Running head: CHLORHEXIDINE OR POVIDONE-IODINE

Comparing Chlorhexidine with Povidone-Iodine for Preventing Surgical Site Infection

Shawnee Cuthbert
Cedar Crest College

Abstract

CHLORHEXIDINE OR POVIDONE-IODINE

Surgical-site infections cause patients pain, can cause extended lengths of stay in the hospital,
and are costly for patients and healthcare facilities. Surgical preparation solutions are used to
remove flora on the patients skin, just prior to a surgical incision, to prevent post-surgical site
infections. Two of the most widely used products are chlorhexidine-alcohol and povidone-iodine.
The purpose of this paper is to demonstrate the significance to nursing, to explore the literature,
give a critical review of the evidence, and synthesize the evidence for the efficacies of using
chlorhexidine-alcohol over povidone-iodine. This paper provides recommendations for providing
patients with the best possible post-surgical outcome, and how the recommendations should be
implemented into the hospital setting. Based on the overall outcome of the results, evidence
favors using chlorhexidine-alcohol as the preferred antisepsis agent over povidone-iodine, in
clean-contaminated surgeries, for preventing post-surgical site infections.
Keywords: chlorhexidine-alcohol, povidone-iodine, surgical-site infection, antisepsis
agents, clean-contaminated surgery.

CHLORHEXIDINE OR POVIDONE-IODINE

Comparing Chlorhexidine with Povidone-Iodine for Preoperative Skin Antisepsis to Prevent

Surgical Site Infection
Many advances in healthcare have been made in recent years. These advances continue to
change and structure the way in which healthcare professionals provide care. Although such
advances have been made, complications may still arise. One of the complications that patients
face is the development of nosocomial infection, specifically for post-operative patients,
surgical-site infection. Surgical-site infections delay wound healing, decrease positive patient
outcomes, increase the patients length of time needed to recover, and increase the financial
burden for patients and for healthcare centers.
One of the most crucial steps before making the surgical incision is surgical-site
preparation. The area of the incision is prepped with an antisepsis solution. These surgical
preparation solutions remove the patients normal flora that can cause post-surgical infections at
the incision site. The antisepsis agents that are most often used for clean-contaminated surgery
are chlorhexidine-alcohol and povidone-iodine. Chlorhexidine-alcohol should be the preferred
agent over povidone-iodine for preventing surgical-site infection. This paper will confirm that by
examining and synthesizing the evidence from multiple studies. Recommendations, with a plan
to implement new protocol, will also be discussed.
Significance to Nursing
The significance of evaluating the effectiveness of both chlorhexidine-alcohol and
povidone-iodine proves beneficial for positive patient outcomes following clean-contaminated
surgery. Patient outcomes are improved if the surgical wound remains free of infection. The
process of surgical antisepsis also proves significant to the nursing profession; in that, the nurse
in the circulating role generally prepares the surgical site. Darouiche, et al. (2010) states, Since

CHLORHEXIDINE OR POVIDONE-IODINE

the patients skin is a major source of pathogens, it is conceivable that improving skin antisepsis
would decrease surgical-site infections (p. 19). In most institutions these two products are often
available to use in the operating theater. The goal for every nurse is to achieve the best outcome
for the patient. Therefore, it is critical for each nurse providing surgical antisepsis to understand
the importance of utilizing the best evidence-based practice with regards to each products
effectiveness of decreasing infection.
Surgical site infections are a burden to overall patient outcomes and are extremely costly
to healthcare institutions. According to Zinn, Jenkins, Swofford, Harrelson, and McCarter
(2010), the incidence of surgical site infections cost approximately $845 million dollars annually
and can increase patients expenses related to healthcare. With regards to patient outcomes in
relation to surgical-site infections, Hakkarainen et al. (2014) explains, They increase mortality,
hospital length of stay, and costs of care (p. 336). Therefore, evaluation of the effectiveness of
each chlorhexidine-alcohol and povidone-iodine antiseptic product, and determining which is
best to prevent surgical-site infection, will aid in improving patient outcomes by decreasing the
incidence of surgical-site infection.
Deciding which of the two antisepsis preparations should be used leads to the following
PICO question: Does cleansing adult pre-operative patients surgical site with chlorhexidinealcohol result in decreased rates of postoperative infection compared to cleansing the surgical
site with povidone-iodine?
The Process of the Literature Search
The process of searching for credible literature that would prove beneficial in answering
the PICO question began with the Cochrane Database. However, the Cochrane Database yielded
less than ten results, most not relevant to the question, citing other uses for chlorhexidine-

