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Systematic Review and Cost Analysis Comparing Use of chlorhexidine with Use of Iodine for Preoperative Skin Antisepsis to Prevent Surgical Site Infection

Published online by Cambridge University Press:  02 January 2015

Ingi Lee*
Affiliation:
Divisions of Infectious Diseases, Philadelphia, Pennsylvania Department of Medicine, and the Center for Evidence-based Practice, Philadelphia, Pennsylvania
Rajender K. Agarwal
Affiliation:
Department of Medicine of the John Stroger Hospital of Cook County, Chicago, Illinois
Bruce Y. Lee
Affiliation:
University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, and the Departments of Medicine, Epidemiology, and Biomedical Informatics of the University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, Pennsylvania
Neil O. Fishman
Affiliation:
Divisions of Infectious Diseases, Philadelphia, Pennsylvania
Craig A. Umscheid
Affiliation:
General Internal Medicine, Philadelphia, Pennsylvania Department of Medicine, and the Center for Evidence-based Practice, Philadelphia, Pennsylvania
*
Hospital of the University of Pennsylvania, Division of Infectious Diseases, 3400 Spruce Street, 3rd Floor, Silverstein Building, Suite E, Philadelphia, PA 19104, (ingi.lee@uphs.upenn.edu)

Abstract

Objective.

To compare use of chlorhexidine with use of iodine for preoperative skin antisepsis with respect to effectiveness in preventing surgical site infections (SSIs) and cost.

Methods.

We searched the Agency for Healthcare Research and Quality website, the Cochrane Library, Medline, and EMBASE up to January 2010 for eligible studies. Included studies were systematic reviews, meta-analyses, or randomized controlled trials (RCTs) comparing preoperative skin antisepsis with chlorhexidine and with iodine and assessing for the outcomes of SSI or positive skin culture result after application. One reviewer extracted data and assessed individual study quality, quality of evidence for each outcome, and publication bias. Meta-analyses were performed using a fixed-effects model. Using results from the meta-analysis and cost data from the Hospital of the University of Pennsylvania, we developed a decision analytic cost-benefit model to compare the economic value, from the hospital perspective, of antisepsis with iodine versus antisepsis with 2 preparations of chlorhexidine (ie, 4% chlorhexidine bottle and single-use applicators of a 2% chlorhexidine gluconate [CHG] and 70% isopropyl alcohol [IPA] solution), and also performed sensitivity analyses.

Results.

Nine RCTs with a total of 3,614 patients were included in the meta-analysis. Meta-analysis revealed that chlorhexidine antisepsis was associated with significantly fewer SSIs (adjusted risk ratio, 0.64 [95% confidence interval, [0.51–0.80]) and positive skin culture results (adjusted risk ratio, 0.44 [95% confidence interval, 0.35–0.56]) than was iodine antisepsis. In the cost-benefit model baseline scenario, switching from iodine to chlorhexidine resulted in a net cost savings of $16-$26 per surgical case and $349,904–$568,594 per year for the Hospital of the University of Pennsylvania. Sensitivity analyses showed that net cost savings persisted under most circumstances.

Conclusions.

Preoperative skin antisepsis with chlorhexidine is more effective than preoperative skin antisepsis with iodine for preventing SSI and results in cost savings.

