I.

Clinical Question Among patients who have burn wounds; is wound cleansing with normal saline more effective than cleansing the wound with water for infection reduction and healing improvement?

II. Citation Evidence Based Medicine: Wound Cleaning Water or Saline? Israeli Journal of Emergency Medicine Vol. 5, No. 4 Oct 2005 Comilla Sasson, MD*, Adam Kennah, MD*, Barry Diner, MD^

III. Summary

The study compared infection rates of acute soft tissue wounds irrigated with tap water vs. sterile saline. The study is listed as a RCT that was conducted on 705 patients which is an adequate size. Patients were randomized into the tap water or saline group depending on if they presented for treatment on an even or odd trial week. This way of dividing patients into groups does not meet the criteria for a RCT and is more quasi-random. The study was flawed because there was no standardized way that the solutions were used for cleansing making it impossible to accurately determine if the solutions or the techniques were responsible for the outcome. It was also noted that practitioners were more generous with the amount of tap water used for irrigation which most likely had an effect on the results. Outcomes were measured by wound infection rate which was defined as having pus and prolonged healing at follow up intervals. The follow up intervals were not defined. The study was conducted on 46 patients that were randomized into tap water and sterile saline groups. Tap water and sterile saline were provided in bottles to allow for the study to be conducted in double blind format. The wounds were cleansed by irrigation.
IV. Results of the Study

Outcomes were measured with pre and post-irrigation wound cultures, and on 48 hour follow up examination. Infection was defined as cellulites, erythema, tenderness, purulent discharge, or wound dehiscence. This study demonstrated similar infection rates with normal saline at 2.8% and tap water at 2.9. The study did say that both solutions

have different physical fluid properties, causing there to be a difference in solution pressures and flow rates when irrigated through a syringe. The article goes on to say the antimicrobial effects of the tap water are most likely due to the fact that the tap water can be irrigated at a higher pressure due to its physical properties, therefore having more irrigation power. They concluded that this increased irrigation power makes tap water an effective alternative to saline. When the authors compiled the research data they came up with the following statistics:
The relative risk (RR) of developing an infection in chronic wounds cleansed

with tap water vs. saline was 0.16 (95% confidence interval [CI] of 0.01-2.96). Tap water is more effective in reducing infection rates in adults with acute wounds with a RR of 0.63 (95% CI of 0.40-0.99). There was no statistically significant difference in infection rates in children with a RR OF 1.07 (95% CI of 0.43-2.64).

The authors concluded that there is no evidence that tap water increases infection rates as compared to sterile saline. The statistics give some evidence that tap water actually prevents infection.
2. Comparison of tap water vs. normal saline in acute wounds: Three trials compared tap water to normal saline in cleansing acute wounds. Two of the studies focused on children. The one adult trial compared 627 acute wounds (<6 hours) that were sutured. This trial demonstrated a statistically significant reduction in infection rates in wounds cleansed with tap water compared with those cleansed with saline (RR 0.55, CI 0.31 to 0.97, p = 0.04). The pooled results of the two pediatric trials included 535 patients and demonstrated no statistically significant difference in wound infection rates (RR 1.07, CI 0.43 to 2.64). . 3. Comparison of tap water vs. normal saline in chronic wounds: One trial of 49 patients compared chronic, non-sutured wounds that were cleansed with either tap water or normal saline. This study reported no statistical difference in wound infection rates (RR 0.16, CI 0.01 to 2.96) or in wound healing (RR 0.57, CI 0.30 to 1.07). This study also reported the use of tap water reduced cost ($1.43 for normal saline vs. $1.16 for tap water). 4. Comparison of water (distilled water and/or cooled, boiled water) vs. normal saline: There was one three-armed study which compared distilled water, normal saline, and cooled boiled water for the irrigation of open fractures. None of the three comparisons demonstrated a statistically significant difference in wound infection rates; however the study was under-powered with only 86 participants and 22 infections.

V. Authors Conclusions/Recommendations Evidence is limited; however one trial suggests that the use of tap water to clean acute wounds reduces the infection rate while other trials conclude that there is no difference in the infection and healing rates between wounds that were not cleansed at all and those that were cleansed with tap water and other solutions. VI. Applicability Yes it is applicable, because water is very accessible than normal saline solution, so it would be easier for the people to clean wounds since it has the same effect with NSS.

VII.

Reviewers Conclusion / Commentary We agree that it is good to clean wounds using water/saline because the wound can be infected if not cleaned. And tap water is advantageous because it is highly accessible, inexpensive, can maintain high pressures right out of the faucet.