Bacterial Sensitivity To Chlorhexidine and Povidone-Iodine Antiseptics Over Time: A Systematic Review and Meta-Analysis of Human-Derived Data

Background Surgical site infection (SSI) is the most common complication of surgery, increasing healthcare costs and hospital stay. Chlorhexidine (CHX) and povidone-iodine (PVI) are used for skin antisepsis, minimising SSIs. There is increasing concern of developing resistance to topical biocides, though clinical implications remain unclear. Outcomes: Determining whether the Minimum Bactericidal Concentration (MBC) for topical preparations of CHX or PVI have changed over time, in microbes relevant to SSI. Methods We included studies reporting the mean bactericidal concentration (MBC) of laboratory and clinical isolates of common microbes to CHX and PVI. Excluding non-human samples and studies using antimicrobial solvents or mixtures with other active substances. MBC was pooled in random effects meta-analyses. Change in MBC over time was explored using meta-regression. Results 79 studies were including, analysing 6218 microbes over 45 years. Most used CHX (93%), with insufficient data for meta-analysis of PVI. There was no change in MBC of CHX to Staphylococci (β 0.12 [-1.13, 1.37]; I2 99%) or Streptococci (β 0.13 [-0.35, 0.62]; I2 97%). Conclusions There is no evidence of reduced susceptibility of common SSI-causing microbes to CHX over time. Providing reassurance that the worldwide guidance that CHX should remain the first-choice agent for surgical skin antisepsis.

The Utility of Perioperative Products for the Prevention of Surgical Site Infections in Total Knee Arthroplasty and Lower Extremity Arthroplasty: A Systematic Review

Surgical site infections (SSIs) are among the most prevalent and devastating complications following lower extremity total joint arthroplasty (TJA). Strategies to reduce the rates can be divided into preoperative, perioperatives, and postoperative measures. A multicenter trial is underway to evaluate the efficacy of implementing a bundled care program for SSI prevention in lower extremity TJA including: (1) nasal decolonization; (2) surgical skin antisepsis; (3) antimicrobial incise draping; (4) temperature management; and (5) negative-pressure wound therapy for selected high-risk patients. The purposes of this systematic review were to provide a background and then to summarize the available evidence pertaining to each of these SSI-reduction strategies with special emphasis on total knee arthroplasty. A systematic review of the literature was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. Five individual literature searches were performed to identify studies evaluating nasal decolonization temperature management, surgical skin antisepsis, antimicrobial incise draping, and negative-pressure wound therapy. The highest level of evidence reports was used in each product review, and if there were insufficient arthroplasty papers on the particular topic, then papers were further culled from the surgical specialties to form the basis for the review. There was sufficient literature to assess all of the various prophylactic and preventative techniques. All five products used in the bundled program were supported for use as prophylactic agents or for the direct reduction of SSIs in both level I and II studies. This systematic review showed that various pre-, intra-, and postoperative strategies are efficacious in decreasing the risks of SSIs following lower extremity TJA procedures. Thus, including them in the armamentarium for SSI-reduction strategies for hip and knee arthroplasty surgeons should decrease the incidence of infections. We expect that the combined use of these products in an upcoming study will support these findings and may further enhance the reduction of total knee arthroplasty SSIs in a synergistic manner.

Bacterial Sensitivity to Chlorhexidine and Povidone-Iodine Antiseptics Over Time: A Systematic Review and Meta-Analysis of Human-Derived Data

Background: Surgical site infection (SSI) is the most common complication of surgery, increasing healthcare costs and hospital stay. Topical biocides such as chlorhexidine (CHX) and povidone-iodine (PVI) are used for skin antisepsis to minimise SSIs. There is an increasing concern of developing resistance to topical biocides, however the clinical implications of this remains unclear. Outcomes: The objective of this review was to determine whether the Minimum Bactericidal Concentration (MBC) for topical preparations of CHX or PVI have changed over time, in microbes relevant to SSI. Methods: We searched for studies which reported the mean bactericidal concentration (MBC) of laboratory and clinical isolates of common SSI causing microbes to CHX and PVI. We excluded samples derived from non-humans and studies using antimicrobial solvents or mixtures of biocides with other active substances. MBC was pooled in random effects meta-analyses and change in MBC over time was explored using meta-regression. Results: 79 studies were including, analysing 6218 microbes between 1976 and 2021. Most studies used CHX (93%) and there was insufficient data for meta-analysis of PVI. Enterobacteriales had the highest MBC for CHX (20 mg/L [95% CI 14, 25]; I 2 95%) whilst MRSA had the lowest (3 mg/L [95% CI 1, 2]; I 2 93%). There was no change in MBC of CHX to Staphylococci (β 0.12 [-1.13, 1.37]; I 2 99%) or Streptococci (β 0.13 [-0.35, 0.62]; I 2 97%). Conclusions: There is no evidence of change in susceptibility of common SSI-causing microbes to CHX over time. This study provides reassurance that the worldwide guidance that CHX should remain the first-choice agent for skin asepsis prior to surgery.

