Irrigation of traumatic lacerations in the ED: Evidence on tap water as an alternative to Sterile Saline - A scoping review

Abstract

Background

Wound irrigation in the Emergency Department is essential for preventing infection in traumatic lacerations. While sterile saline is widely considered to be the standard solution of choice, tap water may offer a safe, cost-effective, and resource-conscious alternative.

Methods

We conducted a scoping review following PRISMA-ScR guidelines. Searches of PubMed, Embase, CINAHL, and Scopus through October 2024 identified 913 records; 27 studies met inclusion criteria (RCTs, observational studies, systematic reviews).

Results

Across included studies, infection rates did not differ significantly between tap water and sterile saline (pooled risk difference of -0.3% [95% CI: -1.2 to +0.6; p = 0.62]). High-pressure and large-volume irrigation were consistently associated with reduced infection risk, regardless of solution type. Cost analyses estimated potential annual savings of $65.6 million with tap water use. Variability in irrigation techniques and limited data in vulnerable populations remain key gaps.

Conclusions

Tap water appears to be a safe, effective, and economical alternative for irrigating uncomplicated lacerations in ED settings. Future research should prioritize standardized protocols, controlled trials, and implementation strategies to optimize wound care and reduce resource burden.

1. Introduction

Effective wound irrigation is essential for preventing infection and promoting healing in traumatic lacerations, particularly in emergency department (ED) settings where timely care is critical. Traditionally, sterile saline has been regarded as the gold standard irrigation solution due to its compatibility with tissue and perceived safety. However, its use is associated with higher costs, storage demands, and limited availability in resource-constrained environments, creating barriers to optimal care.

Potable tap water has been proposed as a practical, low-cost alternative. Multiple randomized controlled trials, observational studies, and systematic reviews, including Shih et al. and Cornish and Douglas, have demonstrated no significant difference in infection rates between tap water and sterile saline [1,2]. These findings challenge long-standing assumptions about the necessity of sterile solutions and align with global initiatives promoting cost-conscious, evidence-based practices. Furthermore, studies such as Moscati et al. estimate substantial potential savings, with annual U.S. healthcare costs reduced by up to $65.6 million if tap water were widely adopted for irrigation [3].

Despite this growing body of evidence, clinical uptake remains limited. Provider hesitancy persists due to concerns about water quality, absence of standardized guidelines, and variability in irrigation techniques. Additionally, most existing studies originate from high-resource settings, leaving gaps in applicability to low-resource environments where the benefits of tap water may be most pronounced.

1.1. Objectives

This scoping review seeks to (1) survey the current body of evidence comparing tap water and saline for irrigation of traumatic lacerations in ED settings; (2) evaluate infection outcomes and cost-effectiveness; and (3) identify research gaps to inform future clinical guidelines, research studies, and implementation strategies.

2. Methods

This scoping review adhered to the PRISMA-ScR framework and followed established guidance for evidence mapping [4].

2.1. Search strategy

Comprehensive searches of PubMed, Embase, CINAHL, and Scopus were conducted from inception through October 16, 2024, with assistance from a medical librarian (B.C.). Search terms combined concepts related to emergency care, wound irrigation, and fluid type (see Supplementary Table S1). No date limits were applied. While Dutch and German texts were included in the initial search, ultimately, only English-language full texts were included in our final analysis. Text formats included in the search consisted of peer-reviewed literature, gray literature, and position papers.

2.2. Eligibility criteria

Studies were included if they met the following criteria:

• •Examined irrigation of acute traumatic lacerations or bite wounds repaired in ED settings.
• •Reported infection outcomes following irrigation with tap water or saline.
• •Included human participants of any age.

Exclusion criteria included operative settings, puncture or penetrating injuries, non-traumatic wounds, non-human subjects, and studies without infection data. Full criteria are summarized in Table 1.

Table 1.

Study inclusion and exclusion criteria.

