Targeted client communication via mobile devices for improving maternal, neonatal, and child health.

The global burden of poor maternal, neonatal, and child health (MNCH) accounts for more than a quarter of healthy years of life lost worldwide. Targeted client communication (TCC) via mobile devices (MD) (TCCMD) may be a useful strategy to improve MNCH. To assess the effects of TCC via MD on health behaviour, service use, health, and well-being for MNCH. In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification. We included randomised controlled trials that assessed TCC via MD to improve MNCH behaviour, service use, health, and well-being. Eligible comparators were usual care/no intervention, non-digital TCC, and digital non-targeted client communication. We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second. We included 27 trials (17,463 participants). Trial populations were: pregnant and postpartum women (11 trials conducted in low-, middle- or high-income countries (LMHIC); pregnant and postpartum women living with HIV (three trials carried out in one lower middle-income country); and parents of children under the age of five years (13 trials conducted in LMHIC). Most interventions (18) were delivered via text messages alone, one was delivered through voice calls only, and the rest were delivered through combinations of different communication channels, such as multimedia messages and voice calls. Pregnant and postpartum women TCCMD versus standard care For behaviours, TCCMD may increase exclusive breastfeeding in settings where rates of exclusive breastfeeding are less common (risk ratio (RR) 1.30, 95% confidence intervals (CI) 1.06 to 1.59; low-certainty evidence), but have little or no effect in settings where almost all women breastfeed (low-certainty evidence). For use of health services, TCCMD may increase antenatal appointment attendance (odds ratio (OR) 1.54, 95% CI 0.80 to 2.96; low-certainty evidence); however, the CI encompasses both benefit and harm. The intervention may increase skilled attendants at birth in settings where a lack of skilled attendants at birth is common (though this differed by urban/rural residence), but may make no difference in settings where almost all women already have a skilled attendant at birth (OR 1.00, 95% CI 0.34 to 2.94; low-certainty evidence). There were uncertain effects on maternal and neonatal mortality and morbidity because the certainty of the evidence was assessed as very low. TCCMD versus non-digital TCC (e.g. pamphlets) TCCMD may have little or no effect on exclusive breastfeeding (RR 0.92, 95% CI 0.79 to 1.07; low-certainty evidence). TCCMD may reduce 'any maternal health problem' (RR 0.19, 95% CI 0.04 to 0.79) and 'any newborn health problem' (RR 0.52, 95% CI 0.25 to 1.06) reported up to 10 days postpartum (low-certainty evidence), though the CI for the latter includes benefit and harm. The effect on health service use is unknown due to a lack of studies. TCCMD versus digital non-targeted communication No studies reported behavioural, health, or well-being outcomes for this comparison. For use of health services, there are uncertain effects for the presence of a skilled attendant at birth due to very low-certainty evidence, and the intervention may make little or no difference to attendance for antenatal influenza vaccination (RR 1.05, 95% CI 0.71 to 1.58), though the CI encompasses both benefit and harm (low-certainty evidence). Pregnant and postpartum women living with HIV TCCMD versus standard care For behaviours, TCCMD may make little or no difference to maternal and infant adherence to antiretroviral (ARV) therapy (low-certainty evidence). For health service use, TCC mobile telephone reminders may increase use of antenatal care slightly (mean difference (MD) 1.5, 95% CI -0.36 to 3.36; low-certainty evidence). The effect on the proportion of births occurring in a health facility is uncertain due to very low-certainty evidence. For health and well-being outcomes, there was an uncertain intervention effect on neonatal death or stillbirth, and infant HIV due to very low-certainty evidence. No studies reported on maternal mortality or morbidity. TCCMD versus non-digital TCC The effect is unknown due to lack of studies reporting this comparison. TCCMD versus digital non-targeted communication TCCMD may increase infant ARV/prevention of mother-to-child transmission treatment adherence (RR 1.26, 95% CI 1.07 to 1.48; low-certainty evidence). The effect on other outcomes is unknown due to lack of studies. Parents of children aged less than five years No studies reported on correct treatment, nutritional, or health outcomes. TCCMD versus standard care Based on 10 trials, TCCMD may modestly increase health service use (vaccinations and HIV care) (RR 1.21, 95% CI 1.08 to 1.34; low-certainty evidence); however, the effect estimates varied widely between studies. TCCMD versus non-digital TCC TCCMD may increase attendance for vaccinations (RR 1.13, 95% CI 1.00 to 1.28; low-certainty evidence), and may make little or no difference to oral hygiene practices (low-certainty evidence). TCCMD versus digital non-targeted communication TCCMD may reduce attendance for vaccinations, but the CI encompasses both benefit and harm (RR 0.63, 95% CI 0.33 to 1.20; low-certainty evidence). No trials in any population reported data on unintended consequences. The effect of TCCMD for most outcomes is uncertain. There may be improvements for some outcomes using targeted communication but these findings were of low certainty. High-quality, adequately powered trials and cost-effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCCMD. Future studies should measure potential unintended consequences, such as partner violence or breaches of confidentiality.

