Abstract Background Surgical site infections (SSIs) account for up to 20% of healthcare-associated infections and significantly increase morbidity, mortality, and healthcare costs. Preoperative decolonization strategies—targeting nasal and/or skin colonization—are variably recommended across surgical disciplines. While benefits have been reported in elective arthroplasty, their efficacy in trauma surgery remains unclear. Methods We conducted a systematic review and meta-analysis in accordance with PRISMA 2020 guidelines and the Cochrane Handbook for systematic reviews and Meta-Analyses. The study protocol was registered in PROSPERO (CRD420250642382). MEDLINE, Cochrane Library, ClinicalTrials.gov, and Google Deep Research were searched up to 26 February 2025. Eligible studies reported on patients undergoing elective lower extremity joint arthroplasty or fracture surgery and compared nasal, skin, or combined decolonization protocols to standard care. Primary outcome was the incidence of SSIs. Risk of bias was assessed using RoB 2 for RCTs and ROBINS-I for observational studies. Results Nineteen studies ( n = 64,796 patients) met inclusion criteria. Of those, five were RCTs and 14 were observational, retrospective or pre-post studies. 17 focused on elective arthroplasty; two addressed fracture surgery. Among orthopedic patients, nasal decolonization reduced SSIs with an OR of 0.65 (95% CI, 0.34–1.22), skin decolonization with an OR of 0.43 (95% CI, 0.29–0.64), and combined strategies with an OR of 0.48 (95% CI, 0.33–0.69). Trauma surgery data were limited and heterogeneous (I² = 81%); the pooled OR for combined decolonization was 0.59 (95% CI, 0.08–4.32), but with conflicting individual study results. Conclusion Nasal and skin decolonization protocols seem to reduce the incidence of SSIs in elective hip and knee arthroplasty. Thereby, skin, nasal and combined decolonization strategies may be used. However, current evidence in fracture surgery remains insufficient and inconsistent. High-quality randomized trials are urgently needed to evaluate decolonization efficacy in lower extremity trauma surgery.
Kurme et al. (2026) studied this question.