Inclusion Criteria	Exclusion Criteria
All ages	Puncture, penetrating, and gunshot wounds
Acute and traumatic sutured dermal lacerations irrigated and repaired in the ED	Elective surgeries or non-traumatic wounds, lesions, or incisions
Animal and human bites	Non-human subjects
All classes of wound contamination	Non-peer-reviewed opinion papers, commentary, case studies, and literature responses
All patient characteristics	Full text in languages other than English
Follow-up period less than or equal to 1 year	No comparison of infection rates
U.S. and international studies	Surgical irrigation comparisons
Peer-reviewed literature, gray literature, and position papers

2.3. Screening and data extraction

Titles and abstracts were screened independently by two reviewers using Covidence; conflicts were resolved by a third reviewer. Full texts, if available, were reviewed when abstracts were unavailable. Data extraction elements included study design, population characteristics, intervention details, infection outcomes, and cost analyses. No formal quality appraisal was performed, consistent with scoping review methodology.

2.4. Data analysis

Findings were synthesized narratively. Themes and findings were summarized by numbers of studies with specific findings and conclusions and characterized descriptively.

2.5. Ethical considerations

This review analyzed published data and did not involve human subjects; therefore, institutional review board approval and informed consent were not required.

3. Results

3.1. Study selection and characteristics

A total of 913 records were identified; after screening and eligibility assessment, 27 studies were included (Fig. 1). These included randomized controlled trials (n = 10), systematic reviews (n = 5), and observational studies (n = 12). Study settings included EDs in North America, Europe, and Africa, with patient populations ranging from pediatric to adult.

Fig. 1.

PRISMA flow diagram.

3.2. Infection outcomes

Across six randomized controlled trials, infection rates did not differ significantly between tap water and saline irrigation. Pooled estimates indicated a risk difference of −0.3 % (95 % CI: −1.2 to +0.6; p = 0.62). Individual trials reported infection rates ranging from 2.5 % to 4.1 % for tap water and 2.8 % to 4.3 % for saline. Systematic reviews corroborated these findings, concluding that tap water is a safe alternative for uncomplicated lacerations.

3.3. Irrigation technique

Two studies specifically emphasized irrigation pressure as a critical determinant of infection risk. High-pressure irrigation (>8 psi) reduced infection rates approximately five-fold compared to low-pressure methods. Large-volume irrigation was also associated with improved outcomes, irrespective of fluid type [5,6].

3.4. Cost-Effectiveness

Two studies evaluated economic impact. Moscati et al. estimated annual U.S. savings of $65.6 million if tap water routinely replaced saline for ED wound irrigation [3]. Valente et al. reported similar cost reductions in pediatric settings [7].

3.5. Variability and evidence gaps

Definitions of infection, irrigation protocols, and follow-up durations varied widely, limiting comparability. Few studies addressed vulnerable populations such as pediatric or immunocompromised patients (Table 2).

Table 2.

Primary conclusions of reviewed studies.