CHLORHEXIDINE OR POVIDONE-IODINE

alcohol. Further searches included the use of electronic databases such as: Google Scholar,
PubMed, ScienceDirect, and WorldCat. Google Scholar and PubMed provided the most relevant
data to the PICO question. The results displayed, using keywords chlorhexidine, povidoneiodine, and surgical-site infection for each database were as follows: Google Scholar (9,290),
ScienceDirect (4,476), WorldCat (336), and PubMed (124). The numerous amounts of results
were refined by creating a custom date range to only include articles published between 2008
and 2016.
Results were further narrowed by using the advanced search criteria. Keywords that were
utilized throughout the search included chlorhexidine-alcohol, povidone-iodine, surgical
prep solutions, antisepsis, alcohol-based skin prep, and surgical site infections. The
keywords within the searches were retrieved using phrase searching, and by using Boolean logic,
for example: chlorhexidine and iodine. Out of the remaining articles, eight articles from
primary sources were chosen that were either randomized controlled trials, meta-analysis and
systematic reviews, or cohort studies. Those eight articles were refined down to three articles
based on whether or not evidence was provided with regards to nursing research and the quality
of the studies. The three articles that were chosen encompassed well-developed methods, large
sample sizes, and a moderate quantity of results that specifically addressed the PICO question.
Critical Appraisal of Evidence
Noorani, Rabey, Walsh, and Davies (2010)
The authors performed a meta-analysis to identify if the incidence of surgical-site
infections was greater using chlorhexidine as an antisepsis, or povidone-iodine solutions in
various clean-contaminated surgeries. Only six eligible studies were identified for the metaanalysis after a systematic review identified 570 possible studies. The article was written in the

CHLORHEXIDINE OR POVIDONE-IODINE

United Kingdom, but was chosen as one of the three final articles since four of the six qualified
research studies were from the United States. Also, the systematic review thoroughly eliminated
irrelevant studies that would not answer the PICO question directly. A meta-analysis is the goldstandard for making evidence-based decisions, and this meta-analysis scored high on the John
Hopkins Nursing Evidence-Based Practice Rating Scale, and received a Level I rating for
strength of the review based on the Melynk & Fineout-Overholt Rating System.
The systematic review identified six appropriate studies, containing 5,031 patients who
used either chlorhexidine or povidone-iodine antisepsis. Only clean-contaminated surgeries
qualified for the meta-analysis. The results corresponding to the individual products were as
follows: The occurrence of surgical-site infections among 2,529 patients was 5.7% when
chlorhexidine was used as the antisepsis. The occurrence of surgical-site infections among 2,502
patients was 7.9% when povidone-iodine antisepsis was used.
The results of the meta-analysis clearly favor the use of chlorhexidine-alcohol over
povidone-iodine to be used to prevent surgical-site infection. The authors recommend
chlorhexidine be used as the preferred antisepsis agent in preoperative patients to reduce
occurrence of surgical-site infections
Darouiche et al. (2010)
The researchers utilized a prospective, randomized controlled trial to determine the
effects of using chlorhexidine-alcohol versus povidone-iodine for the preparation of the patient
for surgery. Results were observed from patients who had similar characteristics, co-morbidities,
types of surgical procedures performed, and antibiotic prophylaxis. A total of 849 patients (409
were in the chlorhexidine-group and 440 were in the povidone-iodine group) were included by
the researchers. Rates of surgical-site infections following the application of chlorhexidine-

