Background: The relative ability of different skin antiseptics to reduce postsurgical infection has not been well studied. Povidone-iodine (Betadine) is widely used in the United States, but chlorhexidine (Peridex)–based agents have recently been shown to reduce vascular catheterization infection rates by about 50 percent compared with povidone. However, no recommendations exist for the preoperative use of specific antiseptic agents. Darouiche and colleagues compared the effectiveness of antiseptic agents in preventing surgical site infections.

The Study: The authors prospectively examined the relative merits of 10% povidone-iodine and 2% chlorhexidine gluconate with 70% isopropyl alcohol in reducing surgical site infections. Adult patients were randomized to have their surgical sites preoperatively scrubbed with either agent. All patients were undergoing clean-contaminated surgery (e.g., gastrointestinal, thoracic), and received systemic prophylactic antibiotics within one hour before the initial incision. The primary end point was surgical-site infection within 30 days, with secondary end points reviewing specific types of postsurgical infections.

Results: A total of 849 patients were randomized to receive a povidone-iodine or a chlorhexidine with isopropyl alcohol skin scrubbing. Participants in both groups had similar baseline traits, presurgical prophylactic antibiotics, and surgery types. The chlorhexidine group had a significantly lower postsurgical infection rate than persons receiving povidone-iodine (9.5 versus 16.1 percent; relative risk [RR] = 0.59). Fewer superficial (RR = 0.48) and deep incisional (RR = 0.33) infections occurred in the chlorhexidine group, although the incidence of organ-space infection and sepsis were similar between groups. Three patients in each study group reported local reactions at the wound site, such as pruritus or erythema, but no serious adverse events were reported.

Conclusion: The authors conclude that using chlorhexidine-alcohol antiseptic before surgery reduced the risk of surgical site infection by 41 percent, compared with povidone-iodine. Although no episodes of fire or chemical skin burn occurred in the study, the authors caution that this is a potential risk when using alcohol-based agents.