Chlorhexidine vs Betadine for Surgical Skin Preparation
Chlorhexidine in alcohol is superior to povidone-iodine (Betadine) for skin preparation before surgery due to its faster onset, longer duration of action, and significantly lower rates of surgical site infections. 1
Comparative Efficacy
- Chlorhexidine gluconate is a potent, broad-spectrum antiseptic effective against nearly all bacteria and yeasts with faster onset and longer duration of action than povidone-iodine 1
- Chlorhexidine retains its efficacy in the presence of blood and has a lower incidence of skin reactions compared to povidone-iodine 1
- Multiple studies demonstrate that chlorhexidine results in a more rapid and superior bactericidal effect that lasts several hours beyond its initial application 1
- Epidural catheters inserted following chlorhexidine skin preparation were six times less likely to be colonized than when povidone-iodine had been used 1
- A large randomized controlled trial found that chlorhexidine-alcohol was significantly more protective than povidone-iodine against surgical site infections (9.5% vs. 16.1%, relative risk 0.59) 2
Formulation Considerations
- Alcoholic solutions of both antiseptics are more effective than aqueous solutions 1
- For chlorhexidine, a 0.5% solution in alcohol is preferred over a 2% solution for central neuraxial blockade procedures due to potential neurotoxicity concerns with higher concentrations 1
- For general surgical procedures, 2% chlorhexidine in 70% alcohol is commonly recommended 1
- A systematic review and meta-analysis found that chlorhexidine was superior to povidone-iodine in preventing postoperative surgical site infections in both clean surgery (RR 0.81) and clean-contaminated surgery (RR 0.58) 3
Application Technique
- The antiseptic solution must be allowed to dry completely before skin palpation or puncture 1
- Equipment should be covered or protected while the antiseptic is applied by swab, applicator, or spray to prevent contamination 1
- The operator should check gloves for contamination with antiseptic and change them if there is any doubt 1
- Application with a swab-stick applicator may help minimize spillage and contamination risks 1
Special Considerations
Anatomical Location
- For shoulder and spine operations, chlorhexidine preparations are recommended due to their effectiveness against Cutibacterium acnes, a common cause of infections in these regions 4
- For hip and knee surgeries, 2% chlorhexidine gluconate cloth the night before and morning of surgery followed by chlorhexidine-alcohol skin prep is recommended 4
Patient Factors
- Chlorhexidine should not be used in patients with known allergies to the agent 5
- For children under two months of age, the volume of chlorhexidine used should be minimized while still ensuring adequate antisepsis 1
- Chlorhexidine should be kept away from eyes, ears, and mouth as it may cause serious and permanent eye injury or deafness when in contact with these areas 5
Safety Precautions
- When using chlorhexidine for central neuraxial blockade, meticulous care must be taken to prevent it from reaching the cerebrospinal fluid due to potential neurotoxicity 1
- Chlorhexidine should not be used in contact with meninges or in the genital area 5
- Both antiseptics can cause allergic reactions, with symptoms including wheezing, difficulty breathing, shock, facial swelling, hives, or rash 5
Algorithm for Selection
- First choice: Chlorhexidine in alcohol for most surgical procedures 1, 2
- Alternative: Povidone-iodine if patient has chlorhexidine allergy 5
- Concentration selection:
- Special anatomical considerations:
In conclusion, the evidence strongly supports the use of chlorhexidine-alcohol as the preferred antiseptic for surgical skin preparation due to its superior efficacy in preventing surgical site infections compared to povidone-iodine.