CHLORHEXIDINE OR POVIDONE-IODINE

alcohol (9.5%) preoperatively were considerably less than those that were prepped with
povidone-iodine (16.1%). Chlorhexidine-alcohol proved to reduce the risk of surgical site
infections present on the superficial (4.2%) and deep (1%) layers of the skin in comparison to
povidone-iodine (8.6% and 3%). Chlorhexidine-alcohol was significantly more effective at
preventing surgical site infections in patients undergoing abdominal surgeries (12.5%), than
povidone-iodine (20.5%).
The authors recommended that preoperative cleansing with chlorhexidine-alcohol is superior to
cleansing with povidone-iodine for preventing surgical-site infection after clean-contaminated
surgery. The results support the researchers conclusion.
Menderes, Ali, Aagaard, and Sangi-Haghpeykar (2012)
The researchers utilized a prospective cohort review that compared the use of
chlorhexidine-alcohol to povidone-iodine. Records for 1,000 women who had undergone
cesarean sections. The case files were reviewed for information to answer which antisepsis
should be used to prevent surgical-site infection following cesarean section surgery.
Theresultsofthisstudyconcludedthatchlorhexidinealcohol,comparedtopovidone
alcohol,hadtheleastamountofpostoperativesiteinfections.Ofthe1,000thatqualifiedfor
review,5.8%ofthewomeninthepovidoneiodinegroupcomparedwith5.0%ofthewomenin
thechlorhexidinealcoholgrouphaddevelopedsurgicalsiteinfections.
Researchersstatedthatthereisnotenoughofasignificantdifferencebetweenthetwo
antisepsisagentstorecommendoneovertheother.Researchers concluded that themost
significantpredictorofsurgicalsiteinfectionistheoperativetime.Foreveryminutespentintra
operatively,thechancesofdevelopingasurgicalsiteinfectionincreasedby1.3%.
Synthesis of the Evidence

CHLORHEXIDINE OR POVIDONE-IODINE

All three studies had the purpose of determining whether povidone-iodine or

chlorhexidine-alcohol should be the preferred agent used to prevent surgical-site infections in
clean-contaminated surgery. Two of the chosen studies proved to provide the most relevant and
sufficient data in accurately answering the PICO question. The third study, the newest of the
three, was chosen since the results, which only slightly favored chlorhexidine, showed that
research should be an on-going process. Evidence should be reviewed and new data should be
considered to determine what the best evidence-based practice in nursing is.
Noorani et al (2010) and Darouiche et al (2010) both concluded that chlorhexidinealcohol should be used as the preferred pre-surgical antisepsis. In six total studies between these
two articles researchers used a randomized controlled trial, to determine the efficacy of using
chlorhexidine-alcohol over povidone-iodine, which is the preferred method of collecting valid
clinical data. The data collected, from a total of 5,031 subjects, supported the recommendations.
Darouiche et al (2010) was one of the six included studies that the systematic review qualified to
be part of the Noorani et al (2010) meta-analysis. Therefore, the numbers from Darouiche (2010)
are included in the above statistics.
Mederes et al (2012), the third study used, conducted a retrospective cohort review. This
review used the records of 1,000 adult cesarean patients. The groups were split equally, whereas
500 subjects received chlorhexidine as the pre-surgical site antisepsis agent, and 500 subjects
received povidone-iodine as the prep. Results of the review showed that there is no significant
difference in surgical-site infections when chlorhexidine and povidone-iodine are compared. The
authors also examined other data which was not used in other studies. Since the difference in
surgical-site infections was not substantial 5.0% for chlorhexidine versus 5.8% for povidone-

CHLORHEXIDINE OR POVIDONE-IODINE

iodine the authors instead concluded that operative time is a bigger factor in determining the
risk for surgical-site infection.
Based on the results of the three articles, a recommendation can clearly be made, that
chlorhexidine-alcohol should be the antisepsis agent nurses apply to the surgical site prior to
surgery.
Recommendations
The presence of many variables, including patient co-morbidities, types of surgeries, and
even the length of the surgery contribute to the chances of developing a surgical-site infection.
The presence of a surgical-site infection that occurs due to these variables can occur regardless of
the type of preparation solutions used. As described in Darouiche et al. (2010) study, 0.7% of the
patients exhibited adverse effects related to the presence of surgical prep solutions. Even though
the chances of adverse effects are low, the occurrence of a potential complication that can be
avoided, should be avoided. Therefore, the first recommendation is that the use of an individual
product should be considered with regards to a patients specific circumstances and what the best
possible outcome would be. The patient should be questioned on previous exposures to surgical
preparation solutions, such as chlorhexidine, ChloraPrep, and iodine.
The second recommendation is that chlorhexidine-alcohol should be used as the preferred
antisepsis in all clean-contaminated surgeries. Clean surgical procedures are ideal situations for
use of surgical preparation solutions, due to the solutions capabilities of providing consistent
activity and rapid action on the skin (Darouiche et al. 2010). This is not the case for procedures
classified as clean-contaminated, such as abdominal surgery. In the presence of cleancontaminated surgical procedures, surgical team members should follow strict sterile technique
and provide prophylactic measures to reduce contamination of the surgical site. The healthcare

