Preoperative skin antisepsis with chlorhexidine gluconate versus povidone-iodine: a prospective analysis of 6959 consecutive spinal surgery patients

Ghobrial, George M.; Wang, Michael Y.; Green, Barth A.; Levene, Howard; Manzano, Glen; Vanni, Steven; Starke, Robert M.; Jimsheleishvili, George; Crandall, Kenneth M.; Dididze, Marina; Levi, Allan D.

doi:10.3171/2017.5.spine17158

Cited by 36 publications

(33 citation statements)

References 37 publications

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“…In a prospective study in patients undergoing elective plastic surgery, a preoperative shower with PVP-I significantly decreased presurgical staphylococcal skin colonization versus controls (P Ͻ 0.0019) (69). Furthermore, the efficacy of preoperative skin decontamination with topical 7.5 or 10% PVP-I was similar to that of topical 2% chlorhexidine in the prevention of SSI in patients undergoing spinal or cardiac surgery, respectively (Table 2) (72,73).…”

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confidence: 92%

“…Four of these studies were prospective with a randomized controlled design (22,(68)(69)(70), and the remaining studies were retrospective database studies with historical controls (71)(72)(73)(74)(75). The main outcome measures were either S. aureus colonization status (68)(69)(70) or the prevention of SSI (22,(71)(72)(73)(74)(75). Current World Health Organization (WHO) guidelines for decolonization recommend intranasal mupirocin with or without chlorhexidine body wash in patients with known S. aureus carriage that are undergoing cardiothoracic or orthopedic surgery 1; patients undergoing other types of surgery with known S. aureus carriage should also be considered for decolonization with the same regimen (1).…”

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confidence: 99%

“…Current World Health Organization (WHO) guidelines for decolonization recommend intranasal mupirocin with or without chlorhexidine body wash in patients with known S. aureus carriage that are undergoing cardiothoracic or orthopedic surgery 1; patients undergoing other types of surgery with known S. aureus carriage should also be considered for decolonization with the same regimen (1). A summary of clinical studies investigating intranasal and topical PVP-I is presented in Table 2 (22,(68)(69)(70)(71)(72)(73)(74)(75).…”

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confidence: 99%

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Povidone Iodine: Properties, Mechanisms of Action, and Role in Infection Control and Staphylococcus aureus Decolonization

Lepelletier¹,

Maillard

Pozzetto

et al. 2020

Antimicrob Agents Chemother

123

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Nasal decolonization is an integral part of the strategies used to control and prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA) infections. The two most commonly used agents for decolonization are intranasal mupirocin 2% ointment and chlorhexidine wash but the increasing emergence of resistance and treatment failure has underscored the need for alternative therapies. This article discusses povidone iodine (PVP-I) as an alternative decolonization agent and is based on literature reviewed during an Expert's workshop on resistance and MRSA decolonization. When compared to chlorhexidine and mupirocin, respectively, PVP-I 10% and 7.5% solution had rapid and superior bactericidal activity against MRSA in in vitro and ex vivo studies. Notably, PVP-I 10% and 5% solutions were also active against both chlorhexidine-resistant and mupirocin-resistant strains, respectively. Unlike chlorhexidine and mupirocin, available reports have not observed a link between PVP-I and the induction of bacterial resistance or cross-resistance to antiseptics and antibiotics. These pre-clinical findings also translate into clinical decolonization, where intranasal PVP-I significantly improved the efficacy of chlorhexidine wash and was as effective as mupirocin in reducing surgical site infection (SSI) in orthopedic surgery. Overall, these qualities of PVP-I make it a useful alternative decolonizing agent for the prevention of S. aureus infections, but additional experimental and clinical data are required to further evaluate the use of PVP-I in this setting.

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confidence: 92%

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confidence: 99%

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confidence: 99%

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Povidone Iodine: Properties, Mechanisms of Action, and Role in Infection Control and Staphylococcus aureus Decolonization

Lepelletier¹,

Maillard

Pozzetto

et al. 2020

Antimicrob Agents Chemother

123

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“…However, on secondary end-point analysis, skin antisepsis with CHG-ALC was associated with significantly higher odd ratios for overall SSI, including prosthetic joint infection [31]. In another trial, skin antisepsis with 7.5% PVP-I in aqueous solution did not show a significant difference to 2% CHG in 70% IPA in the SSI rate after neurosurgical spine procedures in adults [32].…”

Section: Discussionmentioning

confidence: 91%

Povidone-iodine-alcohol is superior to chlorhexidine-alcohol in its antimicrobial efficacy on the anaerobic microbial flora in surgical skin preparation of the shoulder region

