The 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 this patient population was the primary rationale for the PREP-IT study.
Background on the PREP-IT Study
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 knowledge regarding the optimal antiseptic solution for preventing surgical site infections (SSIs) in extremity fracture repairs 1. This study specifically compared isopropyl alcohol-based solutions containing iodine povacrylex with chlorhexidine gluconate.
Evidence of Lack of Consensus
The lack of consensus regarding the optimal antiseptic agent was clearly documented in the literature:
A 2018 cross-sectional survey revealed large variations in practice patterns among orthopedic surgeons regarding antiseptic solution use for fracture surgery. For open fractures, 41.0% of surgeons used iodine-based solutions, 26.7% used chlorhexidine gluconate (CHG)-based solutions, and 31.4% used a combination of both 2.
For closed fractures, the variation was similarly pronounced: 43.8% used CHG-based solutions, 28.1% used iodine-based solutions, and 27.1% used a combination 2.
Despite theoretical concerns about using alcohol in open wounds, 51.4% of surgeons reported using alcohol-based solutions or alcohol alone during skin preparation of open fractures 2.
Why This Lack of Consensus Needed to Be Addressed
Higher Infection Risk: Patients with extremity fractures have nearly 5 times greater risk of developing SSIs compared to elective orthopedic procedures 1.
Conflicting Evidence: Previous studies had shown conflicting results regarding the effectiveness of different antiseptic solutions 3.
Limited Fracture-Specific Evidence: While guidelines existed for general surgery and central neuraxial blockade 4, there was limited evidence specific to orthopedic trauma and fracture repair.
Results of the PREP-IT Study
The PREP-IT study has now provided valuable evidence:
For closed fractures, iodine povacrylex in alcohol resulted in fewer SSIs (2.4%) compared to chlorhexidine gluconate in alcohol (3.3%) 3.
For open fractures, both solutions showed similar infection rates (6.5% for iodine povacrylex vs. 7.3% for chlorhexidine gluconate) 3.
Clinical Implications
This study has important implications for clinical practice:
The findings challenge previous assumptions that chlorhexidine-based solutions are universally superior for surgical antisepsis.
For closed extremity fractures, iodine povacrylex in alcohol appears to be the preferred choice.
For open fractures, either solution may be appropriate.
Conclusion
The lack of consensus on the most effective antiseptic agent for extremity fracture surgery was the primary rationale for conducting the PREP-IT study. This study has now provided evidence-based guidance for choosing between isopropyl alcohol-based solutions containing either iodine povacrylex or chlorhexidine gluconate, addressing a significant gap in orthopedic trauma care.