Chlorhexidine Vs Povidone Iodine in Preventing Infections in Surgical Patients

Introduction

The study question is, what is the superior antsepsis agent between Chlorhexidine Vs Povidone Iodine. Both agents are used in preventing surgical site infection in patients. The aim of the study is, identifying the most effective prevention agent between Chlorhexidine Vs Povidone Iodine. Levin, Amer-Alshiek, Avni, & Lessing 2011, the purpose of preoperative skin antisepsis is removal of soils, resident and transient micro-organism from the surface of the skin and reducing contamination. During surgery, a site infection can cause long-term effects to the patient and distress together with financial constraints to the health institution. Whichever antisepsis chosen, it should effectively work on the organism characteristic at the operative site.  There are two common antisepsis mostly used in medical procedures; chlorhexidine gluconate (CHG) and Povidone iodine (Povl) either in alcoholic or aqueous solution. CHG is more commonly preferred compared to Povl, and its significant is due to its persistent action, that is, imparting antiseptic properties after application (MAGALINI et al., 2013).

Articles summaries

Scowfort, T. (2011). A Critical Review Of The Literature Regarding The Use Of Povidone Iodine And Chlorhexidine Gluconate For Preoperative Skin Preparation’, 22(3). http://dx.doi.org/ISSN 1467-1026

The Tammy Scowcroft article is a critical analysis of studies of preoperative skin preparation effectiveness that will help in preventing surgical skin preparation local policy. The Scowcroft study reveals that robust surgical site skin preparation reduces antibiotic therapy reliance. Using water and soap removes transient organisms and soil while residual microorganisms are removed by robust removal method. To remove resident organisms efficiently, both mechanical and chemical process are required. The mechanical process comprises skin antisepsis solution application with sufficient friction of the applicator in ensuring that all skin fissures and cracks are sufficiently coated with the solution. On the other hand, the chemical process involves both the prevention of rebound colonization and destruction of microorganisms. The article criticizes previous researches through pointing biasness which is caused by either; the researches, sample size, type of procedure, time and accuracy. In each study, Scowcroft explains n details the use of Povidone and CHG, their effectiveness and differences. Many researches reveal that CHG is superior to Povidone, but the article explains that no antisepsis is superior to the other in all instances. Alcohol base is what makes an efficient antisepsis as it has additional agent working alongside the main agent Povl or CHG with CHG remaining more preferable due to its residue effect. Surgical site infection can be reduced by choosing CHG with alcohol and Povl alcohol as Povl in aqueous solution is a weak antisepsis.

MAGALINI, S., PEPE, G., PANUNZI, S., DE’ GAETANO, A., ABATINI, C., & DI GIORGIO, A. et al. (2013). European Review for Medical and Pharmacological Sciences. Observational Study On Preoperative Surgical Field Disinfection: Povidone-Iodine And Chlorhexidine-Alcohol, (17), 3367-3375.

Surgical site infection increase financial constraints, mortality and morbidity representing about a fifth of all healthcare associated infections. The keystone of reducing SSI is preoperative disinfection of the skin. An observation study is carried out to investigate the use of the antisepsis independently during an elective and emergency surgery. This was carried out through observing 100 major surgeries and that were performed by 27 surgeons under a surgeon resident supervision. The auxiliary materials used during the procedure are associated with the type of disinfectant with more auxiliary materials used in Povl disinfectant. The SSI leads to high sanitary cost due to longer hospital stay, and after discharge it can cause readmission. This calls for prevention by adopting a simpler and effective disinfectant irrespective of its cost. According to the article, povidone iodine is not is not the efficient disinfectant in preventing SSI. ChloraPrep which is an alternative product of chlorhexidine in alcohol is more advantageous as it eliminates some of CGH drawbacks. The procedure of Povidine iodine disinfection is associated with operating room time and systematic auxiliary materials cost making costly in the long run.

QUINTAR, M., HAMMADAH, M., WILKOFF, B., & TARAKJI, K. (2015). The Impact Of Changing Antiseptic Skin Preparation Agent Used For Cardiac Implantable Electronic Device (CIED) Procedures On The Risk Of Infection, 38.

The Cardiac Implantable Electronic Device (CIED) infection is the complication associated to elevated morbidity and mortality. CIED implants improve the lives of patients with heart complication leading to increase in the number of implants and their associated complications. The Cleveland clinic electrophysiology lab changed from chlorhexidine- alcohol to povidine iodine as the preoperative skin antiseptic agent during insertion of CIED. This procedure was carried out through reviewing the patients’ medical records undergoing CIED procedure. During CIED procedures, strict surgical techniques should be observed including antiseptic skin preparation and use of perioperative antibiotic. Majority of centers use cephalosporins first generation as the antibiotics of choice and the others use vanomycin. Some centers use povidine-iodine as the antiseptic for skin preparation while others use chlorhexidine-alcohol agents. According to te REPLACE registry, institutions with high infection rates likely use Povidine-iodine more than chlorhexidine-alcohol in their skin preparation. The findings of the research is in contrary to REPLACE registry as more of their cohort have no significant increase in infection of CIED while using povidine-iodine as compared to chlorhexidine alcohol.

