Early Versus Delayed Post-Operative Bathing or Showering To Prevent Wound Complications

Cochrane Database of Systematic Reviews
Early versus delayed post-operative bathing or showering to

prevent wound complications (Review)
Toon CD, Sinha S, Davidson BR, Gurusamy KS
Toon CD, Sinha S, Davidson BR, Gurusamy KS.

Early versus delayed post-operative bathing or showering to prevent wound complications.
Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD010075.
DOI: 10.1002/14651858.CD010075.pub3.
www.cochranelibrary.com
Early versus delayed post-operative bathing or showering to prevent wound complications (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . 3
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Analysis 1.1. Comparison 1 Early versus delayed post-operative bathing and showering, Outcome 1 Surgical site infection. 18
Analysis 1.2. Comparison 1 Early versus delayed post-operative bathing and showering, Outcome 2 Surgical site infection
(sensitivity analysis). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 23
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Early versus delayed post-operative bathing or showering to prevent wound complications (Review) i
[Intervention Review]
Early versus delayed post-operative bathing or showering to

prevent wound complications
Clare D Toon1 , Sidhartha Sinha2 , Brian R Davidson3 , Kurinchi Selvan Gurusamy3

1 Public
Health Research Unit, West Sussex County Council, Chichester, UK. 2 St George’s Vascular Institute, St George’s Hospital,
London, UK. 3 Department of Surgery, Royal Free Campus, UCL Medical School, London, UK
Contact address: Kurinchi Selvan Gurusamy, Department of Surgery, Royal Free Campus, UCL Medical School, Pond Street, London,
NW3 2QG, UK. [email protected].
Editorial group: Cochrane Wounds Group.

Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 7, 2015.
Review content assessed as up-to-date: 30 June 2015.
Citation: Toon CD, Sinha S, Davidson BR, Gurusamy KS. Early versus delayed post-operative bathing or shower-
ing to prevent wound complications. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD010075. DOI:
10.1002/14651858.CD010075.pub3.
ABSTRACT
Background
Many people undergo surgical operations during their life-time, which result in surgical wounds. After an operation the incision is
closed using stiches, staples, steri-strips or an adhesive glue. Usually, towards the end of the surgical procedure and before the patient
leaves the operating theatre, the surgeon covers the closed surgical wound using gauze and adhesive tape or an adhesive tape containing
a pad (a wound dressing) that covers the surgical wound. There is currently no guidance about when the wound can be made wet by
post-operative bathing or showering. Early bathing may encourage early mobilisation of the patient, which is good after most types
of operation. Avoiding post-operative bathing or showering for two to three days may result in accumulation of sweat and dirt on the
body. Conversely, early washing of the surgical wound may have an adverse effect on healing, for example by irritating or macerating
the wound, and disturbing the healing environment.
Objectives
To compare the benefits (such as potential improvements to quality of life) and harms (potentially increased wound-related morbidity)
of early post-operative bathing or showering (i.e. within 48 hours after surgery, the period during which epithelialisation of the wound
occurs) compared with delayed post-operative bathing or showering (i.e. no bathing or showering for over 48 hours after surgery) in
patients with closed surgical wounds.
Search methods
We searched The Cochrane Wounds Group Specialised Register (30th June 2015); The Cochrane Central Register of Controlled
Trials (CENTRAL) (The Cochrane Library); The Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); Ovid
MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; the metaRegister of
Controlled Trials (mRCT) and the International Clinical Trials Registry Platform (ICTRP).
Selection criteria
We considered all randomised trials conducted in patients who had undergone any surgical procedure and had surgical closure of their
wounds, irrespective of the location of the wound and whether or not the wound was dressed. We excluded trials if they included
patients with contaminated, dirty or infected wounds and those that included open wounds. We also excluded quasi-randomised trials,
cohort studies and case-control studies.
Early versus delayed post-operative bathing or showering to prevent wound complications (Review) 1
Data collection and analysis
We extracted data on the characteristics of the patients included in the trials, risk of bias in the trials and outcomes from each trial. For
binary outcomes, we calculated the risk ratio (RR) with 95% confidence interval (CI). For continuous variables we planned to calculate
the mean difference (MD), or standardised mean difference (SMD) with 95% CI. For count data outcomes, we planned to calculate
the rate ratio (RaR) with 95% CI. We used RevMan 5 software for performing these calculations.
Main results
Only one trial was identified for inclusion in this review. This trial was at a high risk of bias. This trial included 857 patients undergoing
minor skin excision surgery in the primary care setting. The wounds were sutured after the excision. Patients were randomised to
early post-operative bathing (dressing to be removed after 12 hours and normal bathing resumed) (n = 415) or delayed post-operative
bathing (dressing to be retained for at least 48 hours before removal and resumption of normal bathing) (n = 442). The only outcome
of interest reported in this trial was surgical site infection (SSI). There was no statistically significant difference in the proportion of
patients who developed SSIs between the two groups (857 patients; RR 0.96; 95% CI 0.62 to 1.48). The proportions of patients who
developed SSIs were 8.5% in the early bathing group and 8.8% in the delayed bathing group.
Authors’ conclusions
There is currently no conclusive evidence available from randomised trials regarding the benefits or harms of early versus delayed
post-operative showering or bathing for the prevention of wound complications, as the confidence intervals around the point estimate
are wide, and, therefore, a clinically significant increase or decrease in SSI by early post-operative bathing cannot be ruled out. We
recommend running further randomised controlled trials to compare early versus delayed post-operative showering or bathing.
PLAIN LANGUAGE SUMMARY