Type
Original Article
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2010

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References

1.Bruce, J, Russell, EM, Mollison, J, Krukowski, ZH. The measurement and monitoring of surgical adverse events. Health Technol Assess 2001;5(22):1194.Google Scholar
2.Kurz, A, Sessler, DI, Lenhardt, R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl f Med 1996;334(19):12091215.Google Scholar
3.Mangram, AJ, Horan, TC, Pearson, ML, Silver, LC, Jarvis, WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20(4):250278.CrossRefGoogle ScholarPubMed
4.National Institute for Health and Clinical Excellence (NICE). Surgical site infection: draft full guideline 2006. http://www.nice.org.uk/CG74. Accessed October 1, 2010.Google Scholar
5.Leaper, DJ, Orr, C, Maung, Z, White, A. Inflammation and Infection: STEP 2000 Module II. Royal College of Surgeons of England. Blackwell Science; 2001.Google Scholar
6.AORN. Standards, Recommended Practices, and Guidelines. Denver; 2006.Google Scholar
7.National Association of Theatre Nurses (NATN). NATN standards and recommendations for safe perioperative practice. Harrogate: NATN; 2004.Google Scholar
8. 3M DuraPrep surgical solution (iodine povacrylex [0.7% available iodine] and isopropyl alcohol, 74% w/w) patient preoperative skin preparation. http://solutions.3m.com/wps/portal/3M/en_US/SH/SkinHealth/products/catalog/?PC_7_RJH9U5230GE3E02LECFTDQG207_nid=GSF83Z3YY XbeJLRV63SXXBgl.Google Scholar
9.Darouiche, RO, Wall, MJ Jr, Itani, KM, Otterson, MF, Webb, AL, Carrick, MM, et al.Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl I Med 2010;362(1):1826.Google Scholar
10.Deeks, JJ, Higgins, J.P.T., Altman, D.G.Analyzing data and undertaking meta-analyses. In: Higgins, J, Green, S, editors. Cochrane Handbook for Systematic Reviews of Interventions. Oxford; 2008:501.Google Scholar
11.Egger, M, Zellweger-Zahner, T, Schneider, M, Junker, C, Lengeier, C, Antes, G. Language bias in randomised controlled trials published in English and German. Lancet 1997;350(9074):326329.CrossRefGoogle ScholarPubMed
12.Begg, CB, Mazumdar, M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994;50:10881101.Google Scholar
13.Jadad, AR, Moore, RA, Carroll, D, Jenkinson, C, Reynolds, DJ, Gavaghan, DJ, et al.Assessing the quality of reports of randomized clinical trials: is blinding necessary?. Control Clin Trials 1996;17(1):112.CrossRefGoogle ScholarPubMed
14.Chalmers, TC, Smith, H Jr, Blackburn, B, Silverman, B, Schroeder, B, Reit-man, D, et al.A method for assessing the quality of a randomized control trial. Control Clin Trials 1981;2(1):3149.CrossRefGoogle ScholarPubMed
15.Guyatt, GH, Oxman, AD, Vist, GE, Kunz, R, Falck-Ytter, Y, Alonso-Coello, P, et al.GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924926.Google Scholar
16.Umscheid, CA, Mitchell, MD, Doshi, JA, Agarwal, R, Williams, K, Brennan, PJ. Estimating the proportion of reasonably preventable healthcare associated infections and associated mortality and costs. In: Program and abstracts of the 19th Annual Scientific Meeting of the Soceity for Healthcare Epidemiology of America 2009.Google Scholar
17.Edwards, PS, Lipp, A, Holmes, A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev 2004;(3):003949.Google Scholar
18.Berry, AR, Watt, B, Goldacre, MJ, Thomson, JW, McNair, TJ. A comparison of the use of povidone-iodine and Chlorhexidine in the prophylaxis of postoperative wound infection. J Hosp Infect 1982;3(1):5563.CrossRefGoogle ScholarPubMed
19.Paocharoen, V, Mingmalairak, C, Apisarnthanarak, A. Comparison of surgical wound infection after preoperative skin preparation with 4% chlor hexidine [correction of chlohexidine] and povidone iodine: a prospective randomized trial. J Med Assoc Thai 2009;92(7):898902.Google Scholar
20.Saltzman, MD, Nuber, GW, Gryzlo, SM, Marecek, GS, Koh, JL. Efficacy of surgical preparation solutions in shoulder surgery. J Bone Joint Surg Am 2009;91(8):19491953.Google Scholar
