Chlorhexidine and povidone-iodine equally effective for skin antisepsis of open fractures undergoing surgical fixation

1. Povidone-iodine and chlorhexidine were comparable in terms of surgical site infections.

2. 16% of patients in both groups required unplanned operation within 1 year of injury.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Surgical site infections are a common occurrence in individuals with open fractures. Povidone-iodine is often used for pre-surgical antiseptic management in such cases. Many studies have shown superiority of chlorhexidine over iodine although its use in open fractures remains unclear. This randomized trial aimed to compare the effect of aqueous 10% povidone-iodine and aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients with an open fracture and undergoing surgical fixation. Primary outcome was surgical site infection within 30 days of a superficial incision and within 90 days of a deep or organ space infection. According to study results, 10% povidone-iodine was comparable to 4% chlorhexidine gluconate for skin antisepsis with regards to occurrence of surgical site infections and unplanned reoperation rates. This study was strengthened by a large sample size with hospitals from various countries, thus increasing its generalizability.

Click to read the study in The Lancet

Relevant Reading: Aqueous chlorhexidine 1% versus 2% for neonatal skin antisepsis: a randomised non-inferiority trial

In-depth [randomized-controlled trial]: Between Apr 8, 2018, and Jun 8, 2021, 3619 patients were screened for eligibility across 14 hospitals in Canada, Spain, and the USA. Included were those ≥18 years with an open extremity fracture treated via surgical fixation. Altogether, 1638 patients (828 to povidone-iodine and 810 to chlorhexidine gluconate) were included in the primary analysis. The mean age of patients was 44.9 years (standard deviation [SD] 18.0) with the majority (62%) being male. The primary outcome of surgical site infection was comparable in the povidone-iodine and chlorhexidine groups (7% each, odds ratio [OR} 1.11, 95% confidence interval [CI] 0.74-1.65, p=0.61). Moreover, an equal proportion of patients in either group (17%) had an unplanned reoperation within 1 year of injury (OR 1.08, 95% CI 0.81-1.46, p=0.59). Overall, findings from this study suggest that 10% povidone-iodine and 4% chlorhexidine gluconate are comparable for antiseptic prophylaxis of surgical open fractures.

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