Antibiotic versus saline wound irrigation after appendectomy for prevention of incisional surgical site infection: a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND

Incisional surgical site infection (SSI) remains a costly complication after appendectomy. Although saline wound irrigation is widely used, the added value of antibiotic irrigation remains uncertain, particularly in the context of antimicrobial stewardship.

AIM: To evaluate whether intraoperative incisional wound irrigation with an antibiotic solution reduces incisional SSI compared with saline irrigation after open appendectomy.

METHODS

We conducted a PRISMA 2020 systematic review and meta-analysis (PROSPERO-CRD420261323864) of randomised controlled trials comparing antibiotic solution versus normal saline wound irrigation during open appendectomy. PubMed/MEDLINE, EMBASE, Web of Science, Scopus, and the Cochrane Library were searched to February 28, 2026. The primary outcome was incisional SSI. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were estimated using a random-effects model. Subgroup analyses, meta-regression, publication bias assessment, GRADE assessment, and trial sequential analysis (TSA) were performed.

FINDINGS: Eight trials involving 2007 participants were included. Incisional SSI occurred in 40/994 patients in the antibiotic-irrigation group and 89/1013 patients in the saline-irrigation group. Antibiotic irrigation was associated with a lower risk of incisional SSI (RR 0.48, 95% CI 0.32-0.71; P=0.0002), with low statistical heterogeneity (I2=7.5%). Subgroup and meta-regression analyses did not identify significant effect modification. The certainty of evidence was low because of risk of bias and indirectness.

CONCLUSION

Low-certainty randomised evidence suggests that antibiotic-solution wound irrigation may reduce incisional SSI after open appendectomy. However, no reproducible regimen can currently be recommended, the benefit was not statistically significant in the small low-risk-of-bias subgroup, and high-quality trials are needed before routine implementation.