Lower-Cost Povidone Iodine Is Non-Inferior to Chlorhexidine for Preventing SSI

Widmer AF, Atkinson A, Kuster SP, et al. Povidone Iodine vs Chlorhexidine Gluconate in Alcohol for Preoperative Skin Antisepsis: A Randomized Clinical Trial. JAMA. 2024.

Editorial: Charles A, Malani PN. Skin Antisepsis to Prevent Surgical Site Infections: Implications for Global Surgery. JAMA. 2024.

Skin preparation prior to skin incision with alcohol-based solutions that contain chlorhexidine gluconate or povidone iodine is an accepted method for reducing skin bacterial counts and protecting against surgical site infection (SSI).

Whether one of these agents is superior to the other is a debated subject; available comparison studies have shown variable results. The World Health Organization recommends chlorhexidine, while the Centers for Disease Control and Prevention recommends povidone-iodine. Cost of chlorhexidine is significantly higher than povidone-iodine.

The authors reported outcomes of a prospective randomized non-inferiority trial conducted in three hospitals in Switzerland; a cohort of 3,360 patients who underwent abdominal or cardiac surgery during the interval 2018–2020 were randomized. Participating hospitals were assigned to use chlorhexidine or povidone-iodine solutions for skin preparation at monthly intervals. Containers of the assigned standard skin preparation solution were distributed to hospitals each month.

The outcome of interest was diagnosis of SSI within 30 days of the surgical procedure. A standard non-inferiority definition was used. The data showed that baseline characteristics and risk for SSI were similar in both comparison groups. SSI was diagnosed in 5.1% of the povidone-iodine group and 5.5% of the chlorhexidine group.

The authors concluded that povidone-iodine was non-inferior to chlorhexidine.

In the editorial that accompanied the article, Charles and Malani noted that nearly 25% of patients in low resource countries develop SSI. These data will provide needed support for the effort to supply less expensive but equally effective skin preparation solutions to these areas.