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Preop chlorhexidine-alcohol more effective than povidone-iodine in preventing surgical-site infections

Clinical Question:
Is preoperative skin cleansing with chlorhexidine-alcohol superior to cleansing with povidone-iodine in preventing surgical-site infections?

Bottom Line:
In patients undergoing clean-contaminated surgery, preoperative skin cleansing with chlorhexidine-alcohol is more effective than cleansing with povidone-iodine in reducing the rate of surgical-site infections. (LOE = 1b)

Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010;362:18-26.  [PMID:20054046]

Study Design:
Randomized controlled trial (double-blinded)


Inpatient (ward only)

Chlorhexidine baths have been shown to reduce bloodstream infections in medical intensive care unit patients; however, a previous systematic review did not show a clear benefit of this treatment in reducing surgical-site infections. Using concealed allocation, these study authors randomized patients undergoing clean-contaminated surgery -- either abdominal, thoracic, gynecologic, or urologic procedures -- to receive preoperative skin cleansing with 2% chlorhexidine gluconate plus 70% isopropyl alcohol (n = 409) or with 10% povidone-iodine (n = 440). All patients received preoperative systemic antibiotic prophylaxis. Only the operating surgeon was aware of the treatment assignment. Investigators followed up patients for 30 days after surgery for development of surgical-site infection. In both groups, patients had a mean age of 53 years, a mean duration of surgery of 3 hours, and similar underlying comorbidities. Analysis was by intention to treat. Patients in the chlorhexidine-alcohol group had a decreased rate of surgical-site infection compared with those in the povidone-iodine group (9.5% vs 16.1%; P = .004; relative risk = 0.59; 95% CI, 0.41-0.85). You would have to treat 15 patients with chlorhexidine-alcohol to prevent 1 additional surgical-site infection (number needed to treat = 15; 11-41). This treatment significantly reduced both superficial and deep incisional infections (superficial: 4.2% vs 8.6%; P = .008; deep: 1% vs 3%; P = .05), but not organ-space infections. The per-protocol analysis, which excluded patients who had clean surgery instead of clean-contaminated surgery and those who did not complete 30-day follow-up, resulted in similar findings. Study-drug-related adverse events were minor and included pruritus and erythema at the surgical site. There was no difference in number of adverse events between the 2 groups.


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