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Multicenter Study
. 2021 Nov 9;5(6):zrab117.
doi: 10.1093/bjsopen/zrab117.

Chlorhexidine versus povidone-iodine skin antisepsis before upper limb surgery (CIPHUR): an international multicentre prospective cohort study

Ryckie G Wade  1   2 , Gráinne Bourke  1   2 , Justin C R Wormald  3 , Joshua Philip Totty  4   5 , Guy Henry Morton Stanley  6 , Andrew Lewandowski  7 , Sandeep Singh Rakhra  8 , Matthew D Gardiner  3   9 ; CIPHUR Collaborative
Collaborators, Affiliations
Multicenter Study

Chlorhexidine versus povidone-iodine skin antisepsis before upper limb surgery (CIPHUR): an international multicentre prospective cohort study

Ryckie G Wade et al. BJS Open. .

Abstract

Introduction: Surgical site infection (SSI) is the most common and costly complication of surgery. International guidelines recommend topical alcoholic chlorhexidine (CHX) before surgery. However, upper limb surgeons continue to use other antiseptics, citing a lack of applicable evidence, and concerns related to open wounds and tourniquets. This study aimed to evaluate the safety and effectiveness of different topical antiseptics before 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 use of CHX or povidone-iodine (PVI) antiseptics in either aqueous or alcoholic form. The primary outcome was SSI within 90 days. Mixed-effects 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: A total of 2454 patients were included. The overall risk of SSI was 3.5 per cent. For elective upper limb surgery (1018 patients), alcoholic CHX appeared to be the most effective antiseptic, reducing the risk of SSI by 70 per cent (adjusted HR 0.30, 95 per cent c.i. 0.11 to 0.84), when compared with aqueous PVI. Concerning emergency upper limb surgery (1436 patients), aqueous PVI appeared to be the least effective antiseptic for preventing SSI; however, there was uncertainty in the estimates. No adverse events were reported.

Conclusion: The findings align with the global evidence base and international guidance, suggesting that alcoholic CHX should be used for skin antisepsis before 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.

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Figures

Fig. 1
Fig. 1
Kaplan–Meier plot of time to surgical site infection for different antiseptics in elective upper limb surgery PVI, povidone–iodine; CHX, chlorhexidine.
Fig. 2
Fig. 2
Forest plot showing the risk factors for surgical site infection PVI, povidone–iodine; CHX, chlorhexidine.
Fig. 3
Fig. 3
Kaplan–Meier plot of time to surgical site infection for different antiseptics in emergency upper limb surgery PVI, povidone–iodine; CHX, chlorhexidine.
See this image and copyright information in PMC

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