Chlorhexidine versus povidone–iodine skin antisepsis before upper limb surgery (CIPHUR): an international multicentre prospective cohort study

Abstract

Introduction Surgical site infection (SSI) is the most common and costly complication of surgery. International guidelines recommend topical alcoholic chlorhexidine (CHX) before surgery. However, upper limb surgeons continue to use other antiseptics, citing a lack of applicable evidence, and concerns related to open wounds and tourniquets. This study aimed to evaluate the safety and effectiveness of different topical antiseptics before upper limb surgery. Methods This international multicentre prospective cohort study recruited consecutive adults and children who underwent surgery distal to the shoulder joint. The intervention was use of CHX or povidone–iodine (PVI) antiseptics in either aqueous or alcoholic form. The primary outcome was SSI within 90 days. Mixed-effects time-to-event models were used to estimate the risk (hazard ratio (HR)) of SSI for patients undergoing elective and emergency upper limb surgery. Results A total of 2454 patients were included. The overall risk of SSI was 3.5 per cent. For elective upper limb surgery (1018 patients), alcoholic CHX appeared to be the most effective antiseptic, reducing the risk of SSI by 70 per cent (adjusted HR 0.30, 95 per cent c.i. 0.11 to 0.84), when compared with aqueous PVI. Concerning emergency upper limb surgery (1436 patients), aqueous PVI appeared to be the least effective antiseptic for preventing SSI; however, there was uncertainty in the estimates. No adverse events were reported. Conclusion The findings align with the global evidence base and international guidance, suggesting that alcoholic CHX should be used for skin antisepsis before clean (elective upper limb) surgery. For emergency (contaminated or dirty) upper limb surgery, the findings of this study were unclear and contradict the available evidence, concluding that further research is necessary.

Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) protocol

“…There is also evidence from observational studies that suggest the type of surgical preparation can influence SSI risk. 21 Finally, while trials do exist in postoperative interventions, they lack validity. 23 …”

“… 20 It has been estimated that SSI following all types of upper limb surgery costs over £450 per patient, with costs being as high as £3,900 for patients requiring longer admissions due to SSI. 21 …”

“…There is no consensus within the literature on the ideal management of hand and wrist trauma to reduce SSI. 19 , 21 - 25 The World Health Organization (WHO) have produced globally used guidelines to help prevent SSIs. 14 However, it is unclear what variability exists in the adherence to these guidelines within hand trauma surgery, which usually involves clean, contaminated, or dirty surgery depending on the injury.…”

Best Practices for Using All Skin Antiseptics and for Using 4% Chlorhexidine Gluconate

“…Plastic and aesthetic RNs and physicians should select antiseptic products for use in clinical practice, after reviewing current research literature (AORN, 2021) and the FDA (2017) final rule for Safety and Effectiveness of Health Care Antiseptics. There are a vast number of studies demonstrating the efficacy of 4% CHG for use as a surgical hand scrub, handwashing agent, or general cleanser for skin and wounds, as well as an antiseptic for preinjection or preoperative skin preparation (Dumville et al, 2013;Wade et al, 2020Wade et al, , 2021.…”

Wrist & Hand

“…This prospective multicentre cohort study from various institutions in the UK assessed the incidence of surgical site infection (SSI) after upper limb surgery using different preparations in both adults and children. 6 The skin preparation was classified according to whether it was aqueous or alcoholic, and whether it was povidone-iodine (PVI), chlorhexidine (CHX), or other. Analyses included mixedeffects time-to-event models for emergency and elective surgery patients, and were analyzed separately.…”