Chlorhexidine versus Povidone-Iodine Skin Antisepsis Prior to Upper Limb Surgery (CIPHUR): An International Multicentre Prospective Cohort Study

Wade, Ryckie; Bourke, Grainne; Wormald, Justin; Totty, Joshua; Stanley, Guy; Lewandowski, Andrew; Rakhra, Sandeep; Gardiner, Matthew; The CIPHUR Collaborative

Abstract

Introduction: Surgical site infection (SSI) is the most common and costly complication of surgery. International guidelines recommend topical alcoholic chlorhexidine (CHX) prior to surgery but upper limb surgeons continue to use other antiseptics, citing an absence of applicable evidence and concerns related to open wounds and tourniquets. This study aimed to evaluate the safety and effectiveness of different topical antiseptics prior to 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 the use of CHX or povidone-iodine (PVI) antiseptics in either aqueous or alcoholic solvents. The primary outcome was SSI within 90 days. Mixed-effect 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: 2454 patients were included. The overall risk of SSI was 3·5%. For elective upper limb surgery (n=1018), alcoholic CHX appeared to be the most effective antiseptic, reducing the risk of SSI by 70% (adjusted HR 0·30 [95% CI 0·11, 0·84]) when compared to aqueous PVI. Concerning emergency upper limb surgery (n=1436), aqueous PVI appeared to be the least effective antiseptic for preventing SSI but there was uncertainty in the estimates. No adverse events were reported.
Discussion: The findings align with the global evidence base and international guidance regarding clean surgery, suggesting that alcoholic CHX should be used for skin antisepsis prior to 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.

Citation

Wade, R., Bourke, G., Wormald, J., Totty, J., Stanley, G., Lewandowski, A., Rakhra, S., Gardiner, M., & The CIPHUR Collaborative. (2021). Chlorhexidine versus Povidone-Iodine Skin Antisepsis Prior to Upper Limb Surgery (CIPHUR): An International Multicentre Prospective Cohort Study. BJS Open, 5(6), Article zrab117. https://doi.org/10.1093/bjsopen/zrab117

• Journal Article Type: Article
• Acceptance Date: Oct 20, 2021
• Online Publication Date: Dec 15, 2021
• Publication Date: 2021-11
• Deposit Date: Oct 28, 2021
• Publicly Available Date: Dec 20, 2021
• Journal: BJS Open
• Print ISSN: 2474-9842
• Publisher: Wiley
• Peer Reviewed: Peer Reviewed
• Volume: 5
• Issue: 6
• Article Number: zrab117
• DOI: https://doi.org/10.1093/bjsopen/zrab117
• Keywords: Surgical complications; Adult; Anti-infective agents, local; Antisepsis; Child; Chlorhexidine; Povidone-iodine; Prospective studies; Safety; Shoulder joint; Surgical procedures, operative; Surgical wound infection; Tourniquets; Arm; Guidelines; Skin; Open
• Public URL: https://hull-repository.worktribe.com/output/3857610