Dörfel

Daeschlein

Maiwald

et al. 2019

Preprint

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Background: Cutibacterium acnes is part of the anaerobic skin microbiome and resides in deeper skin layers. The organism is an important agent of surgical site infections (SSI), particularly in shoulder surgery, and is difficult to target with skin antisepsis. We hypothesized that prolonged preparation with an agent that penetrates deeper into the skin is more effective in shoulder surgery. Thus, we compared two different classes of antiseptics, each combined with alcohol, and each applied with two different contact times. Methods: Shoulders of 16 healthy volunteers were treated for 2.5 min (standard) or 30 min (prolonged) with alcohol-based chlorhexidine (CHG-ALC; 2% w/v CHG, 55% w/v [70% v/v] 2-propanol) or alcohol-based povidone iodine (PVP-I-ALC; 3.24% w/v PVP-I, 38.9% w/v 2-propanol, 37.3% w/v ethanol). Skin sites were sampled before, immediately after, and 3 h after treatment. Results: Aerobic skin flora was reduced more effectively by PVP-I-ALC than by CHG-ALC after 2.5 min and immediate sampling, but not after prolonged contact times and 3-h sampling. Anaerobic flora was reduced more effectively by PVP-I-ALC than by CHG-ALC after standard and prolonged contact times and immediate sampling, but not after 3-h sampling. None of the volunteers reported negative effects from skin antisepsis. Conclusions: PVP-I-ALC is more efficacious than CHG-ALC for topical skin antisepsis regarding the anaerobic flora on the skin of the shoulder. Standard and prolonged contact times demonstrated superiority for PVP-I-ALC for samples taken immediately, but missed significance 3 h after application. The clinical relevance of these findings should be studied with SSI as an endpoint.

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“…However, on secondary end-point analysis, skin antisepsis with CHG-ALC was associated with signi cantly higher odd ratios for overall SSI, including prosthetic joint infection [31]. In another trial, skin antisepsis with 7.5% PVP-I in aqueous solution did not show a signi cant difference to 2% CHG in 70% IPA in the SSI rate after neurosurgical spine procedures in adults [32].…”

Section: Discussionmentioning

confidence: 92%

Povidone-iodine-alcohol is superior to chlorhexidine-alcohol in its antimicrobial efficacy on the anaerobic microbial flora in surgical skin preparation of the shoulder Region

Dörfel

Daeschlein²,

Maiwald

et al. 2020

Preprint

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Background Cutibacterium acnes is part of the anaerobic skin microbiome and resides in deeper skin layers. The organism is an agent of surgical site infections (SSI) in shoulder surgery and is difficult to target with skin antisepsis. We hypothesized that prolonged preparation with an agent that penetrates more deeply into the skin is more effective in shoulder surgery. Thus, we compared two different classes of antiseptics, each combined with alcohol, and each applied with two different contact times. Methods Using a cross-over study design, shoulders of 16 healthy volunteers were treated for 2.5 min (standard) or 30 min (prolonged) with alcohol-based chlorhexidine (CHG-ALC; 2% w/v CHG, 55% w/v [70% v/v] 2-propanol) or alcohol-based povidone-iodine (PVP-I-ALC; 3.24% w/v PVP-I, 38.9% w/v 2-propanol, 37.3% w/v ethanol). Skin sites were sampled before, immediately after, and 3 h after treatment, using a standardized cup-scrub technique. Results Aerobic skin flora was reduced more effectively by PVP-I-ALC than by CHG-ALC after 2.5 min application and immediate sampling (reduction factor [RF] 2.55±0.75 vs. 1.94±0.91, p = 0.04), but not after prolonged contact times and 3-h sampling. Coagulase-negative staphylococci were completely eliminated after PVP-I-ALC application, but still recovered from 3 of 16 and 1 of 16 samples after 2.5-min and 30-min CHG-ALC application and immediate sampling, respectively. Anaerobic flora, mostly consisting of C. acnes, was reduced more effectively by PVP-I-ALC than by CHG-ALC after standard (RF 3.96±1.46 vs. 1.74±1.24, p < 0.01) and prolonged (RF 3.14±1.20 vs. 1.38±1.16, p < 0.01) contact times. Sampling 3 h after treatment did not show any significant difference. None of the volunteers reported adverse events. Conclusions PVP-I-ALC is more efficacious than CHG-ALC for topical skin antisepsis concerning the anaerobic flora on the skin of the shoulder. Standard and prolonged contact times demonstrated superiority for PVP-I-ALC for samples taken immediately, but missed significance 3 h after application. The results underscore the need for protection against C. acnes and coagulase-negative staphylococci in orthopaedic surgery and the need to prevent infections caused by these organisms. The clinical relevance of these findings, however, should be studied with SSI as an endpoint.

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Preoperative skin antisepsis with chlorhexidine gluconate versus povidone-iodine: a prospective analysis of 6959 consecutive spinal surgery patients

Cited by 36 publications

References 37 publications

Povidone Iodine: Properties, Mechanisms of Action, and Role in Infection Control and Staphylococcus aureus Decolonization

Povidone Iodine: Properties, Mechanisms of Action, and Role in Infection Control and Staphylococcus aureus Decolonization

Povidone-iodine-alcohol is superior to chlorhexidine-alcohol in its antimicrobial efficacy on the anaerobic microbial flora in surgical skin preparation of the shoulder region

Povidone-iodine-alcohol is superior to chlorhexidine-alcohol in its antimicrobial efficacy on the anaerobic microbial flora in surgical skin preparation of the shoulder Region

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