Post-operative bathing and showering to prevent wound complications
Many people undergo surgical operations during their life-time. After an operation the surgical wound is closed using stiches, staples,
tape (steri-strips) or an adhesive glue. Usually, towards the end of the surgical procedure and before the person leaves the operating
theatre, the surgeon covers the closed surgical wound using gauze and adhesive tape, or an adhesive tape containing a pad that covers
the surgical wound. This is called a wound dressing. There is currently no guidance about when wounds can be made wet by bathing
or showering post-operatively. Early bathing may encourage the person to move about, which is good after most types of surgery.
Avoiding post-operative bathing or showering for two to three days may result in the accumulation of sweat and dirt on the body, but
early washing of the wound may have a bad effect on healing by irritating the wound and disturbing the healing environment. We
reviewed all the available evidence from the medical literature (up to July 2013) on this issue. In particular, we sought information
from randomised controlled trials, which, if conducted well, provide the most accurate information.
We identified only one randomised controlled trial. This trial was at high risk of bias, i.e. there were flaws in the way it was conducted that
could have given incorrect results.This trial included 857 people undergoing minor skin operations performed at a General Practitioner
(GP) surgery. No steri-strips were used in this trial, as the wounds were stitched. The people running the trial used a method similar
to the toss of a coin to decide which group participants went into. One group of 415 people was advised to remove the dressing 12
hours after surgery and then to bathe normally, while the other group of 442 people was advised to keep the dressing on for at least
48 hours and then to bathe normally. The only outcome of interest reported in this trial was wound infection. The authors reported
no statistically significant difference in the proportion of people who developed wound infection in the two groups (8.5% in the early
bathing group and 8.8% in the delayed bathing group).
There is currently no conclusive evidence available from randomised trials about the benefits, or harms, with regard to wound compli-
cations of early or delayed post-operative showering or bathing. We recommend further randomised controlled trials to compare early
versus delayed post-operative showering or bathing.
Early versus delayed post-operative bathing or showering to prevent wound complications (Review) S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]
Early versus delayed post-operative bathing and showering
Patient or population: patients with closed post-operative incisions

Setting: primary care
Intervention: early post-operative bathing and showering
Control: delayed post-operative bathing and showering
Outcomes Illustrative comparative risks* (95% CI) Relative effect No of Participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)
Assumed risk Corresponding risk
Control (delayed post- Early post-operative

operative bathing and bathing and showering
showering)
Surgical site infection 88 per 1000 85 per 1000 RR 0.96 857 ⊕

(55 to 131) (0.62 to 1.48) (1 study) very low1,2,3,4
*The basis for the assumed risk is the control group risk in the study. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and
the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence

High quality: further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: we are very uncertain about the estimate
1 The trial was of high risk of bias
2 Confidence intervals overlaps 1 and 0.75 or 1.25
3 The total number of events was fewer than 300
4
There were too few trials to assess publication bias
3
BACKGROUND disturbing the healing environment. Exposure to the external en-
vironment may also introduce infection.
Although water-proof dressings are available, and dressings can be
covered by water-proof material, evidence for whether the original
Description of the condition
dressing should be retained, or can be removed within 48 hours of
Many people undergo surgical operations during their life-time. surgery, is not clear and this issue is currently being addressed in
Worldwide, an estimated 234 million surgical procedures are per- another Cochrane systematic review (Toon 2013). However, the
formed each year (Weiser 2008). The world population in 2008 traditional advice has been to cover the wound with a dressing for
was approximately 6.7 billion (PRB 2008). This equates to ap- a period of at least 48 hours, since this is the period during which
proximately one in every 30 people undergoing a surgical opera- epithelialisation of the wound occurs (Lawrence 1998).
tion each year. In most surgical operations, surgeons make a cut
(incision) through the patient’s skin and underlying tissue. After
the operation, the incision is generally closed using stitches, sta- Why it is important to do this review
ples, steri-strips or an adhesive glue, resulting in a closed surgical
wound. Wound dressing is widely used irrespective of the nature of There is currently no guidance regarding when a wound can be
the surgery, the setting (for example, primary or secondary care), made wet by post-operative bathing or showering. Avoiding post-
or the type of patient. operative bathing or showering for two to three days may result
Wounds can be classified in different ways. One accepted clas- in the accumulation of sweat and dirt on the body. If the patient
sification developed by the National Academy of Sciences/Na- wants to bathe or shower before two to three days, based on tra-
tional Research Council (NAS/NRC) and adopted by the Cen- ditional advice, extra precautions are frequently taken to prevent
ters for Disease Prevention and Control (CDC) is to define the the surgical wound from getting wet. This can be inconvenient,
wound as clean, clean-contaminated, contaminated, and dirty or particularly if the wound is on the trunk, rather than the limbs.
infected (Berard 1964; Garner 1986). This classification is shown There has been no previous systematic review assessing the bene-
in Appendix 1. fit of keeping wounds dry by avoiding post-operative bathing or
Towards the end of the surgical procedure, and before the patient showering. This systematic review may provide guidance regard-
leaves the operating theatre, the surgeon usually covers the closed ing when wounds can be made wet by post-operative bathing or
surgical wound using cloth (either gauze and adhesive tape, or an showering.
adhesive tape containing a pad that covers the wound); this is called
a wound dressing. Wound dressings are classified in a number of
ways according to their function (e.g. occlusive, absorbent), type
of material (e.g. hydrocolloid, collagen), and the physical form of OBJECTIVES
the dressing (e.g. ointment, film, foam) (Boateng 2008). To compare the benefits (such as potential improvements to quality
of life) and harms (potentially increased wound-related morbidity)
of early post-operative bathing or showering (i.e. within 48 hours
Description of the intervention after surgery) compared with delayed post-operative bathing or
showering (i.e. no bathing or showering for over 48 hours after
The intervention of interest is post-operative bathing or shower-
surgery) in patients with closed surgical wounds.
ing. This may occur as early as 12 hours post surgery or be delayed
for over a week.
METHODS
How the intervention might work

