What is the preferred antiseptic solution for preoperative antisepsis, 0.7% iodine (iodine) povacrylex in 74% isopropyl alcohol or 2% chlorhexidine (chlorhexidine) gluconate in 70% isopropyl alcohol, for surgical site infection prevention?

Preoperative Antisepsis for Orthopedic Trauma Surgery: PREP-IT Trial Results

Either iodine povacrylex in 74% isopropyl alcohol or 2% chlorhexidine gluconate in 70% isopropyl alcohol may be used for preoperative antisepsis in orthopedic trauma surgery as there is no difference in the risk for surgical site infection (SSI), unplanned reoperation, or chemical burns.

Evidence Summary

The PREP-IT trial specifically compared these two antiseptic solutions in orthopedic trauma patients and found no significant differences in outcomes. This directly addresses the clinical scenario of WS, a 45-year-old male with multiple open fractures requiring surgical fixation.

Guidelines on Skin Antisepsis

Multiple guidelines support the use of chlorhexidine-based solutions for skin antisepsis:

• The ESPEN guidelines on parenteral nutrition recommend 2% chlorhexidine solution in 70% isopropyl alcohol as the most appropriate antiseptic for skin preparation before catheter insertion and for cleansing entry sites 1.

• The ESPGHAN/ESPEN/ESPR/CSPEN guidelines strongly recommend 2% chlorhexidine solution in 70% isopropyl alcohol for skin disinfection before insertion of intravascular devices and for post-insertion site care 1.

• The ERAS Society guidelines for perioperative care in liver surgery state that skin preparation with chlorhexidine 2% is superior to povidone-iodine solution, with a strong recommendation based on moderate evidence 1.

Recent Research Evidence

The American Society for Microbiology's 2024 evidence-based guidelines found that chlorhexidine-based antiseptics were associated with a significant reduction in blood culture contamination rates compared to other antiseptics (RR 0.435,95% CI 0.233-0.814) 1.

However, there are some contradictory findings in the research:

• A 2019 cluster randomized controlled trial in elective arthroplasty (ACAISA study) found that iodine-alcohol had greater efficacy than chlorhexidine-alcohol for preventing surgical site infection (1.0% vs 3.1%, OR 3.06,95% CI 1.26-7.46) 2.

• A 2010 study in the New England Journal of Medicine found that chlorhexidine-alcohol was superior to povidone-iodine for preventing surgical site infections (9.5% vs 16.1%, p=0.004) 3.

Clinical Application for Orthopedic Trauma

For a patient like WS with multiple open fractures requiring surgical fixation:

1. Either antiseptic solution is appropriate:

   • 0.7% iodine povacrylex in 74% isopropyl alcohol
   • 2% chlorhexidine gluconate in 70% isopropyl alcohol

2. Application technique matters:

   • Allow the antiseptic solution to air dry completely before beginning the procedure 1
   • Maintain sterile technique throughout the procedure

3. Special considerations:

   • For patients with known chlorhexidine sensitivity, use alcoholic povidone-iodine solution 1
   • For infants younger than two months, chlorhexidine is not recommended due to potential side effects 1

Avoiding Common Pitfalls

• Drying time: Regardless of which solution is chosen, allow the antiseptic to completely air dry before beginning the procedure to maximize effectiveness 1.

• Proper application: The method of applying antiseptic solution may be just as important as the choice of solution 4. Follow manufacturer's recommendations for application technique.

• Sterile technique: Maintain maximal barrier precautions during the procedure, including sterile gown and gloves 1.

In conclusion, based on the PREP-IT trial results, either antiseptic solution would be appropriate for WS's orthopedic trauma surgery, as neither has demonstrated superiority in preventing surgical site infections, unplanned reoperations, or chemical burns in this specific patient population.