Palmer MJ ，Henschke N ，Bergman H ，Villanueva G ，Maayan N ，Tamrat T ，Mehl GL ，Glenton C ，Lewin S ，Fønhus MS ，Free C ... -  《Cochrane Database of Systematic Reviews》

Mobile phone text messaging for medication adherence in secondary prevention of cardiovascular disease.

Redfern J ，Tu Q ，Hyun K ，Hollings MA ，Hafiz N ，Zwack C ，Free C ，Perel P ，Chow CK ... -  《Cochrane Database of Systematic Reviews》

Perineal techniques during the second stage of labour for reducing perineal trauma and postpartum complications.

Postpartum haemorrhage (PPH) is responsible for around 27% of global maternal deaths. Perineal tears are common in vaginal births and a significant contributor to excessive blood loss. A diversity of perineal techniques are utilised to prevent perineal trauma and reduce the incidence of PPH; however, they lack evidence-based comparisons to understand their effects. To assess the effect of perineal techniques during the second stage of labour on the incidence of and morbidity associated with perineal trauma to prevent postpartum complications. We searched four databases and two trial registers up to 16 April 2024. We checked references, searched citations and contacted study authors to identify additional studies. We included randomised controlled trials (RCTs) of women in the second stage of labour who intended to give birth vaginally, comparing any perineal techniques with control or another perineal technique. We excluded studies that performed perineal techniques outside the second stage of labour. Our critical outcomes were second-, third- and fourth-degree tears measured immediately after birth, and PPH ≥ 500 mL measured within 24 hours after birth. We used the Cochrane risk of bias 2 tool to assess bias in the included RCTs. We synthesised results for each outcome within each comparison using meta-analysis where possible. Where this was not possible due to the nature of the data, we synthesised results narratively. We used GRADE to assess the certainty of evidence for each outcome. We included a total of 17 studies with 13,695 participants. Hands off (or poised) versus hands on Hands off (poised) may result in little to no difference in second-degree tears (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.32 to 1.64; 2 studies; low-certainty evidence) and third- or fourth-degree tears when data are combined (RR 1.27, 95% CI 0.81 to 1.99; 2 studies; low-certainty evidence). The evidence is very uncertain about the effect of hands off (poised) on third-degree tears and fourth-degree tears when reported separately (RR 0.50, 95% CI 0.05 to 5.27; 1 study; very low-certainty evidence and RR 3.00, 95% CI 0.13 to 71.22; 1 study; very low-certainty evidence). Hands off (poised) may result in little to no difference in PPH ≥ 500 mL (RR 1.16, 95% CI 0.92 to 1.47; 1 study; low-certainty evidence). Hands off (poised) probably results in little to no difference in breastfeeding two days after birth (RR 1.02, 95% CI 0.99 to 1.06; 1 study; moderate-certainty evidence) and perineal pain (RR 0.98, 95% CI 0.94 to 1.01; 1 study; moderate-certainty evidence). Vocalisation versus control Vocalisation may result in a reduction in second-degree tears (RR 0.56, 95% CI 0.23 to 1.38; 1 study; low-certainty evidence) and third-degree tears (RR 0.13, 95% CI 0.01 to 2.32; 1 study; low-certainty evidence), but the CIs are wide and include the possibility of no effect. No events were reported for fourth-degree tears (low-certainty evidence). Vocalisation may increase maternal satisfaction (RR 1.19, 95% CI 0.93 to 1.51; 1 study; low-certainty evidence). The evidence is very uncertain about the effect of vocalisation on perineal pain (RR 1.44, 95% CI 0.81 to 2.58; 1 study; very low-certainty evidence). Warm compress on the perineum versus control (hands off or no warm compress) Warm compress on the perineum may result in little to no difference in second-degree tears (RR 0.94, 95% CI 0.72 to 1.21; 2 studies; low-certainty evidence), but likely results in a reduction in third- or fourth-degree tears (RR 0.46, 95% CI 0.27 to 0.79; 3 studies; moderate-certainty evidence). Evidence from two smaller studies is very uncertain about the effect of warm compress on the perineum on third-degree tears (RR 0.51, 95% CI 0.04 to 7.05; 2 studies; very low-certainty evidence) or fourth-degree tears (RR 0.11, 95% CI 0.01 to 2.06; 2 studies; very low-certainty evidence) when reported separately. Warm