Post-operative bathing and showering may remove dead skin cells, Criteria for considering studies for this review
dirt, micro-organisms and sweat that has collected around the
wound edges, and so may reduce risk of infection and promote
wound healing. It is also makes the patient more comfortable. Fur- Types of studies
thermore, early showering or bathing may encourage early mobil- We included randomised clinical trials (RCTs) irrespective of
isation of the patient, which prevents development of deep vein blinding, language, publication status or sample size. We excluded
thrombosis and encourages deep breathing, which can prevent quasi-randomised trials (where the methods of allocating partici-
chest infections. Early mobilisation is encouraged after most op- pants to a treatment are not strictly random, e.g. allocation by date
erations. However, early washing of the surgical wound may af- of birth, day of the week, etc.), cohort studies and case-control
fect healing adversely by irritating or macerating the wound and studies.
Types of participants 2. Number of dressing changes.
People who had undergone any surgical procedure and had surgical 3. Number of hospital visits/home visits for dressing changes.
closure of their wounds, irrespective of the location of the wound 4. Number of patients requiring additional antibiotic therapy
and irrespective of whether the wound was dressed. We excluded (i.e. antibiotic treatment prescribed because of infection in
trials that included people with contaminated, dirty or infected addition to the prophylactic antibiotics that the patient receives).
wounds, and those that were left with open wounds (when the
edges of the wounds are not brought close to each other by sutures,
staples, adhesive tapes or tissue glue). Search methods for identification of studies
Types of interventions Electronic searches

