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Clinical Analysis: Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis

During a surgery, preoperative skin should be treated effectively to avoid the emergence of any source of pathogens causing infections. Therefore, preoperative skin should be cleaned with different antiseptics. However, it is highly essential to find out which type of skin cleansing is more efficient for surgical sites. Numerous studies have been dedicated to defining the supremacy of one antiseptic over another. The advantage of one antiseptic over another will be discussed with regard to surgical sites, cost-effectiveness, and overall quality and consequences of the antiseptic on the post-operative recovery.

Effectiveness of Antiseptics

Before introducing the comparative analysis of the effectiveness of antiseptics, close attention should be paid to the development of new methods for fighting with infections before, during, and after the surgery. In this respect, Wenzel (2010) has explored the history of bacteria to define how they influence operative procedures. In the studies, the scholar has proved that chlorhexidine-alcohol is approved by the Centres for Disease Control and Prevention. At the same time, Wenzel (2010) has found the studies in which three types of surgical scrubs have been tested. It has been reported that the rate of infections was lower when using iodine povacrylex in alcohol as compared to chlorhexidine-alcohol and povidone-iodine. In general, evidence shows that chlorhexidine-alcohol is preferred to povidone-iodine as a main antiseptic used during pre-operative procedures. The use of chlorhexidine baths for reducing the risk of presence of Staphylococcus aureus is also effective.

According to Robinson et al. (2014), “rigorous adherence to the principles of asepsis by all scrubbed personnel is the foundation of surgical site infection prevention” (p. 30). At the same time, the need for disinfection techniques during the dermatological surgery is under the question. In particular, infection rates are low when using non-sterile gloves and could be compared with those when following completely sterile strategies. In fact, a range of sterile and clean techniques is used for the majority of dermatological procedures during surgical sites. Due to the fact that invasiveness and complexity of the procedures enhances, the need for the adherence to the standards is also justified. Aseptic strategies include preoperative preparation for creating a sterile area as well as maintenance of cleanness during the entire procedure. The insurance of a sterile area is based on three elements: preparation of the personnel, patient, and surgical instruments (Robinson et al., 2014). The first two elements should rely on the use of disinfection agency, which should be taken into the deepest consideration. There should be specific requirements for the ideal antiseptic which should undergo specific procedures and conditions under which the bacteria’s environment could be eliminated.

There are several components which are approved for surgical antisepsis, including hand and surgical-site preparation. Each component is premised on specific features and a range of activities, but there should always be a context which involves working knowledge of limitations and strengths (Robinson et al., 2014). For procedures to be carried out, the patient shower should be ensured before the time of surgery. There should also be patients which should undergo standard preparations. Traditional surgical site preparation should start with scrubs. Scrubbing the surgical sites is essential to remove all visible dirt. At the same time, areas that are heavily colonized with bacteria should receive greater attention. In this case, the use of antiseptic is relevant for the condition and location of the surgical site.

Comparative Analysis

The studies by Darouiche et al. (2010), along with those conducted by Yeung, Grewal, Bullock, and Brandes (2013) hypothesise that chlorexidine-alcohol is more effective during preoperative skin cleaning than povidione-iodine. Specifically, Darouiche et al. (2010) relate their studies to pre-operative stage of cleansing believing this stage minimizes the pathology during the post-operative period. At the same time, Yeung et al. (2013) are focused more on genitourinary prosthetic surgery, which is more dangerous because of the great threat of infection.

While analysing other types of surgery, different results have been obtained. Specifically, Menderes, Athar, Aaqaard, and Sanqi-Haqhpeykar (2012) compare these two antiseptics to find out that both are equally effective for women who undergo caesarean deliveries. The cost-effectiveness of povidone-iodine is also justified. However, none of the studies support the superiority of povidone-iodine. To prove that, Mimoz (2010) discovers that chlorhexidine-alcohol is still more effective and of higher quality and, therefore, it should be used in pre-operative stage of surgery irrespective of site to be operated. The review of research studies also proves that chlorhexidine-alcohol is superior in almost all cases, expect for women gynecology. However, it also defines further development of new approaches that can allow conducting other research studies and trials proving the effectiveness or ineffectiveness of the substance.

Surgical site infections can lead to greater rate of morbidity and significant health costs. In this respect, Levin et al. (2011) have discovered that skin cleansing with chlorehexidine-alcohol is more effective than povdone-iodine. The study has been conducted on the basis of retrospective exploration at the Department of Gynecology in Tel Aviv. The patients underwent elective gynaecological laparotomies to treat them with various antisepsis protocols. The results have shown that antisepsis by means of chlorhexidine has led to the decrease of the entire rate of SSI from 14 % to 4.5 % as compared to another type of antisepsis. There were two groups of patients who were identical in terms of medical records and baseline characteristics. Importantly, the surgical procedures were similar, including drains, cuts, and tension suture. The risk factors related t SSI included noninsulin-dependent diabetes, hypertension, and immunodeficiency. In general, the study is of great clinical importance because such analysis can lead to the reduction of morbidity as well as the increase in cost-effectiveness.

