Science, Medicine, and the Anesthesiologist

Conflicting results have been reported with respect to the type of skin antisepsis used prior to surgical incision to repair limb fractures with regard to the development of postoperative surgical-site infections. This cluster-randomized crossover trial (25 Canadian and U.S. hospitals) randomly assigned hospitals to either 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) for antisepsis for surgical repair of extremity fractures with hospitals alternating interventions every 2 months. Analyses were stratified by open versus closed fractures. The primary outcome was surgical-site infections (superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days after surgery). The secondary outcome was unplanned reoperation for fracture-healing complications. Enrollment included 8,485 patients (6,785 closed, 1,700 open fracture). With closed fracture, the primary outcome was significantly different between groups (2.4% iodine vs. 3.3% chlorhexidine; odds ratio, 0.74; 95% CI, 0.55 to 1.00; P = 0.049), while in the open-fracture group no difference was noted (6.5% vs. 7.3%; odds ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). No differences in the secondary outcome, 1-yr outcome, or adverse events between antisepsis groups were noted in either type of fracture population.

Take home message: This multicenter, cluster-randomized trial of iodine povacrylex versus chlorhexidine gluconate skin antisepsis prior to surgical incision for repair of extremity fractures noted a small but statistically significant difference in surgical-site infections in patients with closed, but not open fractures.