Chlorhexidine–alcohol versus povidone–iodine as preoperative skin antisepsis for prevention of surgical site infection in cesarean delivery—a pilot randomized control trial

Objectives To compare the efficacy of chlorhexidine–alcohol and povidone–iodine as preoperative antiseptic skin preparation for prevention of surgical site infection (SSI) after cesarean delivery (CD). Materials and methods A total of 311 eligible women who underwent CS were recruited in the study after fulfilling all the eligibility and exclusion criteria. Patients were randomized into two groups (153 in chlorhexidine–alcohol group and 158 in povidone–iodine group) by a computer-generated randomization table. Patients were followed for a period of 30 days in postoperative period to monitor for SSI. Results The rate of SSI in the chlorhexidine–alcohol group is 5.4% and that of the povidone–iodine group is 8.6%. E. coli, K. pneumoniae, and Acinetobacter baumannii were the most common organisms isolated. E. coli was found in 9.5% of the total SSI cases. Conclusions The study found that the patients who received chlorhexidine–alcohol as skin antiseptic had less chance of developing SSI than those who received povidone–iodine; however, it did not reach a statistical significance. Trial registration Clinical Trials Registry of India CTRI/2018/05/014294. Registered on May 31, 2018

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

ObjectiveTo evaluate whether 1% aqueous chlorhexidine gluconate (CHG) when compared with 2% aqueous chlorhexidine gluconate is non-inferior for neonatal skin antisepsis.DesignParallel, blinded, non-inferiority randomised trial.SettingLevel III, academic, neonatal intensive care unit.PatientsInfants born at 260/7 to 426/7 weeks of gestation from June 2019 to December 2019.InterventionsParticipants were randomised to skin antisepsis by either 1% aqueous CHG or 2% aqueous CHG.Main outcome measuresThe primary outcome was the proportion of negative skin swab cultures after skin antisepsis. Secondary outcomes were local skin reactions at 0, 6, 12 and 24 hours and plasma chlorhexidine levels in a subset of the study population.ResultsA total of 308 neonates with a median gestation age of 34 (31–37) weeks and mean birth weight of 2029 g were randomised on 685 occasions (1% CHG: n=341; 2% CHG: n=344). 93.0% of the post-antisepsis skin swabs were sterile in 1% CHG group compared with 95.6% of the swabs in the 2% CHG group (risk difference −2.7%, 95% CI −6.2% to +0.8%). The lower bound of 95% CI crossed the pre-specified absolute non-inferiority limit of 5%. Neonates developed mild dermatitis on 16 (2.3%) occasions. There was no significant difference in median plasma CHG levels in the two groups, 19.6 (12.5–36.4) and 12.6 (8.7–26.6) ng/mL, respectively.ConclusionsApplication of 1% aqueous CHG was not shown to be non-inferior to 2% chlorhexidine aqueous for skin antisepsis in neonates. There were no severe skin-related adverse events in either of the two groups.Trial registration numberCTRI/2019/06/019822; (http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=33453&EncHid=&userName=CTRI/2019/06/019822)

Chlorhexidine-alcohol versus povidone-iodine as preoperative skin antisepsis for prevention of Surgical Site Infection in Cesarean Section

Objectives: To compare the efficacy of chlorhexidine-alcohol and povidone-iodine as preoperative antiseptic skin preparation for prevention of Surgical site infection(SSI) after Cesarean Section(CS).Materials and Methods: A total of 311 eligible women who underwent CS were recruited in the study after fulfilling all the inclusion and exclusion criteria. Patients were randomized into two groups (153 in Chlorhexidine-alcohol Group and 158 in povidone-iodine Group) by computer-generated randomization table. Patients were followed for a period of 30 days in post operative period to monitor for SSI.Results: The overall rate of SSI was 7%, out of which chlorhexidine-alcohol group had 5.4% and povidone-iodine group had 8.6%. E.coli, K.pneumoniae and Acinetobacter baumannii were the most common organism isolated. E.coli was found in 9.5% of the total SSI cases.Conclusions: The study found that the patients who received chlorhexidine-alcohol as skin antiseptic had less chance of developing SSI than those who received povidone iodine however it did not reach statistical significance.