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. 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.
Annals of Surgery. 2011;253(6):1082-1093. © 2011 Lippincott Williams & Wilkins
Cite this: Updated Recommendations for Control of Surgical Site Infections - Medscape - Jun 01, 2011.