Chlorhexidine-Alcohol Versus Povidone-Iodine for Surgical-Site Antisepsis

Abstract

Conclusion: For clean-contaminated surgery, cleansing of the patient's skin with chlorhexidine-alcohol reduces surgical-site infections compared with cleansing with povidone-iodine. Summary: There are 27 million operative procedures performed annually in the United States (Infect Control Hosp Epidemiol 1999;20:250-78). Surgical-site infections occur in 300,000-500,000 patients in the United States each year (J Am Coll Surg 2008;206:814-9; JAMA 2005;294:2035-42). There are recommendations by the Centers for Disease Control and Prevention (CDC) to use 2% chlorhexidine preparations for preoperative cleansing of sites for insertion of vascular catheters, but no CDC recommendations have been put forth regarding antiseptics to prevent surgical-site infection in surgical procedures. This study compared the efficacy of povidone-iodine and chlorhexidine-alcohol in preventing surgical-site infections in patients with clean-contaminated operations in six university-affiliated hospitals. Patients were randomly assigned to preoperative skin preparation with chlorhexidine-alcohol scrub or povidone-iodine scrub and paint. Surgical-site infection ≤30 days was the primary outcome. Secondary outcomes included individual types of surgical-site infection. There were 849 patients (440 in the povidone-iodine group and 409 in the chlorhexidine-alcohol group) that qualified for intention to treat analysis. Surgical-site infection rates were lower in the chlorhexidine-alcohol group than the povidone-iodine group (9.5% vs 16.1%; relative risk, 0.59; 95% confidence interval, 0.41-0.85; P = .004). With regard to secondary end points, chlorhexidine-alcohol was more protective against surgical-site infections than povidone-iodine for superficial incisional infections (4.2% vs 8.6%, P = .008) and deep incisional infections (1% vs 3%, P = .05). The difference in protection against organ-space infections was 4.4% vs 4.5%. There were 813 patients who remained in the study for 30 days and were subject to a per protocol analysis. Overall results remain similar. No differences were noted in adverse events in the two study groups. Comment: In the accompanying editorial to this article, Dr Richard Wenzel makes the observation that human beings have approximately 1013 total cells, with a total number of colonizing microbes per human being of 1014. Basically, bacteria have a 10:1 numerical advantage! The study indicates that all infections at a specific anatomic site can be reduced with a relatively inexpensive process. By substituting chlorhexidine-alcohol for povidone-iodine, all we need to treat are 17 surgical patients with clean-contaminated wounds to prevent 1 surgical-site infection. Of course, vascular surgical procedures fall primarily into the clean-wound category rather than clean-contaminated, as studied here. Nevertheless, the weight of the available literature with respect to chlorhexidine-alcohol vs povidone-iodine for surgical-site antisepsis clearly indicates that chlorhexidine-alcohol is the preferred agent.