We included trials comparing early post-operative bathing or For the first update of this review we searched the following elec-
showering of surgical wounds within 48 hours of surgery (early tronic databases to identify reports of relevant RCTs in June 2015:
group) with no post-operative bathing or showering for at least • The Cochrane Wounds Group Specialised Register
48 hours after surgery (delayed group). The timing of the post- (searched 30th June 2015);
operative bathing or showering was the intervention of interest. • The Cochrane Central Register of Controlled Trials
We considered trials that compared dressed wounds, and also trials (CENTRAL) (The Cochrane Library 2015, Issue 5);
that left the wound undressed, as eligible for inclusion provided • Ovid MEDLINE (2014 to June Week 3 2013);
that the timing of the post-operative bathing or showering differed • Ovid MEDLINE (In-Process & Other Non-Indexed
between the groups. Co-interventions (such as peri-operative an- Citations, June 29, 2015);
tibiotics) were allowed, provided that they were used equally in • Ovid EMBASE (2014 to 2015 June 29);
the intervention groups. • EBSCO CINAHL (2014 to 30 June 2015).
CENTRAL search strategy:
Types of outcome measures
#1 MeSH descriptor Baths explode all trees
All the early outcomes were measured at 30 days. All the late #2 (bath* or shower*):ti,ab,kw
outcomes were measured at maximal follow-up. #3 (#1 OR #2)
#4 MeSH descriptor Surgical Wound Infection explode all trees
Primary outcomes #5 MeSH descriptor Surgical Wound Dehiscence explode all trees
#6 (surg* NEAR/5 infect*):ti,ab,kw
1. Wound-related early morbidity.
#7 (surg* NEAR/5 wound*):ti,ab,kw
i) Superficial surgical site infections (SSI) (superficial SSI
#8 (surg* NEAR/5 site*):ti,ab,kw
or superficial wound infections).
#9 (surg* NEAR/5 incision*):ti,ab,kw
ii) Deep surgical site infection (deep SSI or deep wound
#10 (surg* NEAR/5 dehisc*):ti,ab,kw
infections).
#11 (wound* NEAR/5 dehisc*):ti,ab,kw
iii) Superficial (partial-thickness) wound dehiscence
#12 (wound NEXT complication*):ti,ab,kw
(separation of sides of the wound).
#13 (#4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11
iv) Complete wound dehiscence (if applicable)
OR #12)
(dehiscence of deep fascial layers or structures deeper to the deep
#14 (#3 AND #13)
fascial layers).
The search strategies for Ovid MEDLINE, Ovid EMBASE and
2. Wound-related delayed morbidity.
EBSCO CINAHL can be found in Appendix 2. We combined
i) Incisional hernia (if applicable).
the Ovid MEDLINE search with the Cochrane Highly Sensitive
ii) Hypertrophic (raised) scar.
Search Strategy for identifying randomised trials in MEDLINE:
iii) Keloid (raised, enlarged) scar.
sensitivity- and precision-maximising version (2008 revision) (
3. Patient health-related quality of life.
Lefebvre 2011). We combined the EMBASE search with the Ovid
We accepted the definitions used by the trial authors for the out-
EMBASE filter developed by the UK Cochrane Centre (Lefebvre
comes. We have presented the ’Summary of findings’ table for all
2011).We combined the CINAHL searches with the trial filters
available primary outcomes (Schünemann 2011).
developed by the Scottish Intercollegiate Guidelines Network (
SIGN 2013). We did not restrict studies with respect to language,
Secondary outcomes date of publication or study setting.
1. Length of hospital stay (includes hospital stay due to any
adverse events, such as falls related to early post-operative We searched the metaRegister of Controlled Trials (mRCT) (http://
showering). www.controlled-trials.com/mrct/) and the ICTRP (International
Clinical Trials Registry Platform) portal maintained by the study authors of the trials to check whether the trial report had
World Health Organization (http://apps.who.int/trialsearch/). been duplicated. We resolved any differences in opinion through
The meta-register includes the ISRCTN Register and NIH Clin- discussion amongst the review authors.
icalTrials.gov Register among other registers. The ICTRP portal
includes these trial registers along with trial registry data from a
number of countries. Assessment of risk of bias in included studies
We followed instructions in the Cochrane Handbook for Systematic
Reviews of Interventions (Higgins 2011b). According to empiri-
Searching other resources
cal evidence (Kjaergard 2001; Moher 1998; Schulz 1995; Wood
We searched the references of the identified trials to identify further 2008), trials judged to be at high risk of bias may generate biased
relevant trials. estimates of treatment effect relating to benefit or harm. We as-
sessed the risk of bias of the trial according to the following do-
mains:
Data collection and analysis
We performed the systematic review following instructions in the Sequence generation
Cochrane Handbook for Systematic Reviews of Interventions (Higgins
1. Low risk of bias: the method used was either adequate (e.g.
2011a).
computer-generated random numbers, table of random
numbers) or unlikely to introduce confounding.
Selection of studies 2. Uncertain risk of bias: there was insufficient information to
Two review authors (CT and KG) identified trials for inclusion assess whether the method used was likely to introduce
independently by going through the titles and abstracts of the confounding.
search results. We obtained the full text of any reference with 3. High risk of bias: the method used was improper and likely
the potential to meet the inclusion criteria based on the titles to introduce confounding.
and abstracts. We made the final selection for inclusion based
on the full text. In addition, another author (RR) searched the
Allocation concealment
literature in general to identify further trials. We have listed the
excluded studies with the reasons for their exclusion. We resolved 1. Low risk of bias: the method used was unlikely to induce
any differences through discussion. bias on the final observed effect (e.g. central allocation).
2. Uncertain risk of bias: there was insufficient information to
assess whether the method used was likely to induce bias on the
Data extraction and management estimate of effect.
Two review authors (CT and KG) independently extracted the 3. High risk of bias: the method used (e.g. open random
following data using a standardised template. allocation schedule) was likely to induce bias on the final
1. Year and language of publication. observed effect.
2. Country.
3. Year of conduct of the trial.
4. Inclusion and exclusion criteria. Blinding of participants and personnel
5. Type of operation (clean, clean-contaminated operation). It would be impossible to blind participants for this intervention.
6. Site of operation (trunk versus limbs). So, we planned to classify patient-reported outcomes such as qual-
7. Number of participants in intervention and control. ity of life as being at high risk of bias, as these are subjective out-
8. Details of intervention and control. comes and a patient’s belief may influence their reporting. How-
9. Details of the dressing. ever, it is possible to blind the healthcare providers. So, we decided
10. Peri-operative antibiotic use. to consider outcomes that were not reported by patients as follows.
11. Outcomes (as described above). 1. Low risk of bias: blinding was performed adequately, or the
12. Risk of bias (as described below). outcome measurement was not likely to be influenced by lack of
13. Evidence of trial funding and source. blinding.
Where multiple reports existed for a trial, we planned to examine 2. Uncertain risk of bias: there was insufficient information to
all the reports for information. We sought clarification for any assess whether the type of blinding used was likely to induce bias
unclear or missing information by contacting the authors of the on the estimate of effect.
individual trials. If there was any doubt about whether the trials 3. High risk of bias: no blinding or incomplete blinding, and
shared the same participants - completely or partially (by identi- the outcome or the outcome measurement was likely to be
fying common authors and centres) - we planned to contact the influenced by lack of blinding.
Blinding of outcome assessors changes, we planned to calculate the rate ratio (RaR) with 95%
1. Low risk of bias: blinding was performed adequately, or the CI. We planned to use RevMan 5 software for performing these
outcome measurement was not likely to be influenced by lack of calculations.
blinding.
2. Uncertain risk of bias: there was insufficient information to
assess whether the type of blinding used was likely to induce bias Unit of analysis issues
on the estimate of effect. The unit of analysis was the patient who had the surgical operation
3. High risk of bias: no blinding or incomplete blinding, and that resulted in the closed wound.
the outcome or the outcome measurement was likely to be
influenced by lack of blinding.
Dealing with missing data
Incomplete outcome data We planned to perform an intention-to-treat analysis whenever
1. Low risk of bias: the underlying reasons for missing data possible (Newell 1992). We planned to impute data for binary
were unlikely to make treatment effects depart from plausible outcomes using various scenarios such as best-best scenario, worst-
values, or proper methods were employed to handle missing data. worst scenario, best-worst scenario, and the worst-best scenario
2. Uncertain risk of bias: there was insufficient information to (Gurusamy 2009). In the best-best scenario, all participants with
assess whether the missing data mechanism in combination with missing data for outcomes would be considered not to have de-
the method used to handle missing data was likely to induce bias veloped a complication. In the worst-worst scenario all partici-
on the estimate of effect. pants with missing data would be considered to have developed a
3. High risk of bias: the crude estimate of effects would clearly complication. In the best-worst scenario, participants with missing
be biased due to the underlying reasons for missing data, and the data in the intervention group would be considered not to have
methods used to handle missing data were unsatisfactory (e.g. developed a complication while those in the control group would
complete case estimate). be considered to have developed a complication. In the worst-best
scenario, participants with missing data in the intervention group
would be considered to have developed a complication while those
Selective outcome reporting
in the control group would be considered not to have developed
1. Low risk of bias: the trial protocol was available and all of a complication.
the trial’s pre-specified outcomes that are of interest in the review For continuous outcomes, we planned to use the available-case
have been reported; or, if the trial protocol was not available, all analysis where intention-to-treat analysis was not possible. We
the primary outcomes in this review were reported. planned to impute the standard deviation from P values according
2. Uncertain risk of bias: there was insufficient information to to instructions in the Cochrane Handbook for Systematic Reviews
assess whether the magnitude and direction of the observed of Interventions (Higgins 2011c), and to use the median for the
effect were related to selective outcome reporting. meta-analysis when the mean was not available. Where it was not
3. High risk of bias: not all of the trial’s pre-specified primary possible to calculate the standard deviation from the P value or the
outcomes were reported. confidence intervals, we planned to impute the standard deviation
We considered trials that we classified as being at low risk of bias, as the highest standard deviation in the other trials included un-
in all the above domains, for a specific outcome as being low bias- der that outcome, fully recognising that this form of imputation
risk trials for that outcome. We considered the other trials to be decreases the weight of the study for calculation of mean differ-
high bias-risk trials. ences and biases the effect estimate towards no effect in case of
standardised mean difference (Higgins 2011d).
Measures of treatment effect
For binary outcomes, we planned to calculate the risk ratio (RR)
Assessment of heterogeneity
with 95% confidence interval (CI). Risk ratio calculations do not
include trials in which no events occurred in either group, whereas We planned to assess heterogeneity by visual inspection of forest
risk difference (RD) calculations do. We planned to report the plots, by Chi2 test with significance set at P value 0.10, and by
risk difference if the results using this association measure were the I2 statistic (Higgins 2002). We planned to use the following
likely to be interpreted differently from risk ratio. For continuous Cochrane guidelines for interpretation of I2 .
variables we planned to calculate the mean difference (MD) for • 0% to 40%: might not be important;
outcomes such as hospital stay and standardised mean difference • 30% to 60%: may represent moderate heterogeneity;
(SMD) with 95% CI for quality of life (where different assessment • 50% to 90%: may represent substantial heterogeneity;
scales might be used). For count data outcomes such as dressing • 75% to 100%: considerable heterogeneity.
We planned to assess the influence of co-interventions such as classified as being at low risk of bias in all the above domains for
the presence of dressing and peri-operative antibiotics, which may a specific outcome as being low bias-risk trials for that outcome.
have an effect on the outcomes by subgroup analysis. 2. Based on the location of the incision (trunk versus limb).
3. Based on whether the surgery is considered clean or clean-
contaminated (Appendix 1).
Assessment of reporting biases 4. Based on whether the wound was covered or exposed.
We planned to use visual asymmetry on a funnel plot to explore 5. Based on whether the patients received any prophylactic
reporting bias in the presence of at least 10 trials (Egger 1997; peri-operative antibiotics.
Macaskill 2001). We also planned to perform the linear regression
approach described by Egger 1997 to determine the funnel plot Sensitivity analysis
asymmetry. We performed a sensitivity analysis by imputing missing data for
binary outcomes using various scenarios such as best-best scenario,
best-worst scenario, worst-best scenario and worst-worst scenario
Data synthesis
(Gurusamy 2009). We planned to perform a sensitivity analysis by
In the absence of clinical heterogeneity, we planned to perform excluding the trials in which the mean and the standard deviation
meta-analyses using the software package RevMan 5 (RevMan were imputed.
2011), and following the recommendations of The Cochrane Col-
laboration (Deeks 2011). We planned to use both random-ef-
fects model (DerSimonian 1986), and fixed-effect model (DeMets
1987), meta-analyses. In case of discrepancy between the two mod- RESULTS
els, we planned to report both results; otherwise we planned to
report the results of the fixed-effect model. We planned to use the
generic inverse method to combine the rate ratios for count data
Description of studies
outcomes.
Results of the search