compress likely results in a large reduction in perineal pain (mean difference (MD) -0.81, 95% CI -1.18 to -0.44; 1 study; moderate-certainty evidence). The evidence is very uncertain about the effect of warm compress on the perineum on maternal satisfaction and PPH ≥ 500 mL. Massage of the perineum versus control (hands off or no usual care) Massage of the perineum may have little to no effect on second-degree tears (RR 1.04, 95% CI 0.89 to 1.21; 4 studies; low-certainty evidence). The evidence is very uncertain about the effect of massage of the perineum on third-degree tears (RR 0.57, 95% CI 0.16 to 2.02; 4 studies; very low-certainty evidence). Massage of the perineum may reduce fourth-degree tears but the CIs are wide and include the possibility of no effect (RR 0.26, 95% CI 0.04 to 1.61; 4 studies; low-certainty evidence). The evidence suggests that massage likely results in little to no difference in perineal pain (RR 0.97, 95% CI 0.90, 1.05; 1 study; moderate-certainty evidence). One study reported 10 participants with postpartum haemorrhage across three interventions (warm compress, massage, control). Combined warm compress and massage of the perineum versus control Combined warm compress and massage of the perineum likely results in a reduction in second-degree tears when compared to a control (RR 0.63, 95% CI 0.46 to 0.86; 1 study; moderate-certainty evidence), but the evidence is very uncertain about the effect on third-degree tears (RR 2.92, 95% CI 0.12 to 70.72; 1 study; very low-certainty evidence). The intervention may result in a reduction in PPH ≥ 500 mL but the CIs are wide and include the possibility of no effect (RR 0.43, 95% CI 0.14 to 1.35; 1 study; low-certainty evidence). Combined warm compress and massage likely results in an increase in maternal satisfaction (MD 0.4, 95% CI -0.01 to 0.81; 1 study; moderate-certainty evidence). Combined warm compress and massage of the perineum versus massage alone Combined warm compress and massage of the perineum may result in little to no difference in second-degree tears (RR 0.95, 95% CI 0.86 to 1.06; 1 study; low-certainty evidence) when compared to massage alone, but the evidence is very uncertain about the effect on third- or fourth-degree tears (RR 0.98, 95% CI 0.06 to 15.49; 1 study; very low-certainty evidence). It may also result in little to no difference in PPH ≥ 500 mL (RR 1.10, 95% CI 0.59 to 2.07; 1 study; low-certainty evidence). The evidence suggests that combined warm compress and massage may result in little to no difference in maternal satisfaction (1 study; low-certainty evidence). Other perineal techniques We also assessed evidence on the following comparisons, but since they are used less frequently in global clinical practice to optimise birth outcomes, we have not presented the results summary here: Ritgen's manoeuvre versus standard care; primary delivery of posterior versus anterior shoulder; massage with enriched oil on the perineum versus massage with liquid wax; petroleum jelly on the perineum versus control; and perineal protection device versus control. Overall, the evidence for the effectiveness of perineal techniques to reduce perineal trauma and postpartum haemorrhage is very uncertain. Very few studies reported rates of postpartum haemorrhage, adverse events, women's or health workers' experience or other important outcomes that allow us to understand the effectiveness and acceptability of perineal techniques to reduce perineal trauma. Prior to any further large trials, research is needed to clarify the types of interventions, including a clear description of the process of development and involvement of relevant stakeholders. There is a need to clarify how the intervention is proposed to achieve its effects. Trials would benefit from process evaluation alongside, to explore context, mechanisms and effects. This Cochrane review was funded (in part) by WHO (APW 2024/1475460). TF, VL and the CIDG editorial base are funded by UK aid from the UK government for the benefit of low- and middle-income countries (project number 300342-104). The views expressed do not necessarily reflect the UK government's official policies. Registration and protocol: PROSPERO, CRD42024537252. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024537252.

Dwan K ，Fox T ，Lutje V ，Lavender T ，Mills TA ... -  《Cochrane Database of Systematic Reviews》

Antioxidants for female subfertility.

