Preoperative skin preparation with either chlorhexidine in alcohol or olanexidine is the most effective for preventing surgical site infections (SSIs), according to results of a systematic review and meta-analysis published in The Lancet Microbe.
Researchers from Amsterdam University Medical Center in the Netherlands searched publication databases through November 2021 for studies of that assessed strategies of SSI prevention. A total of 33 studies were selected for systematic review, 27 of which were also included in a meta-analysis. All included studies were randomized controlled trials in which different preoperative skin antiseptics were compared for the prevention of SSI in adults who underwent surgical procedures of any wound classification. The primary outcome was SSI occurrence, including superficial, deep, and organ-space infections.
There were 27 different antiseptic solutions evaluated among the included studies. The most common antiseptic preparations used in the studies were 2.0% to 2.5% chlorhexidine in alcohol vs aqueous iodine (n=11), 2.0% to 2.5% chlorhexidine in alcohol vs iodine in alcohol (n=7), and aqueous iodine vs iodine in alcohol (n=6).
A total of 17,735 patients were included in this analysis, of whom 2144 (12.1%) developed an SSI.
Compared with aqueous iodine, the researchers found that 1.5% olanexidine (relative risk [RR], 0.49; 95% CI, 0.26-0.92) and 2.0% to 2.5% chlorhexidine in alcohol (RR, 0.75; 95% CI, 0.61-0.92) were both associated with an overall decreased SSI risk among patients with any wound classification.
For studies that assessed preoperative skin antiseptics among patients who underwent clean surgical procedures, the use of any concentration of chlorhexidine in alcohol was associated with a significant decreased risk for SSI compared with aqueous iodine (RR, 0.60; 95% CI, 0.36-0.99). Compared with iodine in alcohol, however, the decreased SSI risk associated with the use of any concentration of chlorhexidine in alcohol was nonsignificant (RR, 0.54; 95% CI, 0.27-1.07). In regard to skin antiseptics for non-clean surgical procedures, 1.5% olanexidine (RR, 0.49; 95% CI, 0.27-0.88) and 2.0% to 2.5% chlorhexidine in alcohol (RR, 0.79; 95% CI, 0.65-0.95) both showed higher protective efficacy against SSIs compared with aqueous iodine.
Results of subgroup analyses that excluded studies with a high risk of bias were similar, showing that 2.0% to 2.5% chlorhexidine in alcohol and 1.5% olanexidine had higher efficacy in preventing SSIs compared with aqueous iodine.
No significant differences were noted among the different skin antiseptics evaluated in regard to the incidence of adverse events. Reported adverse events among the studies included erythema, pruritus, dermatitis, skin irritation, and allergic symptoms, all of which were of mild severity.
Limitations include that the use of 1.5% olanexidine was only evaluated in 1 of the included studies, thus findings pertaining to 1.5% olanexidine may be overvalued.
According to the researchers, “The efficacy of olanexidine was established by a single randomised trial and further investigation is needed.”
Disclosure: An author declared affiliations with industry. Please see the original reference for a full list of disclosures.
Jalalzadeh H, Groenen H, Buis DR, et al. Efficacy of different preoperative skin antiseptics on the incidence of surgical site infections: a systematic review, GRADE assessment, and network meta-analysis. Lancet Microbe. 2022;S2666-5247(22)00187-2. doi:10.1016/S2666-5247(22)00187-2