Summary of findings
We identified a total of 131 unique references through searches
We have presented the ’Summary of findings’ table for all the detailed above. We excluded 125 irrelevant references by going
reported primary outcomes (Schünemann 2011). through titles and abstracts, leaving six references for full assess-
ment. We obtained full texts for these six references. Five references
were excluded for the reasons outlined in the “Characteristics of
Subgroup analysis and investigation of heterogeneity excluded studies” table.This left one trial for inclusion in this re-
We had planned to perform the following subgroup analyses. view (Heal 2006). No further trials were identified by searching
1. Trials with low risk of bias compared with trials with high the references of the included trial. The reference flow is shown in
risk of bias (for the specific outcome). We considered trials Figure 1.
Figure 1. Reference flow
Excluded studies
Included studies
Please see Characteristics of excluded studies. Of the excluded
studies, two were not randomised studies (Betts 2006; Neues
(See “Characteristics of included studies” table.) 2000). Two were quasi-randomised studies (Riederer 1997;
A total of 870 participants, who received minor skin incisions in a Voorhees 1982). In one trial, showering was allowed at least after
primary care setting, took part in this trial. Wounds were sutured three days in both groups (Betts 2006). So, both groups in this
after the excision. Thirteen participants were lost to follow-up. Of trial belonged to the delayed group as defined in this review.
the remaining 857 participants, 415 were randomised to the early
bathing group (dressing removal at 12 hours followed by normal
bathing), and the remaining 442 were randomised to the delayed
Risk of bias in included studies
bathing group (dressing to be retained for a minimum of 48 hours The only trial in included in this review was at high risk of bias.
followed by normal bathing) (Heal 2006). The individual domains are shown in Figure 2.
Figure 2. Risk of bias summary: review authors’ judgements about each risk of bias item for each included
study.
Effects of interventions criteria when assessing SSIs. The authors did not find any signif-
See: Summary of findings for the main comparison Early versus icant difference in the proportion of participants who developed
delayed post-operative bathing and showering SSI. However, the trial was powered to measure a difference of 5%
Only one trial (870 participants) was included in this review (Heal in the SSI proportions and not to measure smaller differences such
2006), and the only outcome it reported was the proportion of as the statistically non-significant 0.3% difference that occurred.
participants who developed an SSI. The confidence intervals overlapped 0.75 and 1.25 (i.e. a relative
risk reduction of 25% or an absolute reduction of 2.2%) which
Surgical site infection means that one cannot rule out a clinically significant difference
There was no significant difference in the proportion of partici- in the proportion of participants who developed the infection be-
pants who developed SSI between the early post-operative bathing tween the groups based on the sample size in the trial. So, we ap-
group and the delayed post-operative bathing group (RR 0.96; pear to have lack of evidence of effect rather than lack of effect.
95% CI 0.62 to 1.48) (Analysis 1.1). Approximately 8.5% of In the secondary care setting, the proportion of participants who
the participants belonging to the early post-operative bathing develop SSIs varies, depending upon various factors, but on aver-
group and 8.8% participants belonging to the delayed post-op- age about 2.5% develop SSI (Steinberg 2009). Approximately 8%
erative group developed SSI Summary of findings for the main of participants in the trial included for this review developed SSI
comparison. (Heal 2006). This may be due to under-reporting of SSI in the sec-
ondary care setting. Irrespective of the reason for the difference in
the proportion of patients who develop SSIs between the primary
Additional information care and secondary care settings, it may be even more difficult to
Since this was the only trial included in the review, the choice be- identify clinically relevant reduction in SSIs in the secondary set-
tween a fixed-effect and random-effects model and the assessment ting. However, other wound complications that are unlikely to oc-
of heterogeneity did not apply, and we did not perform any sub- cur in the primary care setting, such as wound dehiscence and in-
group analysis. Calculating the risk difference (RD -0.00; 95% CI cisional hernias, may occur more frequently in the secondary care
-0.04 to 0.03) did not alter the conclusions. Sensitivity analysis of setting, which makes it easier to power studies (requiring fewer
different methods of imputing the missing outcome data showed number of participants to identify important differences between
no change in the interpretation of results, showing that the miss- the group) in a secondary care setting for the same alpha and beta
ing data did not affect the conclusions (Analysis 1.2). errors. Whichever setting is chosen for future trials, it will be im-
portant to measure patient-reported quality of life.
Reporting bias
We did not perform a funnel plot analysis because of the inclusion Overall completeness and applicability of
of only one trial in this review. evidence
The findings of this review are applicable only to patients under-
going minor skin incisions in the primary care setting and not to
patients undergoing other procedures in a primary care setting,
or any procedure in a secondary care setting. The wounds were
DISCUSSION sutured after the excisions and so this review is applicable only in
patients in whom sutures were used and not in those steri strips
are used.
Summary of main results
This review compared early versus delayed showering and bathing
in the prevention of post-operative wound complications. There Quality of the evidence
was only one trial identified for inclusion in this review (Heal
The overall quality of the evidence was very low as shown in
2006). This trial included participants in the primary care setting,
Summary of findings for the main comparison.
who presented to a participating general practitioner for a minor
skin excision. The participants in the early bathing group removed
the dressing within 12 hours and bathed normally, while the par-
ticipants in the delayed bathing group retained the dressing for at
Potential biases in the review process
least 48 hours before bathing normally. The only outcome of in- Although we performed a thorough review of published literature
terest for the review reported in this trial was SSI. Approximately, and current trials, it is possible that some trial authors conducted
8.5% in the early bathing group and 8.8% of participants in the relevant trials in the pre-trial registration era and did not report
delayed bathing group developed SSI. The trial authors used CDC the results.
Agreements and disagreements with other Implications for research
studies or reviews We recommend further RCTs to compare early versus de-
This is the first review on this topic. The authors of the trial layed showering or bathing post-operatively in different types of
concluded that wounds can be uncovered and allowed to get wet clean and clean-contaminated surgeries involving closed surgi-
in the first 48 hours after minor skin excision without increasing cal wounds. Such trials should include short-term and long-term
the incidence of infection (Heal 2006). We are more cautious wound related complications (at least one year), patient health-
in our conclusion and state that there is currently no evidence related quality of life assessments and resource utilisation (such as
to support either early post-operative bathing, or showering, or cost of dressing changes and treatment of wound related compli-
delayed post-operative bathing, or showering, because clinically cations).
significant increases or decreases in SSIs cannot be ruled out.
ACKNOWLEDGEMENTS
This project was funded by the National Institute for Health Re-
search. Disclaimer of the Department of Health: ’The views and
AUTHORS’ CONCLUSIONS
opinions expressed in the review are those of the authors and do
not necessarily reflect those of the National Institute for Health
Implications for practice Research (NIHR), National Health Services (NHS), or the De-
partment of Health.’
There is currently no conclusive evidence available from ran-
domised controlled trials (RCTs) for the benefits or harms of early We thank the peer reviewers commenting on the protocol of this
versus delayed post-operative showering or bathing in the preven- review, Wounds Group Editors (Richard Kirubakaran and Joan
tion of wound complications, as the confidence intervals around Webster) and referees Dayanithee Chetty and Nancy Munoz) and
the point estimate are wide in the one included trial, and therefore the Cochrane Wounds Group for the support provided. We also
a clinically significant increase or decrease in surgical site infection thank Jenny Bellorini for copy editing the protocol, and Elizabeth
by early post-operative bathing cannot be ruled out. Royle for copy-editing the review.
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Heal 2006 {published data only} wound healing at risk?. Der Chirurg 1997;68(7):715–7.
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∗
of clean and clean-contaminated surgical wounds. Cochrane Indicates the major publication for the study
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Heal 2006
Methods Randomised clinical trial
Participants Country: Australia