CHLORHEXIDINE OR POVIDONE-IODINE

10

staff should be recognizant that such complications can arise and should be taken into
consideration for every patient to achieve better overall patient outcome. Evidence-based
research has proven that chlorhexidine-alcohol reduces surgical-site infection and gives patients
the best possible outcome.
For some patients, the development of an infection does not occur until after discharge
from the hospital. According to Hakkarainen et al. (2014), procedures with shorter average
length of surgery (bariatric, laparoscopic) might have a higher percentage of missed SSI
diagnoses (p. 343). Therefore, the third recommendation is that all patients, especially those that
meet the criteria for early discharge, be assessed and monitored for any possible early signs of an
infection. The patients laboratory work, physical appearance, and mental status should all be
incorporated into the nurses post-operative assessment. As part of this recommendation, nurse
teaching should include the importance of having routine follow-up appointments scheduled
quickly, and adhered to, so the patient can be examined to prevent further possible complications
that may result in an infection.
Implementation Plan
The protocol to replace povidone-iodine with chlorhexidine in all clean-contaminated
surgeries should be implemented to achieve the best patient outcome. The plan for having the
current protocol changed is to give a presentation to the hospital board, highlighting that a
surgical site infection can increase hospital costs on the average of $20,842 per incidence
(Menderes et al., 2012). As a solution, to offset this high cost, the hospital should utilize
chlorhexidine over povidone-iodine to reduce the occurrence of surgical-site infections.
According to Lee et al (2010), chlorhexidine, while more expensive than povidone-iodine, is
more effective in preventing surgical-site infections and results in cost savings for the healthcare

CHLORHEXIDINE OR POVIDONE-IODINE

11

institution. For further cost savings, it is recommended that both povidone-iodine and
chlorhexidine-alcohol surgical prep solutions be made available to be used in all surgical
theaters. The use of each type of preparation solution should also be dependent upon the type of
surgery - clean or clean-contaminated - and the specific patient needs.
For the implementation of practice, the nursing staff should be educated and given
educational material outlining the efficacies of chlorhexidine-alcohol. Information should
include that chlorhexidine-alcohol has been examined and has been proven to provide
significantly better patient outcomes, with regards to the prevention of surgical-site infections.
Nurses should understand why one product is being used over another to eliminate any bias, or
resistance to the change from current protocol.
Conclusion
Surgical-site infections are a significant problem that can cause patients pain, can cause
extended lengths of stay in the hospital, and are costly for patients and healthcare facilities.
Surgical preparation solutions are used to remove flora on the patients skin, just prior to a
surgical incision, to prevent post-surgical site infections. Two of the most widely used products
are chlorhexidine-alcohol and povidone-iodine. Three studies were appraised and the evidence
was synthesized. The evidence showed that chlorhexidine-alcohol is a superior antisepsis agent,
for use in clean-contaminated surgery, over povidone-iodine. Based on the evidence included in
this paper, three recommendations to change hospital protocol were given that provide patients
with the best possible post-surgical outcomes, and a plan for implementing the new protocol was
given for the hospital. In this paper, the PICO question Does cleansing adult pre-operative
patients surgical site with chlorhexidine-alcohol result in decreased rates of postoperative
infection compared to cleansing the surgical site with povidone-iodine was answered.

