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Preoperative antisepsis with topical chlorhexidine in clean-contaminated surgery may reduce postoperative wound infection. Critical Summary Prepared by: Stacy Geisler DDS, PhD; Alexandra Jones BA, BCMB 

OVERVIEW

  • Systematic Review Conclusion:

    Preoperative skin cleansing with chlorhexdine reduces surgical site infection by 32 percent as compared to povidone-iodine solution in clean-contaminated surgery.

  • Critical Summary Assessment:

    Strong evidence suggests that the use of topical chlorhexidine applied to the skin as an antiseptic agent in clean-contaminated surgery is a promising agent in reducing postoperative infections.

  • Evidence Quality Rating:

    Good

A Critical Summary of:

Systematic review and meta-analysis of preoperative antisepsis with chlorhexidine versus povidone-iodine in clean-contaminated surgery

Noorani, A., Rabey, N., Walsh, S. R., Davies, R. J.. British Journal of Surgery. 2010;97(11):1614-20

  • Clinical Questions:

    Is topical chlorhexidine applied to the skin as effective as topical povidone-iodine in reducing post- surgical infection in clean-contaminated surgeries?

  • Review Methods:

    The authors conducted an electronic search of two databases using the search terms 'chlorhexidine', 'povidone-iodine', and 'iodine', seeking articles published between 2000 and 2010. They included only randomized clinical trials involving patients 18 years or older who were undergoing clean-contaminated surgery that required a skin incision or puncture. Two reviewers working independently assessed eligibility of the collected studies as well as risk of bias of individual studies. They calculated pooled odds ratio with 95 percent confidence intervals utilizing random effects modeling. The primary outcome of interest was post-operative surgical site infection. Funnel plots and Egger’s test were utilized to assess publication bias.

  • Main Results:

    Six trials met all inclusion criteria with a total of 5,031 patients. Skin infections occurred in 5.7 percent of patients treated with chlorhexidine prior to incision while 7.9 percent of patients treated povidone-iodine developed infection following surgery. The pooled odds ratio was 0.68 (0.50, 0.94). There was no evidence of heterogenity (Cochran's Q 8.21) or publication bias (Egger's test -0.35) for this outcome.

  • Conclusion:

    Results across studies of preoperative antisepsis techniques demonstrated that treatment of the incision site with chlorhexidine prior to surgery resulted in a 32 percent decrease in the rate of post-surgical skin infection as compared to antisepsis treatment with povidone-iodine. However, the results of all studies should be interpreted with some reservation because the assessors were not blinded.

  • Source of funding:

    Cambridge Colorectal Unit. Addenbrooke’s Hospital

Commentary:

  • Importance and Context:

    Post-surgical infection is a possible complication for any surgery including dental implant surgery, treatment of traumatic injuries to the maxillofacial skeleton, bony reconstruction of the jaws, temporomandibular joint surgery and orthognathic surgery. Antiseptic techniques used in dentistry include both preparation of the skin surrounding the oral cavity as well as the mucosa within the mouth, although some controversy exists as to what is indicated and when (1). Postoperative infection can lead to poor healing outcomes, pain and even death. It is estimated that over 53 million Americans undergo surgery each year. Using agents that limit post-surgical infection can greatly improve surgical outcomes and limit healthcare costs associated with treating postoperative infection.


  • Strengths and Weaknesses of the Systematic Review:

    The authors of this review provide a concise, well-thought out strategy for assessing clinical trials on the effectiveness of chlorhexidine as compared to povidone-iodine in preventing post operative infection in clean- contaminated wounds. Their statistical analysis and methodology is very thorough. Inclusion and exclusion criteria were well considered and applied. Weaknesses of the review include utilizing an outdated technique (Jadad) to assess bias rather than reporting each individual study's bias risk.

  • Strengths and Weaknesses of the Evidence:

    Strengths of the evidence include a very large pooled sample size with a precise point estimate and confidence interval. Weaknesses of the evidence include the use studies with potential bias due to a lack of blinding of the assessor and the use of inconsistent concentrations of the antisepsis agents.

  • Implications for Dental Practice:

    Controversy exists as to which agents provide the best antisepsis for the oral cavity prior to invasive procedures. Some researchers have suggested that povidone-iodine is a better topical agent particularly for periodontal pathogens (2) while others feel that chlorhexidine is superior (3). This review suggests that chlorhexidine is a superior antiseptic agent for the skin in clean-contaminated surgeries.

    Since the studies included in the systematic review were conducted on skin and not mucosa, further research is needed to explore the effectiveness of either agent in the prevention of postoperative infection following invasive dental procedures. Finally studies exploring the relationship between the bacterial flora of the skin surrounding the oral cavity and the oral mucosa and risk of postoperative infection in dentistry would be helpful in deciding which agents are useful and in what application.

    1. Scharf DR, Tarnow DP. Success rates of osseointegration for implants placed under sterile versus clean conditions. J Periodontol 1993:64(10:954-956.
    2 Rahn R. Review presentation on povidone-iodine antisepsis in the oral cavity. Postgrad Med J 1993;69(Supplement 3):S4-S9.
    3 Lim KS, Kam PC. Chlorhexidine--Pharmacology and clinical applications. Anaesth Intensive Care 2008:36(4):502-12.

  • Critical Summary Publication Date: 10/8/2012

These summaries are not intended to, and do not, express, imply, or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. American Dental Association ©

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