Number randomised: 870
Post-randomisation drop-outs: 13 (1.5%)
Revised sample size: 857
Average age: 56 years
Male:female numbers: 457 (51.8%): 413 (48.2%)
Inclusion criteria:
People who presented to a participating general practitioner for a minor skin excision
Exclusion criteria:
1. Excisions on the face
2. Taking oral antibiotics
3. Immediate clinical indication for oral or topical antibiotics post-operatively
4. On immunosuppressive drugs
5. Lacerations
6. A flap, or 2-layer procedure
7. Excision of a sebaceous cyst
Interventions Participants were randomly assigned to 2 groups

Group 1: Early post-operative bathing or showering (n = 415), dressing to be removed
within 12 hours and normal bathing resumed (420 participants were randomised. Five
participants were excluded because of loss to follow-up)
Group 2: Delayed post-operative bathing or showering (n = 442), dressing to be retained
for at least 48 hours, then removed, and normal bathing to resume (450 participants
were randomised. Eight participants were excluded because of loss to follow-up)
Other details: Wounds were sutured in both groups and both groups were asked not to
use antiseptic washes or soaps
Dressing type: melolin and tape
Outcomes SSI
Notes We attempted to contact the authors in January 2013

Source of funding: quote: “Research was funded by a novice research scholarship from the
primary health care research and development fund. The authors’ work is independent
of this funding”
Declaration of interests: none
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection Unclear risk Quote: “After agreeing to participate, patients were ran-
bias) domised by picking a ball out of a hat”
Comment: The number of balls in the hat, whether the pa-
Heal 2006 (Continued)
tient blindfolded, and whether the researcher involved in

this process aware of the clinical details about the patient
before ball was picked were not reported. All these may in-
fluence the randomisation process
Allocation concealment (selection bias) Unclear risk Quote: “After agreeing to participate, patients were ran-
domised by picking a ball out of a hat”
Comment: The number of balls in the hat, whether the pa-
tient blindfolded, and whether the researcher involved in
this process aware of the clinical details about the patient
before ball was picked were not reported. All these may in-
fluence the randomisation process
Blinding of participants and personnel High risk Quote: “No blinding took place”
(performance bias)
All outcomes
Blinding of outcome assessment (detection High risk Quote: “No blinding took place”
bias)
All outcomes
Incomplete outcome data (attrition bias) Low risk Quote: “A total of 13 patients were eventually lost to follow-
All outcomes up”
Comment: imputation using different scenarios did not alter
the conclusions. This shows that the missing data did not
affect the conclusions of the study
Selective reporting (reporting bias) Unclear risk Comment: the trial protocol was not available and all the
primary outcomes of this review were not reported in this
trial
Abbreviation
SSI = surgical site infection
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Betts 2006 Comment on a report
Fraser 1976 Shower or bathing allowed after 3 days in the trial’s early intervention group, but, according to the definitions used
in this review, both groups belong to the delayed group
Neues 2000 Before and after study
(Continued)
Riederer 1997 Quasi-randomised study (alternate allocation)
Voorhees 1982 Quasi-randomised study (allocation by social security number)
DATA AND ANALYSES
Comparison 1. Early versus delayed post-operative bathing and showering
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Surgical site infection 1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
2 Surgical site infection (sensitivity 1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
analysis)
2.1 Best-best scenario 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2.2 Best-worst scenario 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2.3 Worst-best scenario 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2.4 Worst-worst scenario 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
Analysis 1.1. Comparison 1 Early versus delayed post-operative bathing and showering, Outcome 1 Surgical
site infection.
Review: Early versus delayed post-operative bathing or showering to prevent wound complications
Comparison: 1 Early versus delayed post-operative bathing and showering
Outcome: 1 Surgical site infection
Study or subgroup Early bathing Delayed bathing Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Heal 2006 35/415 39/442 0.96 [ 0.62, 1.48 ]
0.5 0.7 1 1.5 2

