pigs and one half covered with polythene film. The other half left uncovered. Biopsies at 3 days indicated that microscopic cell migration was twice the rate in the covered wounds compared to the uncovered wounds. In reporting his observations, Winter wondered if covering wounds and preventing scab formation might aid healing. What is, however, not mentioned when this article is referenced by wound companies and guideline committees is that at 7 days and 11 days there was no difference in the healing rates of the two groups.
Hinman repeated the study in 1963 (3) using the forearm of prisoners and produced similar findings.
We have observed that sunlight appears to help dry the wound allowing a natural dressing, the scab, to form. Sunlight warms the skin, reducing pain and increasing blood flow. Sunlight was the mainstay of treatment prior to the commercialization of wound care (4). As mentioned by the Bluebelle group(5), leaving wounds exposed reduces the number of dressings and the need for wound care nurses to visit every few days to change dressings. A process that is often uncomfortable for patients and offers opportunity for the introduction of infection. Encouraging patients to put their wounds in the sun has the benefit of also encouraging elevation.
Might we propose that modern wound care should be initially guided by R.E.S.T
Rest, Elevation Sunshine and Time.
References
1. Jones V, Grey JE, Harding KG. Wound dressings. BMJ. 2006;332(7544):777-80.
2. Winter GD. Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig. Nature. 1962;193:293-4.
3. Hinman CD, Maibach H. Effect of Air Exposure and Occlusion on Experimental Human Skin Wounds. Nature. 1963;200:377-8.
4. Clendening DL. Beneficial affects of sunlight. Elmira Star Gazette. 1938;Sect. Diet and Health.
5. Blazeby J, Bluebelle Study G. Do dressings prevent infection of closed primary wounds after surgery? BMJ. 2016;353:i2270.
Competing interests: No competing interests
Sir
As a Consultant Surgeon off more than 30 years in a district general hospital I have carried out approximately 25,000 operations and have never used dressings for closed surgical wounds. I would not say that I never had wound infections but can say that I had the lowest rate of wound infection in the hospital. The only research on wound infection in which I took part was a comparison of a new cephalosporin against my standard antibiotic prophylaxis in bowel surgery which was gentamicin and metronidazole. Both groups received one pre operative dose preop and a second eight hours postoperatively if there had been an anastomois or nothing further if a colostomy was performed. There was no significant difference between the two groups as there was only one wound infection in 24 cases. None of the wounds were dressed.
Since retiring I have been the doctor for our local rugby club and have sutured many cuts for the players. The wounds were often muddy and they were either sewed up on the side of the pitch or in the physio room.. Neither environment could be considered as hygienic. Apart from a smear of Vaseline for those who were going straight back on the pitch no dressings were applied. There has been no significant wound infection.
I understand that you could find no rct to verify the practice of dressings versus no dressings but as extensive routine experience of no dressings has been satisfactory why would I want to carry out a trial. The simplest test of the effects of a dressing is to apply a bandaid to your finger and remove it the next day. Is the skin healthy? It has always been my personal view that the best protection against infection is the normal skin flora and anything that damages that is prejudicial. That includes prolonged antibiotic usage and dressings. The white wrinkly look of the skin under a bandaid even in the absence of a surgical wound is not the normal conditions for our symbiotic helpers of normal skin flora.
Yours
Karl Fortes Mayer FRCS
Competing interests: No competing interests
It appears that there is little evidence of dressings preventing infection of closed primary wounds after surgery. However, we must always look at the bigger picture. One of the reasons for using dressings is that they enhance and therefore speed up wound healing, which has its own benefits beyond simply reducing infection risk.
The cost of dressings must also be taken into account. Obviously, there is a cost in the production of sterile dressings in an accredited process, however the cost of some dressings does make me wonder what magical ingredients must be contained inside what is often a glorified sponge.
Has anyone performed a study comparing a commercial dressing to a sterilised kitchen sponge (or even an unsterilised one)? I do wonder sometimes whether we're being milked by our risk-averse mentality.
Competing interests: No competing interests
Re: Do dressings prevent infection of closed primary wounds after surgery?
Many of the comments here highlight that there is much confusion about the value of moist wound management. When a surgeon sutures a wound, this allows the deeper tissues to stay moist, ensuring that moist wound healing will take place. Moist wound healing decreases the risk of infection by allowing the body's immune cells to migrate freely within the wound bed. It also decreases pain and scarring.
Do dressings prevent infection? That question would be better answered by breaking down the evidence according to wound type and dressing type. In addition, Cochrane reviews have many limitations, most notably publication bias. The findings of researchers who do not take the time to publish their findings in indexed journals are omitted. I recently published a protocol for the use of a unique dressing type (polymeric membrane dressings, or PMDs) that continuously clean wounds. In the article I included several tables of evidence to support the claims that these dressings decrease infection rates. Much of the evidence summarized in these tables came from busy independent clinicians who performed cohort studies which they published only as conference posters (two examples are referenced here). However, there is a growing body of evidence to support the use of PMDs on surgical sites in indexed journals, as well.
Blessings,
Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA
Independent Researcher for Rural Areas of Tropical Developing Countries, and Clinical Research, Education, and Charity Liaison for Ferris Mfg. Corp.
1. Benskin LL. Polymeric Membrane Dressings for Topical Wound Management of Patients With Infected Wounds in a Challenging Environment: A Protocol With 3 Case Examples. Ostomy Wound Manage. 2016;62(6):42-50.
2. Rahman S, Shokri A. Total Knee Arthroplasty (TKA) Infections Eliminated and Rehabilitation Improved Using Polymeric Membrane Dressing Circumferential Wrap Technique: 120 Patients at 12-month Follow-up. May 2013.
3. Haik J, Weissman O, Demetrius S, Tamir J. Polymeric Membrane Dressings* for Skin Graft Donor Sites: 6 Years Experience on 1200 Cases. April 2011.
4. Dabiri G, Damstetter E, Phillips T. Choosing a Wound Dressing Based on Common Wound Characteristics. Advances in Wound Care. 2014;5(1):32-41. doi:10.1089/wound.2014.0586.
Competing interests: I work as an independent nurse researcher and for Ferris Mfg. Corp., makers of PolyMem dressings