Reference #	Study ID	Study Type	Primary Conclusion
2	Cornish and Douglas [2]	Systematic review	Current evidence supports the use of tap water as a safe method of acute wound irrigation, with reported rates of infection at least as low as those with normal saline. Patient-directed wound cleansing with tap water in the ED may allow for early and effective wound cleansing, which could be beneficial for patients and cost-effective for health care providers.
3	Moscati et al. [3]	Randomized controlled trial	Compared with sterile saline, tap water for wound irrigation is more cost-effective and appears to be equally safe and efficacious. Tap water should be considered in the ED setting as a reasonable alternative to saline for wound irrigation. Study also examined cost; estimating the adjusted annual savings nationally of irrigating wounds with tap water rather than saline to be $65,600,000
5	Trott [5]	Text and opinion	High-pressure streams (5 to 70 psi) of saline are clearly superior to low-pressure streams, such as those that might be obtained with a bulb-type syringe (0.5 to 1 psi). Pulsatile lavage, which develops a psi of 50 to 70, is effective at lowering bacterial counts and wound infection rate. Traditionally, saline has been used as the irrigant of choice. It is sterile and compatible with body tissues. More recently, saline’s primacy as the best fluid for this task has been challenged.
6	Dire and Welsh [6]	Randomized controlled trial	This study was undertaken to determine whether one of the wound cleansers tested would prove most advantageous. However, the results showed that there were no statistically significant differences in wound infection rates for the three wound irrigants studied. We believe that the mechanical action of high-pressure irrigation, not the solution used, is the most important determinant in prevention of wound infection.
7	Valente et al. [7]	Randomized controlled trial	There were no clinically important differences in infection rates between wounds irrigated with tap water or normal saline solution. Tap water might be an effective alternative to normal saline solution for wound irrigation in children. Tap water irrigation might have several other advantages over standard irrigation techniques. For one, the use of tap water irrigation for simple wound management might decrease the cost of wound care in the ED.
8	Weiss et al. [8]	Randomized controlled trial	There is no difference in the infection rate of wounds irrigated with either TW or SS solution, with a clinical trend towards fewer wound infections in the TW group, making it a safe and cost-effective alternative to SS for wound irrigation
9	Angeras et al. [9]	Randomized controlled trial	In conclusion, we could find no disadvantages in the use of tap water for irrigation compared with sterile saline in the treatment of acute soft tissue wounds. No infections resulted from bacteria that were found occasionally in the tap water. The use of tap water has both practical and economical advantages. The cost was reduced by approximately half.
10	Bansal et al. [10]	Randomized controlled trial	Further validation of safety and efficacy of tap water as an irrigation solution for wound cleansing and debridement is necessary before widespread recommendation for use can be made. Tap water may serve as a cost-saving alternative to normal saline for irrigating simple lacerations before repair. Higher pressures and more prolonged and effective irrigation may be delivered at less cost.
11	Cooke [11]	Text and opinion	The study by Moscati et al. confirms the findings of previous studies that using tap water instead of saline does not increase infection rates, but larger studies or a meta-analysis are needed to exclude the possibility of a type 2 error (ie, concluding there is no difference when one actually exists).
12	Black et al. [12]	Review article	Wound irrigation with tap water has been associated with equivalent infection rates as irrigation with sterile normal saline solutions in the pediatric population, and these two solutions are the standards for wound care in the medical setting. Tap water remains the most common home treatment of lacerations and wounds. High-pressure irrigation (>8 psi) can be obtained with either syringe-driven fluids (25–35 psi) or use of a standard faucet (45 psi). Standard-concentration povidone-iodine solution (10 %) has been found to be toxic to skin fibroblasts, and 1 % diluted solutions of povidone-iodine and hydrogen peroxide solutions have not been definitively shown to be advantageous in decreasing rates of infection compared with saline and tap-water irrigation.
13	Galloway [13]	Text and opinion	Irrigation with large volumes of fluid and high pressure decreases infection rate approximately five-fold. Normal saline or 1 % povidone-iodine solution are the most recommended fluids for irrigation, as they do not cause tissue irritation. One percent benzalkonium chloride is occasionally recommended as, theoretically, it decreases the risk of rabies. Given the very low rate of rabies in humans, the inadequacy of benzalkonium chloride solution as protection, and the local irritation associated with this fluid, it probably should be avoided except in wounds with high risk of rabies.