CHLORHEXIDINE OR POVIDONE-IODINE

12

References
Darouiche, R. O., Wall, M. J., Itani, K. M. F., Otterson, M. F., Webb, A. L., Carrick, M. M., . . .
Berger, D. H. (2010). Chlorhexidinealcohol versus povidone iodine for surgical-site
antisepsis. The New England Journal of Medicine, 362, 18-26. Retrieved from
http://www.nejm.org/doi/full/10.1056/NEJMoa0810988
Hakkarainen, T. W., Dellinger, E. P., Evans, H. L., Farjah, F., Farrokhi, F., Steele, S. R., . . .
Flum, D. R. (2014). Comparative effectiveness of skin antiseptic agents in reducing
surgical site infections: A report from the Washington state surgical care and outcomes
assessment program. The American College of Surgeons, 218(3), 336-344.
doi:10.1016/j.jamcollsurg.2013.11.018
Lee, I., Agarwal, R., Lee, B., Fishman, N., & Umscheid, C. (2010). Systematic review and cost
analysis comparing use of chlorhexidine with use of iodine for preoperative skin
antisepsis to prevent surgical site infection. Infection Control and Hospital Epidemiology,
31(12), 1219-1229. http://dx.doi.org/10.1086/657134
Menderes, G., Ali, N. A., Aagaard, K., & Sangi-Haghpeykar, H. (2012). Chlorhexidine-alcohol
compared with povidone-iodine for surgical-site antisepsis in cesarean deliveries. The
American College of Obstetricians and Gynecologists, 120(5), 1037-1044.
doi:10.1097/AOG.0b013e31826f3bd9
Noorani, A., Rabey, N., Walsh, S., & Davies, R. (2010). Systematic review and meta-analysis of
preoperative antisepsis with chlorhexidine versus povidone-iodine in clean-contaminated
surgery. British Journal of Surgery, 97(11), 1614-1620.
http://dx.doi.org/10.1002/bjs.7214
Zinn, J., Jenkins, J. B., Swofford, V., Harrelson, B., McCarter, S. (2010). Intraoperative

CHLORHEXIDINE OR POVIDONE-IODINE

13

patient skin prep agents: Is there a difference? Association of periOperative

Registered Nurses Journal, 92(6), 662-674. doi:10.1016/j.aorn.2010.07.016
Appendix Summary of Evidence
Author,
Date, Title
of Study,
Journal

Research
Questions/
Hypothesi
s/
Purpose

Methods

Noorani,
A., Rabey,
N., Walsh,
S., &
Davies, R.
(2010).
Systematic
review and
metaanalysis of
preoperativ
e antisepsis
with
chlorhexidi
ne versus
povidoneiodine in
cleancontaminat
ed surgery.
British
Journal of
Surgery

Purpose:
To
determine
whether
povidoneiodine or
chlorhexidi
ne should
be the
preferred
agent to
prevent
SSIs in
cleancontaminat
ed surgery

Design:

Metaanalysis
and
systematic

review
Sample:
6 (5 RCT;

1
prospective
) studies,
containing
5031

patients

Setting:
Hospitals;
follow-up
visits

Study
Variables:
Independent
(IV)
Dependent
(DV)
Research (RV)
RV:
Prepping surgical
site w/
chlorhexidinealcohol
Prepping surgical
site w/ povidoneiodine
Patients 18+ yrs
of age
Cleancontaminated
surgery
Clinical trial
At least 1 clinical
end-point
reported

Results/Findings

Limitati

Measures/
Reliability
Validity
Instruments:

DerSimonian and
Laird randomeffects model
Cochrans Q test
Visual inspection of
funnel plots
Egger test
Statsdirect 2.5.7

Methods of Data
Collection:

MEDLINE and
Embase databases
were searched Jan.
2010, with a
supplemental
search in Feb 2010
Conference
proceedings from
major general
surgery and
gynecological
meetings were
searched from
2000-2010 for
eligible abstracts
Reference lists from
eligible reports
were used to
identify further
eligible studies
Antiseptic
manufacturer
websites were
searched for

One study
Results:
not RCT
Chlorhexidine
Variations
reduced
applicati
postoperative SSI
methods
compared with
agents
povidone-iodine

