Systematic Review and Meta-Analysis of Preoperative Antisepsis with Combination Chlorhexidine and Povidone-Iodine

Importance Effective preoperative antisepsis is recognized to prevent surgical site infection (SSI), although the definitive method is unclear. Many have compared chlorhexidine (CHG) with povidone-iodine (PVI), but there is emerging evidence for combination usage. Objective To conduct a systematic review and meta-analysis to evaluate if combination skin preparation (1) reduces colonization at the operative site and (2) prevents SSI compared with single-agent use. Data Sources A literature search of MEDLINE, Embase, and Cochrane Database of Clinical Trials was performed. Study Selection Comparative, human trials considering the combination use of CHG and PVI, as preoperative antisepsis, to single-agent CHG or PVI use were included. Studies were excluded from meta-analysis if the use or absence of alcohol was inconsistent between study arms. Data Extraction and Synthesis The study was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Main Outcomes and Measures The primary outcome for meta-analysis was surgical site infection. The secondary outcome was colonization at the operative site. Results Eighteen publications with a combination of CHG and PVI use were identified. Of these, 12/14 inferred promise for combination usage, including four trials eligible for meta-analysis. Only one trial reported SSI as its outcome. The remaining three considered bacterial colonization. Combination preparation had a pooled odds ratio for complete decolonization of 5.62 (95% confidence interval 3.2 to 9.7, p < 0.00001). There was no evidence of heterogeneity (Cochran's Q 2.1, 2 df, p = 0.35). Conclusions and Relevance There is emerging, albeit low-quality, evidence in favor of combination CHG and PVI preoperative antisepsis. Further rigorous investigation is indicated.

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Efficacy of Intrawound Treatments to Prevent Surgical Site Infection after Spine Surgery: A Systematic Review and Network Meta-analysis

January 2018 - Pain Physician ◽

10.36076/ppj.2021.24.e709 ◽

2021 ◽

Vol 24 (6) ◽

pp. E709-E720

Keyword(s):

Systematic Review ◽

Cohort Studies ◽

Surgical Site Infection ◽

Spine Surgery ◽

Retrospective Cohort ◽

Povidone Iodine ◽

Meta Analysis ◽

Control Group ◽

Site Infection ◽

Retrospective Cohort Studies

BACKGROUND: Intrawound treatments have been reported to have favorable efficacy for preventing surgical site infection (SSI); however, the best strategy remains unknown. OBJECTIVE: The aim of this systematic review and network meta-analysis was to evaluate the efficacy of intrawound treatments to prevent SSI after spine surgery. STUDY DESIGN: A systematic review and network meta-analysis. METHODS: We searched the Cochrane Library, EMbase, PubMed, Chinese Science and Technology Periodical Database (VIP), China National Knowledge Infrastructure (CNKI), and Wanfang Data from the date of inception to March 2, 2020. The randomized controlled trials (RCTs) and cohort studies were identified and extracted by 2 reviewers independently. We performed a traditional pairwise meta-analysis to evaluate overall efficacy of intrawound treatments. Meanwhile, a network meta-analysis was performed to compare and rank the treatment efficacy using frequentist approach. RESULTS: Thirty-three publications (6 RCTs and 27 retrospective cohort studies) were included, involving 22,763 patients. For pairwise meta-analysis, the combined results showed that the intrawound treatment had a significantly lower SSI rate than the control group (CG) (odds ratio [OR] = 0.41; 95% confidence interval [CI], 0.31–0.55). For network meta-analysis, the treatment of vancomycin (VA) (OR = 0.53; 95% CI, 0.39-0.71), povidone-iodine (PI) (OR = 0.10; 95% CI, 0.04 - 0.23), and vancomycin + povidone-iodine (VA+PI) (OR = 0.25; 95% CI, 0.11-0.58) were found to be significantly more efficacious than CG on reduction of SSI rate. PI ranked first on reducing SSI, followed by PI+HP, VA+PI, gentamicin (GM), VA, and hydrogen peroxide (HP); CG ranked last. LIMITATIONS: Firstly, only 6 RCTs are included in this systematic review. Retrospective cohort studies tend to exaggerate the real results, although most of them are high-quality according to the Newcastle-Ottawa Quality Assessment Scale (NOQAS). More high-quality RCTs need to be included to obtain convincing conclusions. Secondly, the population of this study involves both adult and pediatric cohorts, patients with tumor, congenital disease, or degenerative disease. There is no subgroup analysis for ages and type of diseases, which might have influence on the overall pooled analysis. Thirdly, we define the application of saline solution and no intrawound treatment as the control group, which might ignore their heterogeneity. Fourthly, follow-up periods are variable and the sample size of HP is small. Finally, additional research is needed to compare the complications of different treatments and the benefits of various dosages. CONCLUSION: We found that VA and PI show promising results on reducing SSI. PI is recommended as the most efficacious intrawound treatment to prevent SSI after spine surgery. KEY WORDS: Intrawound treatments, network meta-analysis, spine, surgery, surgical site infection

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