Interesting Medscape Article:

If you are a memeber:

Drinkable Tap Water May Be Suitable for Wound Cleansing


Summary for those who are not:

"This Cochrane review identified no evidence that using tap water to cleanse acute wounds in adults increases infection and some evidence that it reduces it. For chronic wounds cleansed with tap water vs saline, the RR for infection was 0.16. Tap water vs saline was more effective in reducing the infection rate in adults with acute wounds. For children with acute wounds, infection rates were not statistically significantly different with tap water vs saline. Infection rate for open fractures was not statistically significantly different for cleansing with isotonic saline, distilled water, or boiled water.
Wounds cleansed with tap water vs wounds not cleansed at all did not differ in infection rates, and episiotomy wounds cleansed with water or with procaine spirit did not differ in infection rate."


Pete

Am I taking that out of context, or otherwise misunderstanding? Does that mean exactly what it says?

I once read that the pressure and the length of time a wound is cleaned has more to do with how clean it gets than how clean the water is.

And I've heard of studies that show water does not have to be super clean to effectively clean a wound.

Here are more of the details from Medscape:

"Of 11 included trials, 7 compared rates of infection and healing in wounds cleansed with water vs normal saline, 3 trials compared cleansing vs no cleansing, and 1 trial compared procaine spirit vs water. Procaine spirit is a mixture of procaine HCl 2% with spirit 70% and is commonly prescribed for wound cleansing following surgery. Ability to pool the data was limited because there were no standard criteria across the trials for evaluating wound infection. The predominant comparisons were water vs normal saline and tap water vs no cleansing.

When chronic wounds were cleansed with tap water vs normal saline, the relative risk (RR) of developing an infection was 0.16 (95% confidence interval [CI], 0.01 - 2.96). Compared with saline, tap water was more effective in reducing the infection rate in adults with acute wounds (RR, 0.63; 95% CI, 0.40 - 0.99). In children, the use of tap water to cleanse acute wounds was not associated with a statistically significant difference in infection vs saline (RR, 1.07; 95% CI, 0.43 - 2.64).

When wounds were cleansed with tap water or not cleansed at all, there was no statistically significant difference in infection rates (RR, 1.06; 95% CI, 0.07 - 16.50). In a similar fashion, episiotomy wounds cleansed with water or with procaine spirit did not differ in infection rate. For cleansing open fractures, use of isotonic saline, distilled water, and boiled water was not statistically significantly different in the number of fractures that became infected.

"There is no evidence that using tap water to cleanse acute wounds in adults increases infection and some evidence that it reduces it," the review authors write. "However 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. . . . 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."

Keep in mind these are limited studies and it is often difficult to compare field received wounds, which by their very nature will vary in degrees of possible contamination.

I think the take home message is not to take things to an extreme, if all you have is drinkable water (vs. sterile saline) that should suffice for most incidences.

Pete

Doesn't surprise me.

Mostly because sterility is more a scalar then an absolute. Very few things are ever absolutely sterile and if they ever get to that level they seldom stay that way for long.

Also some consideration has to be given toward the difference between non-sterile and non-infective. A material can be loaded with microbes but as long as those microbes are species that the body can handle and/or do not cause disease then being non-sterile is not a problem.

More on-point, the 'cleaning' of a wound using any particular solution would seem to be at least somewhat more effective the more sterile and less infective it is. Sterile water being at least notionally better than non-sterile water.

But there are at least three other factors that come to mind: First, exactly how much less sterile, or more importantly more infective, was the non-sterile solution. Tap water is not sterile but exactly how much more infective is it? Is the difference between tap water and sterile solution meaningless, or at least less important, on a bacteriological and infective level?

The second thought that comes to mind is: How does time play into this? Would an immediate irrigation with less clean water be better than waiting for more clean water? The answer would seem to be affirmative for the longer haul. You certainly wouldn't wait a week for an IV bag of NS to arrive by mail if the water available was relatively clean.

But would waiting thirty minutes to get to a supply of sterile water be justified? Would it be better to irrigate with potable water immediately and removing the worse of the dirt in the wound now or do you take the time to set up provisions for boiling water? Would it be better to do both? Or is the second rinse just more trauma to the already damaged tissue?

The third thought is that in this, and so many other situations, your going to run into the law of diminishing returns. The difference between raw sewage and safe potable water is pretty big. The difference between: 'Wouldn't use it on a bet' and 'We go with what we got'.

With this in mind it doesn't surprise me that the difference between tap water, presumably pretty clean and chlorinated, boiled water and commercial sterile solution would be pretty small.

The study I would like to see is irrigation with water versus irrigation with soap and water followed by a rinse.

Not very. I couldn't find the notes on permitted numbers from three semesters ago for e. coli but allowable for Giardia is removal of 99.9% and viruses is 99.99%.

I've heard that there was a study of regular soap vs anti-bacterial and it made only a very small difference.

That debate is one of my favorites. Soap IS antibacterial.

"Soap IS antibacterial."

I don't think so. Soap is more of a dispersal agent that allows bacteria to be washed away. Something that is 'antibacterial' is something that kills bacterial, isn't it?

Sue

Not sure about the terminology, but I have read reports that compared soap that was and was not antibacterial. The comparison dealt with the amount of bacteria left after hand washing, and if I recall correctly, there was little or no difference between the two types of soap.

Correct, soap is a surfactant--raises stuff up so it can be rinsed away.

"The solution to pollution is dilution"