Chlorhexid
concentr
varied
Chlorhexid
mixed w
isopropy
alcohol i
of 6 trial
Different
operative
procedur
pooled
Postoperat
SSI is a
clinical
diagnosis
dependen
the recor
Varying
definition
SSI amon
the 6 tria
making
outcome
more diff
to compa
Only 1 tria
used
assessors

CHLORHEXIDINE OR POVIDONE-IODINE
Author,
Date, Title
of Study,
Journal

Research
Questions/
Hypothesi
s/
Purpose

Methods

Study
Variables:
Independent
(IV)
Dependent
(DV)
Research (RV)

14
Results/Findings
Measures/
Reliability
Validity
relevant pubs or
presentations

Darouiche,
R. O.,
Wall, M. J.,
Itani, K.
M. F.,
Otterson,
M. F.,
Webb, A.
L., Carrick,
M. M., . .
Berger, D.
H. (2010).
Chlorhexid
ine
alcohol
versus
povidone
iodine for
surgicalsite
antisepsis.
The New
England
Journal of
Medicine

Hypothesi
s:
Preoperativ
e skin
cleansing
w/chlorhex
idinealcohol is
more
protective
against
infection
than is
povidoneiodine

Design:
Randomize
d
controlled
clinical
trial
Sample:
849 Adult
patients
undergoing
cleancontaminat
ed
surgeries
Setting:
6 hospitals

Menderes,
G.,Ali,N.
A.
Aagaard,

Purpose:
To estimate
the
incidence

IV:
Chloraprep (2%

chlorhexidine
gluconate and
70% isopropyl
alcohol)

IV:
Scrub Care Skin
Prep Tray
(aqueous
solution of 10%
povidone-iodine)
DV:
Rate of SSIs
RV:

Methods of Data
Collection:
Weekly follow-up
calls to patients in
30 day post-op
period
Culturing of
suspected
infections in 30
day post-op period

Patients 18+yrs of
age
Systemic
antibiotics
Duration of
surgery
Abdominal/
non-abdominal
surgery
Preoperative
shower
Type of infection

Design:
RV:
Retrospecti 500 women w/
chlorhexidineve Cohort
alcohol prep
review

Limitati

Methods of Data
Collection:
Data abstraction
from 1,000 prior

Result:
The overall SSI
rate was
significantly
lower in the
chlorhexidinealcohol group
than in the
povidone-iodine
group

complete
blinded t
intervent
Pr
ris
fac
to
de
pin
SS
the
sam
ma
inc
et
pro
ilit
rec
ng
fal
po
e
res
Th
po
ne
iod
sam
ha
mo
pa
st
the
ch
xid
alc
sam

Limitation
Results:
Lack of
Both prep
randomiz
solutions had
n-not a R
similar SSI rates.

CHLORHEXIDINE OR POVIDONE-IODINE
Author,
Date, Title
of Study,
Journal

Research
Questions/
Hypothesi
s/
Purpose

Methods

K.,&
Sangi
Haghpeyka
r,H.
(2012).
Chlorhexid
inealcohol
compared
with
povidone
iodinefor
surgical
site
antisepsis
incesarean
deliveries.
The
American
Collegeof
Obstetricia
nsand
Gynecolog
ists

of SSI
using
chlorhexidi
ne-alcohol
compared
w/
povidoneiodine
among
women
having
cesarean
sections.

Sample:
1,000
consecutiv
e cases of
women
who
underwent
a c-section
Setting:
Ben Taub
General
Hospital,
Houston,
Texas

Study
Variables:
Independent
(IV)
Dependent
(DV)
Research (RV)
500 women w/
povidone-iodine
prep
SSI
Patient
Demographics
Duration of
cesarean
delivery
Altered immunity
Incision type
Method of skin &
subcutaneous
tissue closure
Systemic
antibiotics
Surgeon level
Previous
abdominal
surgeries
Foreign material
at surgical site
Use of
preoperative clip
Remote infection

15
Results/Findings

Limitati

Measures/
Reliability
Validity
patients charts
including
operative reports,
nursing records, &
anesthesia reports

Using one
setting
Skin closu
methods
varied
Higher % (
v 29%) o
patients i
the povid
iodine sa
underwe
emergen
sections
Duration o
section
delivery
significa
longer am
chlorhex
-alcohol
group