Updated Recommendations for Control of Surgical Site Infections

J. Wesley Alexander, MD, ScD; Joseph S. Solomkin, MD; Michael J. Edwards, MD


Annals of Surgery. 2011;253(6):1082-1093. 

In This Article

Skin Decontamination

Alcohol has been used as a skin disinfectant for more than 150 years. It is clearly the most effective short-term antimicrobial but it is highly flammable. Furthermore, there is no persistence of the antimicrobial effect. A method using hand rubbing with 75% aqueous alcoholic solution compared to hand-scrubbing protocols with antiseptic preparation of 4% povidine iodine or 4% chlorhexidine gluconate show that there was no difference in the incidence of surgical site infection, but the hand-rubbing protocol was better tolerated (SDC-38). Alcohol hand gel preps were also well tolerated compared to soap and water handwashing (SDC-39). Conversally, several comparisons of chlorhexidine versus povidone-iodine have reported that chlorhexidine is more effective in reduction of skin bacteria and that chlorhexidine and alcohol provided even better reduction of bacteria.[5] There have been several extensive reviews concerning antiseptic agents for preoperative skin preparation (SDC-40-42). The general conclusions of these reviews were that alcohol rubs were as effective as aqueous scrubs, chlorhexidine gluconate was more effective than povidone-iodine scrubs, and subsequent 2- to 3-minute scrubs were more effective than subsequent 30-second scrubs.

Combinations of alcohol and chlorhexidine or alcohol and an iodophor have been formulated to paint the area of the incision leading to a longer lasting barrier than prepping with aqueous materials. A recent study (SDC-43) showed that the overall rate of positive skin cultures was significantly lower in patients prepped with the chlorhexidine/alcohol product compared to an iodophor/alcohol product, and both of these were more effective in reducing positive cultures than a group prepped with aqueous povidone-iodine. In contrast, a very recent segmental observational study of 3209 operations showed a lower infection rate in patients prepped with iodine povacrylex (4.8%) compared to a chlorhexidine/alcohol product (8.2%) (SDC-44). The only randomized trial found a greater than 40% reduction in total surgical-site infections among patients undergoing clean-contaminated surgery who had received a single chlorhexidine-alcohol scrub as compared with a povidone-iodine scrub (SDC-45).


Reduction of skin bacteria on hands of the surgical team with the use of various preparations is a surrogate marker for the occurrence of wound infections. Hand scrubs of 2 to 3 minutes using a chlorhexidine/alcohol based product will provide the greatest reduction in skin bacteria. The best reduction in microbes at the operative site seems to be with an iodine povacrylex/alcohol or chlorhexidine/alcohol-based products.


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