M.G. Showell, R. Mackenzie‐Proctor, V. Jordan, and R.J. Hart, “Antioxidants for Female Subfertility,” Cochrane Database of Systematic Reviews, no. 8 (2020): CD007807, https://doi.org/10.1002/14651858.CD007807.pub4 This Editorial Note is for the above article, published online on August 27, 2020, in Cochrane Library (cochranelibrary.com), and has been issued by the Publisher, John Wiley & Sons Ltd, in agreement with Cochrane. The Editorial note has been agreed due to concerns discovered by the Cochrane managing editor regarding the retraction of six studies in the Review (Badawy et al. 2006, 10.1016/j.fertnstert.2006.02.097; El Refaeey et al. 2014, 10.1016/j.rbmo.2014.03.011; El Sharkwy & Abd El Aziz 2019a, https://doi.org/10.1002/ijgo.12902; Gerli et al. 2007, https://doi.org/10.26355/eurrev_202309_33752, full text: https://europepmc.org/article/MED/18074942; Ismail et al. 2014, http://dx.doi.org/10.1016/j.ejogrb.2014.06.008; Hashemi et al. 2017, https://doi.org/10.1080/14767058.2017.1372413). In addition, expressions of concern have been published for two studies (Jamilian et al. 2018, https://doi.org/10.1007/s12011-017-1236-3; Zadeh Modarres 2018, https://doi.org/10.1007/s12011-017-1148-2). The retracted studies will be moved to the Excluded Studies table, and their impact on the review findings will be investigated and acted on accordingly in a future update. Initial checks indicate that removal of the six retracted studies did not make an appreciable difference to the results. Likewise, the studies for which Expressions of Concern were issued will be moved to the Awaiting classification table; they did not report any review outcomes, so removal will have no impact on the review findings. A couple may be considered to have fertility problems if they have been trying to conceive for over a year with no success. This may affect up to a quarter of all couples planning a child. It is estimated that for 40% to 50% of couples, subfertility may result from factors affecting women. Antioxidants are thought to reduce the oxidative stress brought on by these conditions. Currently, limited evidence suggests that antioxidants improve fertility, and trials have explored this area with varied results. This review assesses the evidence for the effectiveness of different antioxidants in female subfertility. To determine whether supplementary oral antioxidants compared with placebo, no treatment/standard treatment or another antioxidant improve fertility outcomes for subfertile women. We searched the following databases (from their inception to September 2019), with no language or date restriction: Cochrane Gynaecology and Fertility Group (CGFG) specialised register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and AMED. We checked reference lists of relevant studies and searched the trial registers. We included randomised controlled trials (RCTs) that compared any type, dose or combination of oral antioxidant supplement with placebo, no treatment or treatment with another antioxidant, among women attending a reproductive clinic. We excluded trials comparing antioxidants with fertility drugs alone and trials that only included fertile women attending a fertility clinic because of male partner infertility. We used standard methodological procedures expected by Cochrane. The primary review outcome was live birth; secondary outcomes included clinical pregnancy rates and adverse events. We included 63 trials involving 7760 women. Investigators compared oral antioxidants, including: combinations of antioxidants, N-acetylcysteine, melatonin, L-arginine, myo-inositol, carnitine, selenium, vitamin E, vitamin B complex, vitamin C, vitamin D+calcium, CoQ10, and omega-3-polyunsaturated fatty acids versus placebo, no treatment/standard treatment or another