Favours early bathing Favours delayed bathing
Analysis 1.2. Comparison 1 Early versus delayed post-operative bathing and showering, Outcome 2 Surgical
site infection (sensitivity analysis).
Review: Early versus delayed post-operative bathing or showering to prevent wound complications
Comparison: 1 Early versus delayed post-operative bathing and showering
Outcome: 2 Surgical site infection (sensitivity analysis)
Study or subgroup Early bathing Delayed bathing Risk Ratio Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
1 Best-best scenario
Heal 2006 35/420 39/450 0.96 [ 0.62, 1.49 ]
2 Best-worst scenario
Heal 2006 35/420 47/450 0.80 [ 0.53, 1.21 ]
3 Worst-best scenario
Heal 2006 40/420 39/450 1.10 [ 0.72, 1.67 ]
4 Worst-worst scenario
Heal 2006 40/420 47/450 0.91 [ 0.61, 1.36 ]
0.5 0.7 1 1.5 2

Favours early bathing Favours delayed bathing
APPENDICES
Appendix 1. Classification of surgical wounds
Clean wound
• Uninfected operative wounds
• No inflammation is encountered
• Respiratory, alimentary, genital or uninfected urinary tracts are not entered
• Primarily closed
Clean-contaminated wound
• Respiratory, alimentary, genital or urinary tract is entered under controlled conditions
• Without unusual contamination
• No evidence of infection or major break in sterile technique is encountered
Contaminated wound
• Open, fresh accidental wounds or operations with major breaks in sterile technique or gross spillage from the gastrointestinal
(Continued)
tract or incisions in which acute, non-purulent inflammation is encountered
Dirty wound
• Old traumatic wounds with retained devitalised tissue or those that involve existing clinical infection or perforated viscera (i.e.
the organisms causing post-operative infection were present in the operative field before the operation)
Appendix 2. Search strategies for Ovid MEDLINE, Ovid EMBASE and EBSCO CINAHL
Ovid MEDLINE
1 exp Baths/ (3957)
2 (bath* or shower*).tw. (36625)
3 or/1-2 (38425)
4 exp Surgical Wound Infection/ (26607)
5 exp Surgical Wound Dehiscence/ (5878)
6 (surg* adj5 infect*).tw. (16779)
7 (surg* adj5 wound*).tw. (9236)
8 (surg* adj5 site*).tw. (9649)
9 (surg* adj5 incision*).tw. (5636)
10 (surg* adj5 dehisc*).tw. (510)
11 (wound* adj5 dehisc*).tw. (2472)
12 wound complication*.tw. (2608)
13 or/4-12 (62103)
14 3 and 13 (172)
15 randomized controlled trial.pt. (336449)
16 controlled clinical trial.pt. (85145)
17 randomized.ab. (239415)
18 placebo.ab. (134484)
19 clinical trials as topic.sh. (162409)
20 randomly.ab. (172076)
21 trial.ti. (103449)
22 or/15-21 (778802)
23 (animals not (humans and animals)).sh. (3688338)
24 22 not 23 (717732)
25 14 and 24 (42)
Ovid EMBASE
1 exp bath/ (6289)
2 (bath* or shower*).tw. (47427)
3 or/1-2 (49522)
4 exp surgical infection/ (21898)
5 exp wound dehiscence/ (8738)
6 (surg* adj5 infect*).tw. (23054)
7 (surg* adj5 wound*).tw. (11816)
8 (surg* adj5 site*).tw. (13403)
9 (surg* adj5 incision*).tw. (7890)
10 (surg* adj5 dehisc*).tw. (656)
11 (wound* adj5 dehisc*).tw. (3215)
12 wound complication*.tw. (3353)
13 or/4-12 (73526)
14 3 and 13 (213)
15 Randomized controlled trials/ (19909)
16 Single-Blind Method/ (16360)
17 Double-Blind Method/ (113205)
18 Crossover Procedure/ (34922)
19 (random$ or factorial$ or crossover$ or cross over$ or cross-over$ or placebo$ or assign$ or allocat$ or volunteer$).ti,ab. (1169094)
20 (doubl$ adj blind$).ti,ab. (137016)
21 (singl$ adj blind$).ti,ab. (12796)
22 or/15-21 (1220635)
23 animal/ (1798609)
24 human/ (13718400)
25 23 not 24 (1346855)
26 22 not 25 (1180734)
27 14 and 26 (34)
EBSCO CINAHL
S27 S14 and S26
S26 S15 or S16 or S17 or S18 or S19 or S20 or S21 or S22 or S23 or S24 or S25
S25 MH “Quantitative Studies”
S24 TI placebo* or AB placebo*
S23 MH “Placebos”
S22 TI random* allocat* or AB random* allocat*
S21 MH “Random Assignment”
S20 TI randomi?ed control* trial* or AB randomi?ed control* trial*
S19 AB ( singl* or doubl* or trebl* or tripl* ) and AB ( blind* or mask* )
S18 TI ( singl* or doubl* or trebl* or tripl* ) and TI ( blind* or mask* )
S17 TI clinic* N1 trial* or AB clinic* N1 trial*
S16 PT Clinical trial
S15 MH “Clinical Trials+”
S14 S3 and S13
S13 S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11 or S12
S12 TI wound complication* OR AB wound complication*
S11 TI wound* N5 dehisc* OR AB wound* N5 dehisc*
S10 TI surg* N5 dehisc* OR AB surg* N5 dehisc*
S9 TI surg* N5 incision* OR AB surg* N5 incision*
S8 TI surg* N5 site* OR AB surg* N5 site*
S7 TI surg* N5 wound* OR AB surg* N5 wound*
S6 TI surg* N5 infect* OR AB surg* N5 infect*
S5 (MH “Surgical Wound Dehiscence”)
S4 (MH “Surgical Wound Infection”)
S3 S1 or S2
S2 TI ( bath* or shower* ) OR AB ( bath* or shower* )
S1 (MM “Bathing and Baths”)
Appendix 3. Databases searched for the original review
For the original version of this review, in July 2013 we searched the following electronic databases to identify reports of relevant RCTs:
• The Cochrane Wounds Group Specialised Register (searched 3 July 2013);
• The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 6);
• The Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library 2013, Issue 6);
• Ovid MEDLINE (1946 to June Week 3 2013);
• Ovid MEDLINE (In-Process & Other Non-Indexed Citations, July 02, 2013);
• Ovid EMBASE (1974 to 2013 Week 26);
• EBSCO CINAHL (1982 to 28 June 2013).
WHAT’S NEW
Last assessed as up-to-date: 30 June 2015.
Date Event Description
10 July 2015 New citation required but conclusions have not changed No new studies identified, conclusions remain unchanged
10 July 2015 New search has been performed First update, new search
CONTRIBUTIONS OF AUTHORS
Clare Toon developed the review, completed the first draft, performed part of the writing or editing of the review, made an intellectual
contribution and approved the final version prior to submission.
Sidhartha Sinha: developed the protocol, completed the first draft, performed part of the writing or editing of the protocol, made an
intellectual contribution and approved the final review version prior to submission.
Brian Davidson conceived the review question, secured funding, made an intellectual contribution, advised on the review and approved
the final version prior to submission.
Kurinchi Gurusamy: conceived the review question, developed and coordinated the protocol, secured funding, completed the protocol
and co-ordinated the review. Completed and edited the first draft review, made an intellectual contribution, advised on the review,
approved the final version prior to submission and is guarantor for the review. Screened the citations for the first update and approved
the updated review prior to submission.
Contributions of editorial base

