Best Surgical Site Antiseptic Under Debate
LAS VEGAS — Surgeons agree that applying a combination solution to a patient's skin before surgery offers the best protection against surgical site infections. However, controversy remains over which solution works best: iodine povacrylex in isopropyl alcohol or chlorhexidine plus isopropyl alcohol.
Dr. Robert G. Sawyer, a professor of surgery at the University of Virginia, Charlottesville, favors iodine povacrylex plus alcohol, a combination marketed under the trade name DuraPrep. His preference is based on results from a sequential implementation design study involving 3,209 procedures that he led at the University of Virginia. The study showed that preoperative application of the iodine povacrylex and alcohol combination produced a significantly lower rate of surgical site infections, compared with chlorhexidine plus isopropyl alcohol or a povidone-iodine scrub paint combination (Infect. Control Hosp. Epidemiol. 2009;30:964–71).
The opposing view, presented by Dr. Kamal M.F. Itani at the meetinga favors the chlorhexidine-alcohol combination marketed as ChloraPrep. He cited results from a multicenter, randomized trial of 849 patients showing that preoperative skin cleansing with the chlorhexidine plus alcohol mix led to significantly fewer surgical site infections, compared with patients treated with povidone-iodine (N. Engl. J. Med. 2010;362:18–26).
Dr. Sawyer's study “is the only one that found DuraPrep superior to ChloraPrep. All the other studies showed ChloraPrep was superior. I'm convinced that ChloraPrep is the agent to use,” Dr. Itani said in an interview. Dr. Sawyer's study “was an outlier in the historical data comparing chlorhexidine-based and iodine-based antiseptics. It doesn't make sense that a company will spend $5 million [for a new study] comparing an agent shown inferior in background studies. No one would fund that,” said Dr. Itani, a professor of surgery at Boston University.
He also found fault with other features of the Virginia study: It was neither randomized nor blinded; it was done at a single center; the sequential design may have introduced differences in patient demographics; and, during the third phase of the study that used iodine povacrylex, new operating rooms opened at the hospital that led to surgery on less-complex patients with shorter surgery times.
Dr. Itani also stressed that chlorhexidine and alcohol fulfills all of the criteria required for an ideal presurgical antiseptic: It is broad spectrum; remains active in the presence of organic matter; produces a low allergic or toxic response; and has minimal systemic absorption, rapid bactericidal activity, and persistent activity on the skin.
One strength of the Virginia study was its large size, with a total of more than 3,000 patients, Dr. Sawyer pointed out during a presentation at the meeting.
“The final story has not been written on these products. I think we need another go at this to get the ultimate answer. In a perfect world, the next study would be a head-to-head comparison” of iodine povacrylex in isopropyl alcohol and chlorhexidine and isopropyl alcohol, he said in an interview.
Disclosures: Dr. Sawyer has been a consultant to Pfizer, Merck & Co., Wyeth, Schering-Plough, and Ethicon. Dr. Itani has received consulting fees from Klein & Co. and a research grant from Cardinal Health, the company that markets ChloraPrep. Both the University of Virginia study and the multicenter study they discussed were done without commercial funding.
'I'm convinced that ChloraPrep is the agent to use.'
Source DR. ITANI
