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Objective To compare use of chlorhexidine with use of iodine for preoperative skin antisepsis with respect to effectiveness in preventing surgical site infections (SSIs) and cost. Methods We searched the Agency for Healthcare Research and Quality website, the Cochrane Library, Medline, and EMBASE up to January 2010 for eligible studies. Included studies were systematic reviews, meta-analyses, or randomized controlled trials (RCTs) comparing preoperative skin antisepsis with chlorhexidine and with iodine and assessing for the outcomes of SSI or positive skin culture result after application. One reviewer extracted data and assessed individual study quality, quality of evidence for each outcome, and publication bias. Meta-analyses were performed using a fixed-effects model. Using results from the meta-analysis and cost data from the Hospital of the University of Pennsylvania, we developed a decision analytic cost-benefit model to compare the economic value, from the hospital perspective, of antisepsis with iodine versus antisepsis with 2 preparations of chlorhexidine (ie, 4% chlorhexidine bottle and single-use applicators of a 2% chlorhexidine gluconate [CHG] and 70% isopropyl alcohol [IPA] solution), and also performed sensitivity analyses. Results Nine RCTs with a total of 3,614 patients were included in the meta-analysis. Meta-analysis revealed that chlorhexidine antisepsis was associated with significantly fewer SSIs (adjusted risk ratio, 0.64 [95% confidence interval, [0.51–0.80]) and positive skin culture results (adjusted risk ratio, 0.44 [95% confidence interval, 0.35–0.56]) than was iodine antisepsis. In the cost-benefit model baseline scenario, switching from iodine to chlorhexidine resulted in a net cost savings of $16–$26 per surgical case and $349,904–$568,594 per year for the Hospital of the University of Pennsylvania. Sensitivity analyses showed that net cost savings persisted under most circumstances. Conclusions Preoperative skin antisepsis with chlorhexidine is more effective than preoperative skin antisepsis with iodine for preventing SSI and results in cost savings.

Dapsone, used for prevention of Pneumocystis jirovecii infections, has been reported to cause hemolytic anemia and methemoglobinemia; its tolerability in solid organ transplant recipients is not well described. We investigated dapsone-related adverse events in patients undergoing solid organ transplantation from 1999 to 2004. Transplant providers identified patients for the investigators who then reviewed the patients' hospital and outpatient records. Sixteen solid organ transplant recipients fit case definitions for dapsonerelated hemolytic anemia (n = 11) or methemoglobinemia (n = 5). Median time from event to dapsone discontinuation was 15 days; all patients improved after drug discontinuation. G6PD enzyme activity was normal in all patients whose test results were available. Dapsone may be associated with hemolytic anemia or methemoglobinemia, even with normal G6PD levels. These events are often not promptly recognized, and drug discontinuation is delayed. Dapsone-related hemolytic anemia or methemoglobinemia should be considered in solid organ transplant recipients with unexplained anemia or hypoxia.

Objective To systematically evaluate the effect of extracorporeal membrane oxygenation (ECMO) on survival in adults with acute respiratory failure (ARF), to help inform institutional decisions about implementing an ECMO program or transferring patients to experienced ECMO centers during the H1N1 influenza pandemic. Data Sources National Guideline Clearinghouse, Medline, EMBASE, AHRQ Evidence-based Practice reports, National Institute for Health and Clinical Excellence, Cochrane Library, International Network of Agencies for Health Technology Assessment, citation review. Study Selection Studies of ECMO in adult ARF, reporting mortality rates for at least 10 patients in ECMO and non-ECMO groups. Data Extraction Mortality rates were abstracted for all patients and for influenza patients. Risk ratios were meta-analyzed using random-effects methods and assessed for heterogeneity. Data Synthesis There are no evidence-based clinical guidelines on the use of ECMO in influenza patients. Three randomized controlled trials and three cohort studies evaluated ECMO in ARF patients; none reported specifically on influenza patients. Meta-analysis of the RCTs revealed significant heterogeneity in risk of mortality. The summary risk ratio found by the meta-analysis was 0.93 [95% confidence interval (CI): 0.71 – 1.22]. The most recent trial found a reduction in mortality and severe disability at 6 months among patients in whom ECMO was considered. Observational studies suggest that ECMO for ARF due to viral pneumonia is associated with improved mortality compared with other etiologies of ARF. Conclusions The best evidence to guide decisions regarding the use of ECMO for influenza patients stems from trials of ECMO for ARF of all etiologies, among which significant heterogeneity exists, and from case series describing outcomes of ECMO in patients with influenza. Thus, there is insufficient evidence to provide a recommendation for ECMO use among patients with respiratory failure due to influenza. However, clinicians should consider ECMO within the context of other salvage therapies for ARF.