Noorani, Rabey, Walsh, and Davies (2010) have also focused on the analysis of antiseptic agents to define what measures could be taken to decrease morbidity and provide more cost-effective methods during operative procedures. However, the analysis of chlorhexidine and povidone-iodine for pre-operating antisepsis was ambiguous. To explore the issue, a meta-analysis of relevant trials has been introduced to define whether preoperative antisepsis with the chosen antiseptic agents was effective. Additionally, the review of 5031 patients has shown that chlorhexidine must be used for reducing preoperative infection in a clean-contaminated surgery. Additionally, Harrop et al. (2012) have analysed the risk factors during surgery and antisepsis of surgical sites. The scholars have also argued that nosocomial infections are the most common ones and these complications lead to delay in would healing, revision surgery, increased use of antibiotics, and length of hospital stay. Along with other studies, this one introduces the risk factors as well as the most effective antiseptics used for avoiding infection. It has been concluded that there are many other risks complicating the post-surgical recovery, including the colonization with methicillin-resistant and S. aureus. Additionally, in the studies by Kang, Kim, and Kim (2012), the attention has been paid to the analysis of 2,755 samples of 10 % povidone-iodine application, where 31 were regarded as contaminated. In contrast, 60 out of 3.064 samples were also considered to be contaminated after 0.5 % of chlorhexidine-alcohol was applied. Although both types of antiseptic agents turned out to be effective, it has been defined that chlorhexidine-alcohol has a higher rate of contamination as compared to povidone-iodine. Still, continuous exploration and further monitoring is required for proper management and collection of blood culture.

The Role of Alcohol in Antiseptic Agents

As it has been presented, chlorhexidine-alcohol is more superior in terms of antisepsis, and there are many other studies which focus on the analysis of the evident advantages of the agent. As such, Maiwald, Widmer, and Rotter (2010) have introduced a more detailed study that focuses on the components of chlorhedixine that contribute to the reduction of bacteria during a pre-operative stage. Specifically, the scholars argue that “alcohols are the most rapid acting skin antiseptics, whereas both clhorhexidine and povidone-iodine only have intermediate speed of action” (Maiwald, Widmer, & Rotter, 2010, p. 1095). Therefore, alcohol is the key component that contributes to greater antiseptic effect. Additionally, Maiwald and Chan (2012) have explored the role of alcohol in these antiseptic agents. In particular, the scholars have performed a literature review focused on clinical trials that investigate chlorhexidine elements for vascular insertion of catheter, blood culture collection, and surgical skin preparation. It has been found that the synthesis of chlorhexidine and alcohol could be more effective for pre-operative procedures. Evidence has also been found regarding the effectiveness of chlorhexidine along for treating catheter colonization. However, this agent is not effective for dealing with bloodstream infections.

Although chlorhexidine-premised option and alcohol-based povidone-iodine antiseptic have been considered as more effective in comparison with povidone-iodine for skin processing at catheter insertion sites, their abilities to decrease infection have not been compared in this context. In this respect, Mimoz et al. (2007) have conducted the study in which central venous catheters were inserted into jugular veins and they were processed by 5% povidone-iodine as well as with 0.25% chlorhexidine gluconate, 0.025% benzalkonium chloride, and 4 % benzylic alcohol. The options are used for skin processing before the injection and as applications during the following changes. The results have shown that chlorhexidine related to 50% decrease in catheter colonization, eliminating the threat of bloodstream infection. Therefore, the attention should be paid to the analysis of the percentage of alcohol in antiseptic substances as well.

Apart from surgical sites, there are many cases when antiseptics are used. In order to learn the essence of disinfection, it is essential to explore the blood culture and related threat of contamination. Caldeira, David, and Sampaio (2011) have discussed the problem of skin antiseptics that prevents blood contamination. They have discovered that alcoholic iodine tincture was less effective than povidone-iodine in blood contamination prevention. Importantly, the scholars have discovered that alcohol was superior to iodinated products to reduce contamination. The relation between povidone-iodine and alcohol was not useful. Therefore, alcoholic chlorhexidine solution decreased blood culture as compared to povidone-iodine. Additionally, Bode et al. (2010) have presented their view on surgical site infection and antiseptics. Specifically, the studies focused on the S. aureus which is the major risk for associated infections, whose decolonization of nasal sites could decrease the risk. The results have shown that an alcohol agent plays a crucial role in disinfection. The attention should be paid to the analysis of the role of alcohol as part of other antiseptic agents.

Surgical site infections can be dangerous because they can cause heat, pain, and redness of skin, not mentioning other dangerous complications. Therefore, surgical procedures should be planned accurately to define the level of infection in different areas. Depending on this fact, it is possible to define what type of antisepsis could be used. For instance, there are different degrees of contamination, and a surgical wound could not become infected in a post-operative period unless it is poorly processed before the procedure. At this point, Dumville, McFarlane, Edwards, Lipp, and Holmes (20113) have argued that the removal of bacteria and decrease of ratio of commensal organisms by means of antiseptic is effective before the surgery. Therefore, the antisepsis has become a common pre-operative procedure to reduce the risk of infection during the surgery.