antioxidant. Only 27 of the 63 included trials reported funding sources. Due to the very low-quality of the evidence we are uncertain whether antioxidants improve live birth rate compared with placebo or no treatment/standard treatment (odds ratio (OR) 1.81, 95% confidence interval (CI) 1.36 to 2.43; P < 0.001, I2 = 29%; 13 RCTs, 1227 women). This suggests that among subfertile women with an expected live birth rate of 19%, the rate among women using antioxidants would be between 24% and 36%. Low-quality evidence suggests that antioxidants may improve clinical pregnancy rate compared with placebo or no treatment/standard treatment (OR 1.65, 95% CI 1.43 to 1.89; P < 0.001, I2 = 63%; 35 RCTs, 5165 women). This suggests that among subfertile women with an expected clinical pregnancy rate of 19%, the rate among women using antioxidants would be between 25% and 30%. Heterogeneity was moderately high. Overall 28 trials reported on various adverse events in the meta-analysis. The evidence suggests that the use of antioxidants makes no difference between the groups in rates of miscarriage (OR 1.13, 95% CI 0.82 to 1.55; P = 0.46, I2 = 0%; 24 RCTs, 3229 women; low-quality evidence). There was also no evidence of a difference between the groups in rates of multiple pregnancy (OR 1.00, 95% CI 0.63 to 1.56; P = 0.99, I2 = 0%; 9 RCTs, 1886 women; low-quality evidence). There was also no evidence of a difference between the groups in rates of gastrointestinal disturbances (OR 1.55, 95% CI 0.47 to 5.10; P = 0.47, I2 = 0%; 3 RCTs, 343 women; low-quality evidence). Low-quality evidence showed that there was also no difference between the groups in rates of ectopic pregnancy (OR 1.40, 95% CI 0.27 to 7.20; P = 0.69, I2 = 0%; 4 RCTs, 404 women). In the antioxidant versus antioxidant comparison, low-quality evidence shows no difference in a lower dose of melatonin being associated with an increased live-birth rate compared with higher-dose melatonin (OR 0.94, 95% CI 0.41 to 2.15; P = 0.89, I2 = 0%; 2 RCTs, 140 women). This suggests that among subfertile women with an expected live-birth rate of 24%, the rate among women using a lower dose of melatonin compared to a higher dose would be between 12% and 40%. Similarly with clinical pregnancy, there was no evidence of a difference between the groups in rates between a lower and a higher dose of melatonin (OR 0.94, 95% CI 0.41 to 2.15; P = 0.89, I2 = 0%; 2 RCTs, 140 women). Three trials reported on miscarriage in the antioxidant versus antioxidant comparison (two used doses of melatonin and one compared N-acetylcysteine versus L-carnitine). There were no miscarriages in either melatonin trial. Multiple pregnancy and gastrointestinal disturbances were not reported, and ectopic pregnancy was reported by only one trial, with no events. The study comparing N-acetylcysteine with L-carnitine did not report live birth rate. Very low-quality evidence shows no evidence of a difference in clinical pregnancy (OR 0.81, 95% CI 0.33 to 2.00; 1 RCT, 164 women; low-quality evidence). Low quality evidence shows no difference in miscarriage (OR 1.54, 95% CI 0.42 to 5.67; 1 RCT, 164 women; low-quality evidence). The study did not report multiple pregnancy, gastrointestinal disturbances or ectopic pregnancy. The overall quality of evidence was limited by serious risk of bias associated with poor reporting of methods, imprecision and inconsistency. In this review, there was low- to very low-quality evidence to show that taking an antioxidant may benefit subfertile women. Overall, there is no evidence of increased risk of miscarriage, multiple births, gastrointestinal effects or ectopic pregnancies, but evidence was of very low quality. At this time, there is limited evidence in support of supplemental oral antioxidants for subfertile women.

