Preoperative Antiseptic Selection for Extremity Fracture Surgery
Either iodine povacrylex in 74% isopropyl alcohol or chlorhexidine gluconate in 70% isopropyl alcohol may be used for preoperative antisepsis in this patient, as there is no significant difference in the risk for surgical site infection, unplanned reoperation, or chemical burns based on the PREP-IT trial.
Evidence from the PREP-IT Trial
The PREP-IT trial, a recent large-scale cluster-randomized crossover trial conducted at 25 hospitals in the United States and Canada, provides the most definitive evidence for this clinical scenario 1. This trial specifically examined preoperative skin antisepsis in patients with extremity fractures, making it directly applicable to our patient with open fractures of the right pelvis, femur, and ankle.
Key findings from the PREP-IT trial:
For open fractures (like our patient has):
- Surgical site infection occurred in 6.5% of patients in the iodine povacrylex group vs. 7.3% in the chlorhexidine gluconate group
- No statistically significant difference was found (odds ratio 0.86; 95% CI 0.58-1.27; p=0.45)
- Frequencies of unplanned reoperation and serious adverse events were similar between groups
For closed fractures (included for completeness):
- A small but statistically significant difference favoring iodine povacrylex was observed (2.4% vs. 3.3% infection rate; p=0.049)
Guidelines and Additional Evidence
Current guidelines provide somewhat conflicting recommendations:
The 2023 ERAS Society guidelines for liver surgery recommend chlorhexidine-alcoholic solution, noting it is associated with lower surgical site infection rates compared to povidone-iodine 2.
A 2020 guideline for dialysis unit infection prevention recommends alcohol-based chlorhexidine (>0.5% solution) for disinfection, with povidone iodine or 70% alcohol as acceptable alternatives 2.
The American Society for Microbiology's 2024 evidence-based guidelines showed that chlorhexidine was associated with a 56.5% reduction in blood culture contamination rates compared to other antiseptics 2.
Considerations for This Patient
For this specific patient with open fractures:
Type of surgery: The patient has open fractures requiring surgical fixation, which matches the open fracture population in the PREP-IT trial.
Timing: The patient has already undergone initial debridement and is now scheduled for definitive fixation, similar to the PREP-IT trial protocol.
Risk factors: The patient has no significant past medical history that would influence antiseptic selection.
Potential Pitfalls and Caveats
Chemical burns: Neither antiseptic solution has been shown to have a higher risk of chemical burns in the PREP-IT trial.
Antimicrobial resistance: Long-term concerns about antimicrobial resistance exist for both agents but should not influence immediate clinical decision-making.
Cost considerations: While cost may differ between products, this should not be the primary consideration when infection prevention is the goal.
Conclusion
Based on the most recent and highest-quality evidence from the PREP-IT trial, either 0.7% iodine povacrylex in 74% isopropyl alcohol or 2% chlorhexidine gluconate in 70% isopropyl alcohol is an appropriate choice for this patient with open fractures. The trial showed no significant difference in infection rates, reoperation rates, or adverse events between these two antiseptic solutions for open fractures.