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Kamel C, McGahan L, Mierzwinski-Urban M, et al. Preoperative Skin Antiseptic Preparations and Application Techniques for Preventing Surgical Site Infections: A Systematic Review of the Clinical Evidence and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2011 Jun.

Cover of Preoperative Skin Antiseptic Preparations and Application Techniques for Preventing Surgical Site Infections: A Systematic Review of the Clinical Evidence and Guidelines

Preoperative Skin Antiseptic Preparations and Application Techniques for Preventing Surgical Site Infections: A Systematic Review of the Clinical Evidence and Guidelines [Internet].

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6.1. Summary of Evidence

This review on preoperative skin antiseptic preparations and application techniques summarizes clinical trial data and recommendations from 21 clinical studies and one evidence-based clinical practice guideline.5,1227,3034 Eighteen studies on the comparative clinical effectiveness of preoperative skin antiseptic preparations provided information about pre-surgical showers,1217 and antiseptic preparation compared with hygiene,18,19 antiseptics,2027 and draping.20,30,31 Three RCTs and one cohort study compared different techniques for applying preoperative skin antiseptics.20,3234

Two previous systematic reviews36,37 examined the effectiveness of pre-surgical showering on the reduction of skin flora and SSIs. The findings in these reviews were mixed. One36 found no evidence of the benefit of pre-surgical bathing with CHG, and the other37 found CHG bathing to be effective at reducing skin flora. These reviews were based on literature published before 2001. This review, which is based on more recent clinical trials, supports the idea that pre-surgical showering with CHG is effective for reducing skin flora. In one included study, PI was used as a pre-surgical showering solution, and two studies compared PI surgical site preparation with soap and water or saline wound irrigation. None of these studies found a reduction in SSIs with PI use. Current UK clinical practice guidelines5 found that CHG showering or bathing reduces SSIs, but is no more effective than soap and water.

Current Canadian practice is guided by the Safer Healthcare Now! “Preventing Surgical Site Infection” bundles,6 which recommend the use of CHG in alcohol for infection prevention. In this review, no conclusions could be drawn about which surgical site antiseptic is more effective for reducing SSIs. A meta-analysis was not possible because of the heterogeneity of antiseptic preparations and surgery types among the studies. These mixed results are in contrast to two systematic reviews38,39 that suggest CHG is more effective than PI for skin disinfection before surgery. These previous reviews consider some studies that were excluded from this review based on a lack of post-operative assessment, or inappropriate population or procedures of interest (Bibbo,40 Ostrander,41 Culligan,42 and Saltzman29). However, the findings of this systematic review agree with those of a previous review43 that indicates there is insufficient evidence to support one antiseptic over another, and those of a clinical practice guideline5 that recommends the use of CHG or PI for preoperative skin preparation. The Safer Healthcare Now! guidelines6 were not included in this review, because they were not based on a systematic literature search.

Three studies20,30,31 described the use of iodophor-impregnated incise drapes. They agree with current evidence-based clinical practice guidelines,5 published in the UK, in finding that the use of iodophor-impregnated incise drapes reduces the rate of SSI. The guideline also recommends against the use of non-antimicrobial drapes, but no studies making that comparison were identified for inclusion in this review.

Preoperative skin antiseptics were applied in a variety of ways (for example, scrubbing, painting, or combination) across all studies included in this review. Four studies20,3234 directly compared the effectiveness of different application methods. Evidence from three RCTs indicates that the application method is not a crucial factor in reducing SSI rates in surgical patients, and this finding is consistent with clinical practice guidelines5 that found no difference between PI scrub and paint and paint alone. One large retrospective cohort study suggests scrub and paint reduced composite wound infection after Caesarean section by 31% compared with paint alone.34

One clinical practice guideline5 based on a systematic literature review provided recommendations for the prevention and treatment of surgical site infection in the UK. These guidelines were partly based on some of the studies that were included in this review and are consistent with our findings, with the exception of the recommendations regarding pre-surgical showering. This difference is likely due to the fact that there was no overlap in studies, because the guideline recommendations were based on a meta-analysis of trials that were published in 1992 or earlier.


Overall, the studies were of varying quality. Evidence was drawn from a mix of RCTs and non-randomized trials, although the method of randomization was generally poorly reported. Efforts were made to blind outcome assessors, but patients and surgeons often were not blinded, thus compromising internal validity. Studies included a spectrum of surgical procedures and wound classifications, so the ability to form generalizations for all patients undergoing surgery is limited. Interventions and comparators were not always well described, and antisepsis methods varied from study to study. This limits the ability to draw conclusions about specific solution strengths and protocols, but does provide a picture of the effectiveness of each antiseptic. However, disinfectant products are sometimes mixed with an alcohol or an aqueous base. Because alcohol has antiseptic properties, this makes it difficult to perform direct comparisons and draw overall conclusions about a particular disinfectant.

This review examines the evidence on the clinical effectiveness of pre-surgical antiseptic skin preparation solutions and application techniques. The adverse events related to antiseptic choice were considered in this review, but not every included study reported this outcome. This review, therefore, does not address the safety related to each skin preparation method, nor does it consider cost-effectiveness, which may be of interest when establishing clinical protocols. Safety issues will be addressed in a supplementary report. Because no Canadian trials were identified for inclusion in this review, generalizability to a Canadian health care context may be limited.

Copyright © CADTH (June 2011)

You are permitted to make copies of this document for non-commercial purposes provided it is not modified when reproduced and appropriate credit is given to CADTH.

Links: This document may contain links to other information available on the websites of third parties on the Internet. CADTH does not have control over the content of such sites. Use of third-party sites is governed by the owners’ own terms and conditions set out for such sites. CADTH does not make any guarantee with respect to any information contained on such third-party sites and CADTH is not responsible for any injury, loss, or damage suffered as a result of using such third-party sites.

Industry: The following manufacturers were provided with an opportunity to comment on an earlier version of this report: 3M Canada, AstraZeneca Canada Inc., CareFusion. All comments that were received were considered when preparing the final report.

Bookshelf ID: NBK174539
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