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American Association for Hand Surgery

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Chlorhexidine versus Povidone-Iodine Skin Antisepsis Prior to Upper Limb Surgery (CIPHUR): An International Multicentre Prospective Cohort Study
Ryckie George Wade, MBBS MSc MClinEd MRCS FHEA GradStat1, Grainne Bourke, MB BCh BAO FRCSI FRCS(Plast)2, Justin C R Wormald, MBBS MRes MRCS3, Joshua Philip Totty, MBBS PGCertRes MRCS MD FHEA4, Guy Henry Morton Stanley, BMBS MS DMCC DTM&H5, Sandeep Singh Rakhra, MBBS BMedSci DipClinEd6, Matthew Gardiner, MA PhD3 and Andrew Lewandowski, BSc MBBS MPhil7, (1)Department of Plastic and Reconstructive Surgery, University of Leeds, Leeds, United Kingdom, (2)Leeds Teaching Hospitals Trust, Leeds, United Kingdom, (3)University of Oxford, Oxford, United Kingdom, (4)Hull York Medical School, Hull, United Kingdom, (5)Fiona Stanley Hospital, Murdoch, WA, Australia, (6)Alfred Health, Melbourne, VIC, Australia, (7)Mater Adults Hospital, South Brisbane, QLD, Australia

Background: Surgical site infection (SSI) is the most common and costly complication of surgery. Given the accelerating antimicrobial crisis and rising rates of upper limb surgery, there is a need to reduce SSI. International guidelines recommend topical alcoholic chlorhexidine (CHX) prior to surgery but upper limb surgeons continue to use other antiseptics, citing an absence of applicable evidence and unresolved safety concerns in relation to open wounds and tourniquets. This study aimed to evaluate the safety and efficacy of different topical antiseptics prior to upper limb surgery.
Methods: This international multicentre prospective cohort study recruited consecutive adults and children who underwent surgery distal to the shoulder joint. The intervention was the use of CHX or povidone-iodine (PVI) antiseptics in either aqueous or alcoholic solvents. The primary outcome was SSI within 90 days. The secondary outcome was antiseptic-related adverse events (e.g., ignition fires or chemical burns beneath tourniquets). Mixed-effect time-to-event models were used to estimate the risk (hazard ratio, HR) of SSI for patients undergoing elective and emergency upper limb surgery.
Results: Overall, 2454 patients were included. The overall risk of SSI was 3·5% (elective surgery 2·8%, emergency surgery 4·0%). For elective upper limb surgery (n=1018), alcoholic CHX reduced the risk of SSI by 70% (adjusted HR 0·30 [95% CI 0·11, 0·84], Figure 1) and was superior to all other antiseptics. If surgeons switched to alcoholic CHX for elective surgery, then 44 patients would need to be treated to prevent 1 infection. Concerning emergency upper limb surgery (n=1436), aqueous PVI appeared to be the least effective antiseptic for preventing SSI but there was uncertainty in the estimates (Figure 2). Overall, the preoperative antiseptic used was the factor which reduced the risk of SSI most (Figure 3). No adverse events (fires, burns or hypersensitivity reactions) were reported.
Conclusions: In the context of zero adverse events, skin antisepsis for patients undergoing elective upper limb surgery should be performed using alcoholic CHX of the highest possible concentration e.g., chlorhexidine gluconate 4% in 70% isopropyl alcohol. For emergency (contaminated or dirty) upper limb surgery, our findings contradict the wider literature so no reliable conclusions can be drawn, and further research is necessary.



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