Showell MG ，Mackenzie-Proctor R ，Jordan V ，Hart RJ ... -  《Cochrane Database of Systematic Reviews》

Interventions to prevent surgical site infection in adults undergoing cardiac surgery.

Surgical site infection (SSI) is a common type of hospital-acquired infection and affects up to a third of patients following surgical procedures. It is associated with significant mortality and morbidity. In the United Kingdom alone, it is estimated to add another £30 million to the cost of adult cardiac surgery. Although generic guidance for SSI prevention exists, this is not specific to adult cardiac surgery. Furthermore, many of the risk factors for SSI are prevalent within the cardiac surgery population. Despite this, there is currently no standard of care for SSI prevention in adults undergoing cardiac surgery throughout the preoperative, intraoperative and postoperative periods of care, with variations in practice existing throughout from risk stratification, decontamination strategies and surveillance. Primary objective: to assess the clinical effectiveness of pre-, intra-, and postoperative interventions in the prevention of cardiac SSI. (i) to evaluate the effects of SSI prevention interventions on morbidity, mortality, and resource use; (ii) to evaluate the effects of SSI prevention care bundles on morbidity, mortality, and resource use. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid, from inception) and Embase (Ovid, from inception) on 31 May 2021. gov and the WHO International Clinical Trials Registry Platform (ICTRP) were also searched for ongoing or unpublished trials on 21 May 2021. No language restrictions were imposed. We included RCTs evaluating interventions to reduce SSI in adults (≥ 18 years of age) who have undergone any cardiac surgery. We followed the methods as per our published Cochrane protocol. Our primary outcome was surgical site infection. Our secondary outcomes were all-cause mortality, reoperation for SSI, hospital length of stay, hospital readmissions for SSI, healthcare costs and cost-effectiveness, quality of life (QoL), and adverse effects. We used the GRADE approach to assess the certainty of evidence. A total of 118 studies involving 51,854 participants were included. Twenty-two interventions to reduce SSI in adults undergoing cardiac surgery were identified. The risk of bias was judged to be high in the majority of studies. There was heterogeneity in the study populations and interventions; consequently, meta-analysis was not appropriate for many of the comparisons and these are presented as narrative summaries. We focused our reporting of findings on four comparisons deemed to be of great clinical relevance by all review authors. Decolonisation versus no decolonisation Pooled data from three studies (n = 1564) using preoperative topical oral/nasal decontamination in all patients demonstrated an uncertain direction of treatment effect in relation to total SSI (RR 0.98, 95% CI 0.70 to 1.36; I2 = 0%; very low-certainty evidence). A single study reported that decolonisation likely results in little to no difference in superficial SSI (RR 1.35, 95% CI 0.84 to 2.15; moderate-certainty evidence) and a reduction in deep SSI (RR 0.36, 95% CI 0.17 to 0.77; high-certainty evidence). The evidence on all-cause mortality from three studies (n = 1564) is very uncertain (RR 0.66, 95% CI 0.24 to 1.84; I2 = 49%; very low-certainty evidence). A single study (n = 954) demonstrated that decolonisation may result in little to no difference in hospital readmission for SSI (RR 0.80, 95% CI 0.44 to 1.45; low-certainty evidence). A single study (n = 954) reported one case of temporary discolouration of teeth in the decolonisation arm (low-certainty-evidence. Reoperation for SSI was not reported. Tight glucose control versus standard glucose control Pooled data from seven studies (n = 880) showed that tight glucose control may reduce total SSI, but the evidence is very uncertain (RR 0.41, 95% CI 0.19 to 0.85; I2 = 29%; numbers need to treat to benefit (NNTB) = 13; very-low certainty evidence). Pooled data from seven studies (n = 3334) showed tight glucose control may reduce all-cause mortality, but the evidence is very uncertain (RR 0.61, 95% CI 0.41 to 0.91; I2 = 0%; very low-certainty evidence). Based on four studies (n = 2793), there may be little to no difference in episodes of hypoglycaemia between tight control vs. standard control, but the evidence is very uncertain (RR 2.12, 95% CI 0.51 to 8.76; I2 = 72%; very low-certainty evidence). No studies reported superficial/deep SSI, reoperation for SSI, or hospital readmission for SSI. Negative pressure wound therapy (NPWT) versus standard dressings NPWT was assessed in two studies (n = 144) and it may reduce total SSI, but the evidence is very uncertain (RR 0.17, 95% CI 0.03 to 0.97; I2 = 0%; NNTB = 10; very low-certainty evidence). A single study (n = 80) reported reoperation for SSI. The relative effect could not be estimated. The certainty of evidence was judged to be very low. No studies reported superficial/deep SSI, all-cause mortality, hospital readmission for SSI, or adverse effects. Topical antimicrobials versus no topical antimicrobials Five studies (n = 5382) evaluated topical gentamicin sponge, which may reduce total SSI (RR 0.62, 95% CI 0.46 to 0.84; I2 = 48%; NNTB = 32), superficial SSI (RR 0.60, 95% CI 0.37 to 0.98; I2 = 69%), and deep SSI (RR 0.67, 95% CI 0.47 to 0.96; I2 = 5%; low-certainty evidence. Four studies (n = 4662) demonstrated that topical gentamicin sponge may result in little to no difference in all-cause mortality, but the evidence is very uncertain (RR 0.96, 95% CI 0.65 to 1.42; I2 = 0%; very low-certainty evidence). Reoperation for SSI, hospital readmission for SSI, and adverse effects were not reported in any included studies. This review provides the broadest and most recent review of the current evidence base for interventions to reduce SSI in adults undergoing cardiac surgery. Twenty-one interventions were identified across the perioperative period. Evidence is of low to very low certainty primarily due to significant heterogeneity in how interventions were implemented and the definitions of SSI used. Knowledge gaps have been identified across a number of practices that should represent key areas for future research. Efforts to standardise SSI outcome reporting are warranted.

Cardiothoracic Interdisciplinary Research Network ，Rogers LJ ，Vaja R ，Bleetman D ，Ali JM ，Rochon M ，Sanders J ，Tanner J ，Lamagni TL ，Talukder S ，Quijano-Campos JC ，Lai F ，Loubani M ，Murphy GJ ... -  《Cochrane Database of Systematic Reviews》