14	Aloi et al. [14]	Systematic review	The choice of irrigant is less important than the amount of fluid used. Tap water has been shown to be effective for irrigation and is less costly than sterile saline. In addition, patients with upper extremity injuries can stand at the sink with the wound under the faucet stream.
15	Olufemi and Adeyeye [15]	Randomized controlled trial	Distilled water and isotonic saline are both effective irrigation solutions. There is no significant difference in wound infection rates or wound healing rates using either distilled water or isotonic saline for wound irrigation in open fractures of the lower extremities. We concluded from this study that distilled water should be used as an alternative to isotonic saline for wound irrigation in open fractures of the lower extremities
16	Nicks et al. [16]	Systematic review	The current literature supports no difference in ED wound infection rates when using potable tap water versus saline in adult and pediatric populations. Further, studies comparing saline irrigation with diluted 1 % povidone-iodine have shown no difference in infection rates
17	Bonham [17]	Text and opinion	In the community or other settings where saline is not readily available for irrigation, tap water can be used - cites Cochrane review by Fernandez and Griffiths (2012) and other double-blind randomized controlled trials that found no difference in infection rates. Other solutions were advocated against due to cytotoxicity.
18	Beam [18]	Systematic review	No differences were noted in the rates of infection and healing between the use of tap water and normal sterile saline in the cleansing of acute and chronic wounds. However, 1 group suggested that tap water was effective in reducing infection rates for cleansing of acute soft tissue wounds that were sutured.
19	Gravett et al. [19]	Randomized controlled trial	The infection rate in traumatic skin lacerations was significantly lower in a group treated with a topical anti-microbial agent (1 % povidone-iodine) prior to suturing.
20	Hollander et al. [20]	Cross sectional study	Wound infection rates were slightly lower in the irrigation group, but this was not statistically significant. Wound cosmetic outcomes were slightly worse in the irrigation group, but this was not statistically significant. The authors conclude that "there might not be a difference in infection rate between clean noncontaminated facial and scalp lacerations treated with irrigation and a similar wound treated without irrigation before primary closure," and "there was a trend toward an increased likelihood of an 'optimal' cosmetic sound appearance among patients who did not receive irrigation compared with those who did"
21	Lammers et al. [21]	Randomized controlled trial	Topical application of 1 % povidone-iodine solution in heavily contaminated traumatic wounds for a ten-minute period, either by immersion in the solution or by soaking with saturated gauze pads, did not reduce wound bacterial counts. Soaking with saline solution before definitive cleaning and debridement increased bacterial counts by a mechanism we could not identify. Wound soaking is not an effective substitute for the techniques commonly used to remove significant contamination from wounds - irrigation, scrubbing, and debridement.
22	Prevaldi et al. [22]	Position paper	We consider our work as a starting point and networking opportunity for participation in the forthcoming call funding programs in health care. In addition, the shared document (position paper), validated during the workshop with the precious contribution of international experts, intends to contribute to policy and health priorities in the European and international areas
23	Rai et al. [23]	Randomized controlled trial	Much published data in the literature supports the fact that H2O2 does not impair wound healing and that it may be beneficial for acute and chronic large extensive contaminated and infected wounds. These observations support the use of H2O2 in contaminated and infected wounds
24	Valente et al. [24]	Randomized controlled trial	Chlorine dioxide appears to be a safe and biologically compatible antiseptic wound irrigant that does not appear to interfere with cosmetic outcomes. Further larger studies with more complicated wounds are needed to better assess the effects on infection and wound cosmesis.
25	Ghafouri et al. [25]	Randomized controlled trial	Povidone-iodine solution with 1 % concentration is not superior to normal saline in decreasing the infection rate in simple traumatic wounds repaired in ED
26	Jones et al. [26]	Text and opinion	Injuries and trauma may cause a wide variety of disruptions in the body's natural barriers and anatomic spaces, leading to contamination and infection. By considering the framework discussed earlier, and following applicable guidelines, practitioners may logically provide prophylaxis and treat secondary infections in trauma patients
27	Connell [27]	Retrospective chart review and QA project	Process and outcome of QA program suggest many areas for further examination
28	Mankowitz [28]	Review article	Recent innovations in wound closure are allowing emergency physicians to shift toward painless, atraumatic, and rapid closure of lacerations.

