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What’s New in the
Patient Safety World
March 2024
Battle of the
Antiseptics
There are often arguments about which antiseptic is best. There are both alcohol-based antiseptics and aqueous-based antiseptics. For efficacy against infections, most guidelines favor the alcohol-based ones, keeping in mind your choice of antiseptic may have other considerations, such as flammability or allergy to specific components. But even among the alcohol-based antiseptics, there has always been a question as to whether those with chlorhexidine are superior to those with iodine and vice versa. Our November 15, 2020 Patient Safety Tip of the Week “Which Antiseptic?” addressed many of the issues seen in studies comparing these disinfectants.
Results of the PREPARE study were just published (PREP-IT Investigators 2024), a randomized crossover study of an iodine-based disinfectant and a chlorhexidine-based one in patients undergoing fixation of a closed lower-limb or pelvic fracture and a population of patients undergoing fixation of an open fracture. The study was conducted at 25 trauma centers in the U.S. and Canada and included 6785 patients with a closed fracture and 1700 patients with an open fracture. Hospitals were randomly assigned to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) for preoperative antisepsis. Every 2 months, the hospitals alternated interventions. Importantly, the manufacturers of the 2 disinfectants had no role in funding or design of the study.
For closed fractures, surgical site infection rate was 2.4% with a solution of iodine povacrylex, compared to 3.3% for surgeries with a solution of chlorhexidine gluconate. For patients with open fractures, the infection risk was similar with both disinfectants. Also, the frequency of unplanned reoperation and the results of analyses of 1-year outcomes and serious adverse events were similar in the two groups. There were no surgical fires in either group.
The absolute risk reduction with the iodine-based disinfectant was 0.8%, meaning that there would be about 1 fewer infection per 100 closed fracture surgeries. Nevertheless, given the high volume of such traumatic fractures in the US, this could translate into a substantial reduction of overall site infections for the population as a whole. Since all the cases in PREPARE were traumatic orthopedic cases, we’d be hesitant to extrapolate the results to other surgeries. We’d look for similar randomized crossover studies to address those.
The accompanying editorial (Rogers 2024) notes that there is a need more innovative trials testing novel approaches to further lower the infection risk and, perhaps, a deeper understanding of the individual patient’s microbiome may allow for tailored interventions to further decrease the incidence of infection.
References:
The PREP-IT Investigators. Skin
Antisepsis before Surgical Fixation of Extremity Fractures. N Engl J Med 2024;
390: 409-420
https://www.nejm.org/doi/full/10.1056/NEJMoa2307679?query=featured_home
Rogers SO, Wenzel RP. Lister Revisited — Skin Antisepsis before Fracture Fixation. N Engl J Med 2024; 390:466-467
https://www.nejm.org/doi/full/10.1056/NEJMe2314785
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