Sistla, S., Prabhu, G., & Sadasivan, J. (2010). Minimizing Wound Contamination in a ‘Clean’ Surgery: Comparison of Chlorhexidine-Ethanol and Povidone-Iodine. Chemotherapy, 56, 261-267. http://dx.doi.org/DOI: 10.1159/000319901

This article compares the efficacy of chlorhexidine-alcohol and povidine-iodine as skin preparation antisepsis in trauma and orthopedic surgery. After orthopedic procedures, any infection is devastating to the patient and frustrating to the surgeon with expensive and long-term consequences. The amount of bacterial flora is one a major potential risk factor during skin incision in an operative site. It is thus essential to have an effective antimicrobial during skin preparation before surgery to reduce contamination of the surgical wound causing infection. This study aim was identifying the bacterial flora on orthopedic patients’ skin prior to a clean surgery by evaluating the efficacy of povidine-iodine and chlorhexidine in eradicating the pathogenic bacteria from the site. The SSI of orthopedic has reduced in the developed countries but the developing countries’ rates vary according to the country. In orthopedics, many strategies have been employed to help in reduction of SSI rate including using effective skin preparation agents.  Generally, the study found out that the skin bacterial flora in general orthopedic clients was similar to the to the specialty orthopedic surgery publish. The commonest bacterial found was staphylococcus epidermidis followed by anaerobe Propionibacterium spp. According to the study, both agents were able to reduce the rate of positive culture after skin preparation. However, CHG-A is better and advisable in eradicating the positive aerobes due to its persistent action on the aerobes and also suppress the skin organism counts during surgery. 

Kulkarni,, A. & Awode, R. (2013). A prospective randomised trial to compare the efficacy of povidone-iodine 10% and chlorhexidine 2% for skin disinfection. Indian Journal Of Anaesthesia, 57(3). Retrieved from http://E-mail: kaivalyaak@yahoo.co.in

This study was carried in tertiary referral cancer center with sixty consecutive adults who had requested an elective surgery that required insertion of CVC or epidural. All the patients were immune competent and were given pre-operative antibiotic. It was unlikely that the prophylactic antibiotic prevented bacterial growth. Existing literature on efficacy of Povi and CGH-A is conflicting, with alcohol chlorhexidine superior than povidine iodine. The groups were divided in to two and the CGH-A group contamination rate was much lower as compared to their counterparts. This is in contrast to some of previous studies which suggest that both agents work and perform the same. The superiority of CGH was shown by two meta-analyses in pre-operative abdominal wall and vascular site catheter care antisepsis as compared to povidine. The most common skin commensal according to the study is staphylcoccuss epidermidis with the staphylococcus aureus as the epidural infection causative organism because staphylococcus aureus is more resistant to cutaneous disinfectants as compared to other microbes. The study found that in cutaneous antisepsis, there is no different between 10% povidone-iodine aqueous solution and 2%chlorhexidine gluconate with alcohol in terms of side effects, efficacy and cost. 2% chlorhexide can be suitable during emergency due to its short contact time.

Obamuyide, H., Omololu, A., Oluwatosin, O., & Ifesanya, A. (2015). East Cent.Afr. J.Surg. Comparison Between Chlorhexidine-Alcohol And Providone Iodine Skin Preparation Solutions In Orthopedic And Trauma Surgery At An African Tertiary Hosipital, 20.

This article is based from a prospective study in a large medical centre including 556 adult clients who were undergoing elective inguinal hernia repair. Hernia repair isconsidered a clean surgery and any wound infection is still a major issue in developing coutries. This discricipancy with the developed countries is caused by inadequate health infrastructure, financial constraints and some logistic reasons. There is greater need for skin decontamination due to the perineam proximity with the groin and lack of conclusive efficacy evidence on prophylactic antibiotics in reducing SSI. In the preoperative skin preparation, antisepsis like Povi and CGH-A are used. Infection Infction of a woud after inguinal hernia is a major problem because developing countries due to certain practices like shaving instead of clipping the hair, poor personal hygiene and low social economic strata. Skin flora colony count is higher after antiseptic preparation. Prolonged pree hospital stay can be caused by high bacterial counts. 

Levin,, I., Amer-Alshiek, J., Avni, A., & Lessing,, J. (2011). Chlorhexidine and Alcohol Versus Povidone-Iodine for Antisepsis in Gynecological Surgery. JOURNAL OF WOMEN’S HEALTH, 20(3). http://dx.doi.org/10.1089=jwh.2010.2391

This article is based from a retrospective study carried ot on gynaecological department tertiary medical institute. Some methods have been directed by the study in reducing SSI, and the major one is maintaining normthemia as oppossed to hyperthermia. A regression analysis carried out revealed that SSIs risk factors are associated with immunodeficiency status, older age, obesty, hypertension and use of tension sutures. The study found that the risk of SSI infection was 3.2 higher while using pividone as compared to the chlorhexide.  Antsepsis with chlorhexide and alcohol reduced the SSI rate compared to the povidone with iodine. Using a 2% chlorhexidine with 70% alcohol is more superior to 10% povidone with iodine.

