Systematic Review and Meta-Analysis of Preoperative Antisepsis with Combination Chlorhexidine and Povidone-Iodine

Abstract

Surgical site infection (SSI) is a significant cause of postoperative morbidity and mortality, increasing length of hospital stay and cost of care. [1][2][3] SSIs are the second most common cause of health care associated infection; U.S. studies have estimated a $45 billion annual cost. 4 Since Joseph Lister popularized the role of preoperative antisepsis in the 1800s, attempts to identify the optimal process and/or agent have resulted in several trials and much scientific tribulation. 5 Despite this effort, no absolute has emerged; a good example is the efforts to identify which AbstractImportance Effective preoperative antisepsis is recognized to prevent surgical site infection (SSI), although the definitive method is unclear. Many have compared chlorhexidine (CHG) with povidone-iodine (PVI), but there is emerging evidence for combination usage. Objective To conduct a systematic review and meta-analysis to evaluate if combination skin preparation (1) reduces colonization at the operative site and (2) prevents SSI compared with single-agent use. Data Sources A literature search of MEDLINE, Embase, and Cochrane Database of Clinical Trials was performed. Study Selection Comparative, human trials considering the combination use of CHG and PVI, as preoperative antisepsis, to single-agent CHG or PVI use were included. Studies were excluded from meta-analysis if the use or absence of alcohol was inconsistent between study arms. Data Extraction and Synthesis The study was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Main Outcomes and Measures The primary outcome for meta-analysis was surgical site infection. The secondary outcome was colonization at the operative site. Results Eighteen publications with a combination of CHG and PVI use were identified. Of these, 12/14 inferred promise for combination usage, including four trials eligible for meta-analysis. Only one trial reported SSI as its outcome. The remaining three considered bacterial colonization. Combination preparation had a pooled odds ratio for complete decolonization of 5.62 (95% confidence interval 3.2 to 9.7, p < 0.00001). There was no evidence of heterogeneity (Cochran's Q 2.1, 2 df, p ¼ 0.35). Conclusions and Relevance There is emerging, albeit low-quality, evidence in favor of combination CHG and PVI preoperative antisepsis. Further rigorous investigation is indicated.

Randomized clinical trial of single skin sterilization with a povidone–iodine applicatorversusconventional skin sterilization in abdominal surgery

“…Various reports on wound infection control have been published, and guidelines have also been provided by the CDC and the UK National Institute for Health and Care Excellence. Regarding skin sterilization before surgery, some studies have shown efficacy for various types of disinfectant, but there remains inadequate evidence with respect to disinfection procedures and amounts of disinfectant used.…”

Current preoperative antisepsis in neurosurgery: an example of the challenges in implementing evidence-based medicine to surgical practice

“…9,[12][13][14][15][16][17] In addition, their application in an alcohol solution as compared with an aqueous solution is probably more effective. This is more clearly the case for CHG. 17 However, we have recently demonstrated through meta-analysis 18 and a large prospective series 19 that CHG in combination with PVI is more effective at reducing surgical site infection than a single agent alone. This is reinforced with precedent that CHG and PVI have different mechanisms of action and efficacy against bacterial and fungal pathogens and ultimately have a theoretical synergistic effect.…”

Sequential use of povidone-iodine and chlorhexidine for cutaneous antisepsis: A systematic review

“…A meta-analysis found that "complete bacterial decolonization" of surgical sites was more likely with sequential use of povidone-iodine and chlorhexidine than either antiseptic alone (odds ratio [OR], 0.18; 95% confidence interval [CI], 0.1-0.31]). 11 This finding may reflect different mechanisms of action of these antiseptic agents. In addition to the aforementioned studies, concurrent use of these antiseptics leads to a greater reduction of Staphylococcus aureus on mucosal tissue compared to either antiseptic alone.…”