Rationale for the PREP-IT Study: Comparing Antiseptic Solutions for Extremity Fracture Surgery
The lack of consensus on the most effective agent to use in isopropyl alcohol-based solutions for preoperative antisepsis in extremity fracture surgery was the primary rationale for the PREP-IT study.
Background on Surgical Site Infection Prevention
Surgical site infections (SSIs) represent a significant challenge in orthopedic trauma surgery, with patients undergoing extremity fracture repair having nearly 5 times greater risk of infection compared to elective orthopedic procedures 1. Preoperative skin antisepsis is a cornerstone of SSI prevention.
The Knowledge Gap That Led to PREP-IT
The PREP-IT (Program of Randomized Trials to Evaluate Pre-operative Antiseptic Skin Solutions in Orthopaedic Trauma) study was designed to address a critical gap in evidence:
While preoperative skin antisepsis is standard practice, there was limited evidence to guide the choice of antiseptic solution specifically for orthopedic fracture repair 1
There was no consensus on whether iodine-based or chlorhexidine-based alcohol solutions were more effective at preventing SSIs in extremity fracture surgery 1, 2
The study specifically compared 0.7% iodine povacrylex in 74% isopropyl alcohol versus 2% chlorhexidine gluconate in 70% isopropyl alcohol 2
Why This Question Needed Answering
Several factors made this research question important:
Previous studies on surgical skin antisepsis had produced conflicting results 2
Most previous trials were underpowered to detect differences in SSI rates 3
Guidelines contained conflicting recommendations about optimal antiseptic agents 4
The high-risk nature of fracture surgery demanded evidence-specific to this population
What PREP-IT Found
The PREPARE trial (part of PREP-IT) found that:
For closed fractures: Iodine povacrylex in alcohol resulted in fewer surgical site infections (2.4%) compared to chlorhexidine gluconate in alcohol (3.3%) 2
For open fractures: No significant difference was found between the two antiseptic solutions 2, 5
Clinical Implications
The PREP-IT study provides evidence that can immediately impact clinical practice:
- For closed extremity fractures, iodine povacrylex in alcohol appears to be the superior choice
- Surgeons may consider standardizing their approach by using iodine povacrylex in alcohol for all fracture types 5
Conclusion
The PREP-IT study was designed to address the lack of consensus on the most effective antiseptic agent in alcohol-based solutions for preoperative skin preparation in extremity fracture surgery. This knowledge gap was the primary rationale for conducting this large-scale, pragmatic trial.