Reichman and Greenberg (2009) have introduced their review of surgical site infection to define how it relates to surgical mortality. The prevention and reduction of infections embrace a meticulous operative strategy, timely administration of relevant preoperative antibiotics as well as a range of preventive measures directed at reducing the threat of viral, bacterial, and fungal contamination proposed by the operating staff, the patient’s endogenous flora and the operating room environment. Therefore, there should be efficient methods of preventing these techniques. Additionally, Edmiston et al. (2008) have demonstrated a sentinel technique for decreasing the threat of site infection. In the research study, they have focused on chlorhexidine gluconate skin foci that were defined after pre-operative skin disinfection employing 4% soap of CHG-impregnated polyester cloth.

Apart from surgical site disinfection, it is essential to define the sources of colonization, including such aspects as hand hygiene, operating environment, and many other factors contributing to complications. In this respect, Lankford et al. (2003) have defined what the leading components and nature of healthcare-related infections diseases are. Specifically, the scholars argue, “a cornerstone of infection control is ensuring that health-care workers wash their hands at appropriate times” (Lankford et al., 2003, p. 217). Therefore, although the standards prove that hand washing is the most crucial procedure to reduce infection invasion and development, the research studies show that unacceptable worker’s hygiene could also be a serious threat to nosocomial infection.

The comparative study conducted by Grabsch, Mitchell, Hooper, and Turnidge (2004) have provided an analysis of the effectiveness of chlorhexidine-alcohol in surgical rub. The cross-over research has been presented to compare the antisepsis substance in alcohol regimen and understand whether it is more effective than povidone-iodine scrub or not. The research has been conducted with regard to the skin asepsis regiment applied. The results have revealed that chlorhexidine regimen has led to sustained and effective reductions of bacterial percentage during surgical procedures. Additionally, Lee, Agarwal, Lee, Fishman, and Umscheid (2010) have made a comparative analysis of chlorhexidine and iodine during the preoperative skin disinfection. In particular, the scholars have also identified reviews and randomized control trials that compare preoperative skin antisepsis with iodine and with chlorhexidine to evaluate the outcomes for SSI disinfection. The results have shown that randomized control trials composed of 3,614 patients have been involved in meta-analysis that focuses on greater effectiveness of chlorhexidine antisepsis. It has also been concluded that preoperative skin disinfection with chlorhexidine is much more effective as compared to preoperative skin antisepsis made by means of iodine to reduce the consequences of bacteria colonization and improve the cost-effectiveness of healthcare establishments.

The use of chlorhexidine-alcohol and povidone iodine is rarely discussed because of the lack of evidence proving their effectiveness. Nonetheless, Anderson, Horn, Lin, Parks, and Peterson (2010) have focused on the analysis of the compatibility of the agents. Specifically, they have studied the effectiveness of antiseptic agents in fighting against S. aureus, staphylococcus epidermidis, acinetobacter baumannii, pseudomonas aeruginosa, and Escherichia coli by means of micro-broth dilution techniques. The bacterial concentration was composed of bacterial burden and colony-formed units that were compared with bacterial densities. The results have shown that chlorhexidine gluconate showed dose-dependent activity of bacteria, which is much more effective than it has been with povidone-idoine. The concentration indices, therefore, demonstrate that combining these two substances does not influence the antisepsis process negatively. Furthermore, the data from the infection model analysis assumes that there is an evident benefit of combining these two antiseptics. The use of chlorhexidine could be dangerous due to the possible threat of burns. The injuries and burns could be the result of the increased ratio of alcohol in the antiseptic agent. In this respect, Sivathasan, Ramamurthy, and Pabla (2010) have introduced specific trends and nature of possible damages caused by the antiseptic agent. Specifically, they argue, “antiseptic-associated chemical burns occur due to a combination of chemical injury, maceration, and pressure effects in an anesthetized patient unable to recoil from the irritant stimulus” (Sivathasan et al., 2010, p. 813). Additionally, Maiwald, Widmer, and Rotter (2011) have failed to find the sufficient evidence for supporting the effectiveness of chlorhexidine.

The overall clinical analysis of the randomized control trials along with meta-analysis has shown the evident superiority of chlorhexidine-alcohol over povidone-iodine. However, the preference given to the former is explained by the presence of alcohol in the antiseptic agent. Additionally, the substance could be used for disinfection of areas with different levels of contamination. For instance, povidone-iodine could still be effective for antisepsis of insignificantly contaminated areas. In general, there are also studies proving greater effectiveness of substances when used in combination. The importance of alcohol in skin preparation is also discussed in the studies by Swenson and Sawyer (2010) who have also introduced their quasi-experimental study to define the superiority of alcohol-induced antiseptics and provide evidence of inferiority of iodophor substances. The results have revealed that the use of iodophors separately to disinfect the skin before the surgery is less effective than the use of chlorhexidine-alcohol. Therefore, this practice should be reconsidered.

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