Synthesis

Surgical site infection may be caused by factors like, obesity, smoking, diabetes, HIV infection, long preoperative stays, malnutrition, alcohol abuse, corticosteroids, blood loss and prolonged operative time (Scowfort, 2011). During surgery, bacterial contamination is the main cause of SSI and the client’s skin is the major cause of wound contaminants. The amount of bacterial flora in a patient’s skin is the major SSI potential risk factor (Kulkarni, & Awode, 2013). In minimizing this risk, many strategies are employed to reduce the risk including, the use of preoperative skin preparation, perioperative antibiotics and antibiotics impregnated incise drapes. It is thus essential to prepare the skin with an effective antimicrobial solution before surgery to reduce contamination.

Many articles are biased with inadequate sample sizes, the duration of surgeries and thus they cannot be used to rule on the local policy. As illustrated in the Scowfort article, chlorhexinade without alcohol is not effective as with alcohol. Comparing thus the two makes the CGH-A to be more effective in preventing SSL infections.

Similarities and Differences

CGH-A according to almost all the articles is more superior as compared to the Povi because of the alcohol content. Povi requires mostly auxillary items like swabs, gloves, gauzes and others. This is differential from Scowfrot who poits out that none of the agent can exist alone and that both of them are fairly important. Alcohol has been demonstrated as a good base in skin preparation solution and penetrates the skin fissures and cracks more. It also dries quickly and thus is why CGH-A is more effective with less time as Povi require the site to dry up first before the procedure. In order to reduce SSI, all the articles have demonstrated the importance of disinfecting the skin before preoperative procedures. 

All the articles have illustrated the PVI time to be longer in comparison with CGH. All skin incision requires use of antisepsis; no stated solution is the best due to the insufficient research on the same. Hernia repair, also known as clean surgery contains infection s especially in the inguinal areas. Wound infection according to all the articles leads to prolonged stay in hospital, financial constrain, time wastage and some lead to other surgeries. Amount of bacteria flora at the incision site during the procedure, the method and agent to use depends with the site, emergency, auxiliary materials, time and cost. Pivodone as illustrated by some articles is cheaper thus its fame, but cost should not be the only factor but effectiveness should be the key

Conclusion

Chlorhexidine in aqueous solution is less effective as compared to when with alcohol. Alcohol is the key agent in the killing of the microorganism thus no agent is more superior than the other if they both have alcohol.All most all articles have suggested that chlorhexidane glucanote with alcohol to be more effective as compared to the povidone with iodine. This is because the CGH-A has a high residual effect as compared to theaquoues iodine. Developing countries are lagging behind in SSL even in Hernia repair because of poor infrastructures, economic status, and other factors and should maximize in ensuring no contamination during surgery. In my opinion, chlorhexidine with alcohol is more popular and effective in preventing contamination.

References

Kulkarni,, A. & Awode, R. (2013). A prospective randomised trial to compare the efficacy of povidone-iodine 10% and chlorhexidine 2% for skin disinfection. Indian Journal Of Anaesthesia, 57(3). Retrieved from http://E-mail: kaivalyaak@yahoo.co.in

Levin,, I., Amer-Alshiek, J., Avni, A., & Lessing,, J. (2011). Chlorhexidine and Alcohol Versus Povidone-Iodine for Antisepsis in Gynecological Surgery. JOURNAL OF WOMEN’S HEALTH, 20(3). http://dx.doi.org/10.1089=jwh.2010.2391

MAGALINI, S., PEPE, G., PANUNZI, S., DE’ GAETANO, A., ABATINI, C., & DI GIORGIO, A. et al. (2013). European Review for Medical and Pharmacological Sciences. Observational Study On Preoperative Surgical Field Disinfection: Povidone-Iodine And Chlorhexidine-Alcohol, (17), 3367-3375.

Obamuyide, H., Omololu, A., Oluwatosin, O., & Ifesanya, A. (2015). East Cent.Afr. J.Surg. Comparison Between Chlorhexidine-Alcohol And Providone Iodine Skin Preparation Solutions In Orthopedic And Trauma Surgery At An African Tertiary Hosipital, 20.

QUINTAR, M., HAMMADAH, M., WILKOFF, B., & TARAKJI, K. (2015). The Impact Of Changing Antiseptic Skin Preparation Agent Used For Cardiac Implantable Electronic Device (CIED) Procedures On The Risk Of Infection, 38.

Scowfort, T. (2011). A Critical Review Of The Literature Regarding The Use Of Povidone Iodine And Chlorhexidine Gluconate For Preoperative Skin Preparation’, 22(3). http://dx.doi.org/ISSN 1467-1026Sistla, S., Prabhu, G., & Sadasivan, J. (2010). Minimizing Wound Contamination in a ‘Clean’ Surgery: Comparison of Chlorhexidine-Ethanol and Povidone-Iodine. Chemotherapy, 56, 261-267. http://dx.doi.org/DOI: 10.1159/000319901