21.Veiga, DF, Damasceno, CA, Veiga-Filho, J, Figueiras, RG, Vieira, RB, Florenzano, FH, et al.Povidone iodine versus Chlorhexidine in skin antisepsis before elective plastic surgery procedures: a randomized controlled trial. Plast Reconstr Surg 2008;122(5):170e171e.Google Scholar
22.Culligan, PJ, Kubik, K, Murphy, M, Blackwell, L, Snyder, J. A randomized trial that compared povidone iodine and Chlorhexidine as antiseptics for vaginal hysterectomy. Am J Obstet Gynecol 2005;192(2):422425.CrossRefGoogle ScholarPubMed
23.Ostrander, RV, Botte, MJ, Brage, ME. Efficacy of surgical preparation solutions in foot and ankle surgery. J Bone Joint Surg Am 2005;87(5):980985.Google Scholar
24.Bibbo, C, Patel, DV, Gehrmann, RM, Lin, SS. Chlorhexidine provides superior skin decontamination in foot and ankle surgery: a prospective randomized study. Clin Orthop 2005;438:204208.Google Scholar
25.Brown, TR, Ehrlich, CE, Stehman, FB, Golichowski, AM, Madura, JA, Eitzen, HE. A clinical evaluation of Chlorhexidine gluconate spray as compared with iodophor scrub for preoperative skin preparation. Surg Gynecol Obstet 1984;158(4):363366.Google Scholar
26.Chaiyakunapruk, N, Veenstra, DL, Lipsky, BA, Saint, S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med 2002;136(11):792801.Google Scholar
27.Zamora, JL, Price, MF, Chuang, P, Gentry, LO. Inhibition of povidone-iodine's bactericidal activity by common organic substances: an experimental study. Surgery 1985;98(1):2529.Google Scholar
28.Larson, E, Bobo, L. Effective hand degerming in the presence of blood. J Emerg Med 1992;10(1):711.Google Scholar
29.Ayliffe, GA. Surgical scrub and skin disinfection. Infect Control 1984;5(1):2327.CrossRefGoogle ScholarPubMed
30.Gregoire, G, Derderian, F, Le Lorier, J. Selecting the language of the publications included in a meta-analysis: is there a Tower of Babel bias? J Clin Epidemiol 1995;48(1):159163.Google Scholar
31.Chalmers, TC, Berrier, J, Sacks, HS, Levin, H, Reitman, D, Nagalingam, R. Meta-analysis of clinical trials as a scientific discipline. II: Replicate variability and comparison of studies that agree and disagree. Stat Med 1987;6(7):733744.Google Scholar
32.Chalmers, TC, Levin, H, Sacks, HS, Reitman, D, Berrier, J, Nagalingam, R. Meta-analysis of clinical trials as a scientific discipline. I: Control of bias and comparison with large co-operative trials. Stat Med 1987;6(3):315328.Google Scholar
33.Pham, B, Klassen, TP, Lawson, ML, Moher, D. Language of publication restrictions in systematic reviews gave different results depending on whether the intervention was conventional or complementary. J Clin Epidemiol 2005;58(8):769776.Google Scholar
34.Moher, D, Fortin, P, ladad, AR, Juni, P, Klassen, T, Le Lorier, J, et al.Completeness of reporting of trials published in languages other than English: implications for conduct and reporting of systematic reviews. Lancet 1996;347(8998):363366.Google Scholar
35.Moher, D, Pham, B, Lawson, ML, Klassen, TP. The inclusion of reports of randomised trials published in languages other than English in systematic reviews. Health Technol Assess 2003;7(41):190.Google Scholar
36.Herwaldt, LA, Cullen, JJ, Scholz, D, French, P, Zimmerman, MB, Pfaller, MA, et al.A prospective study of outcomes, healthcare resource utilization, and costs associated with postoperative nosocomial infections. Infect Control Hosp Epidemiol 2006;27(12):12911298.Google Scholar
37.Dimick, JB, Pronovost, PJ, Cowan, IA, Lipsett, PA. Complications and costs after high-risk surgery: where should we focus quality improvement initiatives? J Am Coll Surg 2003;196(5):671678.Google Scholar
38.Kirkland, KB, Briggs, JP, Trivette, SL, Wilkinson, WE, Sexton, DI. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999;20(11):725730.CrossRefGoogle ScholarPubMed
39.Perencevich, EN, Sands, KE, Cosgrove, SE, Guadagnoli, E, Meara, E, Piatt, R. Health and economic impact of surgical site infections diagnosed after hospital discharge. Emerg Infect Dis 2003;9(2):196203.Google Scholar