Chlorhexidine versus povidone–iodine skin antisepsis before upper limb surgery (CIPHUR): an international multicentre prospective cohort study
Author:
Wade Ryckie G12ORCID, Bourke Gráinne12ORCID, Wormald Justin C R3ORCID, Totty Joshua Philip45ORCID, Stanley Guy Henry Morton6ORCID, Lewandowski Andrew7ORCID, Rakhra Sandeep Singh8ORCID, Gardiner Matthew D39ORCID, Bindra R, Sher M, Thomas M, Morgan S D J, Hwang B, Santucci W, Tran P, Kopp L, Kunc V, Hamdi A, Grieve P P, Mukhaizeem S A, Blake K, Cuggy C, Dolan R, Downes E, Geary E, Ghadge A, Gorman P, Jonson M, Jumper N, Kelly S, Leddy L, McMahon M E, McNamee C, Miller P, Murphy B, O'Halloran L, O’Shea K, Skeens J, Staunton S, Timon F, Woods J, Cortinovis U, Sala L, Zingarello V, Jusoh M H, Sadagatullah A N, Georgieva G, Pejkova S, Nikolovska B, Srbov B, Hamid H K S, Mustafa M, Abdelrahman M, Amin S M M, Bhatti D, Rahman K M A, Jumabhoy I, Kiely J, Kieran I, Lo A C Q, Wong K Y, Allan A Y, Armes H, Horwitz M D, Ioannidi L, Masterton G, Chu H, Talawadekar G D, Tong K S, Chan M, Tredgett M, Hardie C, Powell-Smith E, Gilham N, Prokopenko M, Ahmad R, Davies J, Zhen S, Dargan D, Pinder R M, Koziara M, Martin R, Reay E, Cochrane E, Elbatawy A, Green F, Griffiths T, Higginbotham G, Louette S, McCauley G, Natalwala I, Salt E, Ahmed R, Goon P, Manton R, Segaren N, Cheung G, Mahoney R, Sen S, Clarkson D, Collins M, Bolt A, Lokanathan P, Ng A, Jones G, Jones J W M, Kabariti R, Rhee S J, Herron J, Kay A, Cheung L K, Thomson D, Jugdey R S, Yoon H, L Z, Southgate J, Brennan C, Kiani S, Zabaglo M, Haider Z A, Poulter R, Sheik-Ali A, Watts A, Jemec B, Redgrave N, Dupley L, Greenhalgh M, Vella J, Harris H, Robinson A V, Dupre S, Teelucksingh S, Gargan A, Hettiaratchy S, Jain A, Kwasnicki R, Lee A, Thakkar M, Berwick D, Ismail N, Mahdi M, Rodrigues J, Liew C, Saadya A, Clarkson M, Brady C, Harrison R, Rayner A, Nolan G, Phillips B, Madhusudan N,
Affiliation:
1. Leeds Institute for Medical Research, University of Leeds, Leeds, UK 2. Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK 3. Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK 4. Department of Plastic and Reconstructive Surgery, Hull University Teaching Hospitals, Castle Hill Hospital, Cottingham, East Riding of Yorkshire, UK 5. Centre for Clinical Sciences, Hull York Medical School, Hull, UK 6. Department of Plastic Surgery, Fiona Stanley Hospital, Murdoch, Western Australia 7. Department of Plastic Surgery, Mater Adults Hospital, Raymond Terrace, South Brisbane, Queensland, Australia 8. Department of Anaesthesiology, Alfred Health, Melbourne, Victoria, Australia 9. Department of Plastic Surgery, Frimley Health NHS Foundation Trust, Slough, UK
Abstract
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.
Funder
National Institute for Health Research Clinical Lecturer funded by Health Education England (HEE)/NIHR Royal College of Surgeons of England and the British Society of Surgery for the Hand
Publisher
Oxford University Press (OUP)
Cited by
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