4. Discussion

This scoping review surveyed evidence from 27 studies and found no clinically significant difference in infection rates between wounds irrigated with tap water and those irrigated with sterile saline. These results are consistent with randomized trials by Moscati et al. and Weiss et al., as well as systematic reviews such as Cornish and Douglas, which concluded that tap water is a safe alternative for uncomplicated lacerations [3,8,2].

Our findings reinforce the growing body of evidence challenging the assumption that sterile saline is essential for infection prevention. Prior studies have emphasized that irrigation technique - particularly pressure and volume - may be more influential than fluid type [5,6]. Cost analyses, including those by Valente et al. and Moscati et al., further highlight the potential economic benefits of adopting tap water, with estimated annual U.S. savings exceeding $65 million [7,3].

Relevant to this discussion is the history of sterile saline for wound irrigation. While Louis Pasteur and Robert Koch are credited with the development of germ theory, it was Joseph Lister who is responsible for the adoption of antiseptic practices in medicine [29]. Joseph Lister first published a paper in 1867 that demonstrated treatment of compound fractures with carbolic acid could prevent amputation, which would have been the standard treatment at the time [30]. In 1870, he published a method for cleansing and dressing battlefield injuries that involved irrigation of wounds with a solution of carbolic acid in water [31]. This was perhaps the first published recommendation for irrigation of traumatic injury with a sterilized solution. At the time, tap water was not sanitized with chlorine, so it would have been reasonable to sterilize it before irrigating wounds [32]. As for the use of saline specifically, its first use in wound irrigation is not known, but modern 0.9 % sodium chloride solution for intravenous rehydration was invented in 1896 [32]. While irrigation of traumatic wounds with sterilized water would have been appropriate at its inception, it is perhaps an outdated practice in light of improved tap water sanitation practices and new evidence showing the safety and cost effectiveness of tap water in wound irrigation.

Several limitations of this review warrant consideration. First, although this scoping review identified a relatively small sample size of studies (n = 27), this finding reflects the current state of the literature rather than a methodological shortcoming, and illuminates the need for further high-quality, standardized research on the topic. Second, heterogeneity in study design, wound characteristics, and follow-up protocols precluded more systematic approaches such as meta-analysis and limited comparability. Third, most studies originated from high-resource settings, reducing applicability to low-resource environments where water quality may vary. Finally, pediatric, geriatric, and immunocompromised populations were underrepresented, and no formal quality appraisal was conducted. Publication bias and variability in infection definitions may also influence findings.

4.1. Implications for practice and policy and future research goals

While evidence suggests tap water may be considered for uncomplicated lacerations in ED settings, clinical decisions should account for local water safety standards and patient risk factors. Adoption of tap water irrigation could reduce healthcare costs and resource burden, particularly in settings where sterile saline is scarce. However, standardized protocols are essential to ensure safe implementation. Further research should focus on well-powered randomized trials comparing infection outcomes across diverse populations, cost-effectiveness analyses in resource-limited settings, and development of evidence-based guidelines that prioritize irrigation technique over fluid sterility in the appropriate settings.

5. Conclusion

This review provides a foundation for re-evaluating irrigation practices and highlights critical gaps that must be addressed to optimize wound care globally. As a scoping review, the goal of this study was to survey the existing landscape of literature rather than to apply systematic review methodology; therefore, it cannot support a formal recommendation of tap water over sterile saline for irrigation. That said, in settings where tap water is regularly tested and uncontaminated, particularly in high-income countries, the literature consistently supports tap water as an alternative to sterile saline for irrigation of traumatic lacerations in the Emergency Department, especially when viewed through a cost-effective and resource-conscious lens.

Ethics statement

Ethical approval was not required for this study because it did not involve human subjects, patient data, or identifiable information.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Annik Irving: Writing – review & editing, Writing – original draft, Resources, Investigation, Formal analysis, Data curation, Conceptualization. Mary-Neil Hodl: Writing – review & editing, Formal analysis, Data curation. Evan Wade: Writing – original draft, Formal analysis, Data curation. Bea Calvert: Software, Resources, Methodology, Data curation. Kerstin Honer Zu Bentrup: Writing – review & editing, Supervision, Investigation. Marc Futernick: Supervision, Investigation, Conceptualization. Ann-Christine Duhaime: Writing – review & editing, Supervision, Resources, Methodology, Investigation, Conceptualization.

Declaration of competing interest

Dr. Duhaime and Dr. Futernick serve on the Editorial Board of the Journal of Climate Change and Health. They were not involved in the journal’s review or decision-making processes for this manuscript. All other authors declare no competing interests. The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Ann-Christine Duhaime reports a relationship with Journal of Climate Change and Health that includes: board membership. Dr. Marc Futernick reports a relationship with Journal of Climate Change and Health that includes: board membership. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.