Susan O’Meara, Editor: Advised on methodology, interpretation and content. Edited the review and approved the review for submission.
Sally Bell-Syer: co-ordinated the editorial process. Advised on methodology, interpretation and content. Edited the review and the
updated review.
Ruth Foxlee: designed the search strategy, provided the search results and edited the search methods section.
Rachel Richardson: edited the review.
DECLARATIONS OF INTEREST
Clare Toon: none declared.
Sidhartha Sinha: none declared.
Brian Davidson: none declared.
Kurinchi Gurusamy: none declared.
SOURCES OF SUPPORT
Internal sources
• No sources of support supplied
External sources
• National Institute for Health Research (NIHR - UK Government organisation for health research), UK.
NIHR provides financial support for K Gurusamy and the Cochrane Wounds Group for completing the review and editorial support
respectively.
• This project was supported by the National Institute for Health Research, via Cochrane Infrastructure funding to Cochrane
Wounds. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic
Reviews Programme, NIHR, NHS or the Department of Health, UK.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

None.
INDEX TERMS
Medical Subject Headings (MeSH)

Bandages; Baths [adverse effects; ∗ methods]; Minor Surgical Procedures [adverse effects]; Postoperative Care [adverse effects; ∗ methods];
Quality Improvement; Quality of Life; Randomized Controlled Trials as Topic; Surgical Wound Infection [∗ complications; epidemi-
ology; prevention & control]; Sutures; Time Factors; Wound Healing
MeSH check words

Humans

Early Versus Delayed Post-Operative Bathing or Showering To Prevent Wound Complications

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Early Versus Delayed Post-Operative Bathing or Showering To Prevent Wound Complications

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Cochrane Database of Systematic Reviews

Early versus delayed post-operative bathing or showering to

Toon CD, Sinha S, Davidson BR, Gurusamy KS

Toon CD, Sinha S, Davidson BR, Gurusamy KS.

Early versus delayed post-operative bathing or showering to

Clare D Toon1 , Sidhartha Sinha2 , Brian R Davidson3 , Kurinchi Selvan Gurusamy3

Editorial group: Cochrane Wounds Group.

PLAIN LANGUAGE SUMMARY

Early versus delayed post-operative bathing and showering

Patient or population: patients with closed post-operative incisions

Assumed risk Corresponding risk

Control (delayed post- Early post-operative

Surgical site infection 88 per 1000 85 per 1000 RR 0.96 857 ⊕

GRADE Working Group grades of evidence

How the intervention might work

Types of interventions Electronic searches

Results of the search

Higgins 2011a Newell 1992

Higgins 2011c Schulz 1995

Characteristics of included studies [ordered by study ID]

Methods Randomised clinical trial

Participants Country: Australia

Interventions Participants were randomly assigned to 2 groups

Notes We attempted to contact the authors in January 2013

Bias Authors’ judgement Support for judgement

tient blindfolded, and whether the researcher involved in

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Betts 2006 Comment on a report

Neues 2000 Before and after study

Riederer 1997 Quasi-randomised study (alternate allocation)

Voorhees 1982 Quasi-randomised study (allocation by social security number)

Comparison 1. Early versus delayed post-operative bathing and showering

Comparison: 1 Early versus delayed post-operative bathing and showering

Outcome: 1 Surgical site infection

0.5 0.7 1 1.5 2

Comparison: 1 Early versus delayed post-operative bathing and showering

Outcome: 2 Surgical site infection (sensitivity analysis)

0.5 0.7 1 1.5 2

tract or incisions in which acute, non-purulent inflammation is encountered

Date Event Description

Contributions of editorial base

DIFFERENCES BETWEEN PROTOCOL AND REVIEW

Medical Subject Headings (MeSH)

MeSH check words

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