chlorhexidine/alcohol is not superior to other skin ... · chlorhexidine/alcohol is not superior to...
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Chlorhexidine/Alcohol is Not Superior to Other Skin
Preparations in the Prevention of Surgical Site Infections
Joon H. Lee, Research ResidentUniversity of Colorado Department of Surgery
Surgical Site Infections
• 2-5% of all patients undergoing surgery
• Approximately 300,00-500,000 SSI/year
• Cost $3,000-$29,000 per patient per SSI
• Cost to US health care system: $10 Billion
AJ Mangram. Am J Infect Control. 1999; DJ Anderson. Infect Dis Clin N Am. 2010
Current CDC Recommendations for Skin Preparation
1. Skin free of gross contamination2. Apply antiseptic in concentric circles
beginning at site of proposed incision3. Area large enough to extend
incision/create new incisions, drains4. No preference for chlorhexidine or iodine5. No preference for +alcohol/-alcohol
AJ Mangram. Am J Infect Control. 1999.
Studies of Different Skin Preps
Cochrane Review 2009:
• 7 Included Studies – all RCT
• Inclusion specific to “Clean” cases
• Only a single study found a significant
difference: AR Berry. J Hosp Infect. 1982.
Cochrane Review 2009
“There is insufficient evidence from randomised trials to support or refute
the use of antiseptic preparation of skin at operative sites, or of one antiseptic
over another”
Berry et al.
• RCT in single center in Edinburgh; n=866
• Povidone-iodine 10% in alcohol vs.
0.5% Chlorhexidine in spirits
• 14.8% (Iodine) vs 9.7% (Chlorhex);p=0.03
AR Berry. J Hosp Infect. 1982.
Berry et al.
“In patients who underwent operations on the large bowel and other laparotomies,
wound abnormalities were less common in the povidone-iodine than in the
chlorhexidine group…”
AR Berry. J Hosp Infect. 1982.
Berry et al.
AR Berry. J Hosp Infect. 1982.
Berry et al.
“We conclude that, on the evidence of this study, there is no overwhelming case for
using one compound rather than the other as an all-purpose preparation and scrub.”
AR Berry. J Hosp Infect. 1982.
ChloraPrep
• Randomized Multicenter (6) Controlled Trial; n=849
• 2% Chlorhexidine in 70% Iso- propyl alcohol vs. 10% povidone-iodine aqueous paint
• Clean-contaminated cases• 9.5% (Iodine) vs. 16.1% (ChloraPrep) SSI
(p=0.004)
RO Darouiche. N Engl J Med. 2010
Critique of Darouiche et al.
• Unusually high number of post-operative SSIs in povidone-iodine group (16.1%)
• Failure to include the bactericidal alcohol solvent in both treatment groups
BR Swenson. Infect Control Hosp Epidemiol. 2010.
Superiority of Iodine
• Controlled Sequential Implementation Study• N=3209• Three skin preps:
– Povidone scrub vs.– Chloraprep vs.– Iodine povacrylex in alcohol (Duraprep)
• Ongoing data collection for SSI for NSQIP
BR Swenson. Infect Control Hosp Epidemiol. 2009.
Swenson et al.• Infection control measures standardized
prior to initiation of trial (3.5% absolute risk reduction in SSI)
BR Swenson. Infect Control Hosp Epidemiol. 2009.
Tx Paint Chlora- Prep
DuraPrep
% SSI 6.4* 7.1* 3.9*
*p=0.002
Swenson et al.• Subgroup analysis versus Darouiche et al.
for clean-contaminated cases:
BR Swenson. Infect Control Hosp Epidemiol. 2009.
Darouiche et al. Swenson et al.
Iodine Paint 16.1% 8.7%*ChloraPrep 9.5% 10.7%*DuraPrep 5.9%*
*p=0.02
Swenson et al.• Subgroup analysis versus Darouiche et al.
for clean-contaminated cases:
BR Swenson. Infect Control Hosp Epidemiol. 2009.
Darouiche et al. Swenson et al.
Iodine Paint 16.1% 8.7%*ChloraPrep 9.5% 10.7%*DuraPrep 5.9%*
*p=0.02
Conclusions
• Skin preparation with Iodine-povidone paint possibly inferior
• Lack of consensus based on data for overall superior prep
• Iodine-based preparations in alcohol may be superior
This is Never Sterile
No matter how much Chlorhexidine or Iodine in alcohol you use…
