Chlorhexidine versus povidone–iodine skin antisepsis before upper limb surgery (CIPHUR): an international multicentre prospective cohort study
Authors: Wade Ryckie G , Bourke Gráinne , Wormald Justin C R , Totty Joshua Philip , Stanley Guy Henry Morton , Lewandowski Andrew , Rakhra Sandeep Singh , Gardiner Matthew D ,   The CIPHUR Collaborative, Bindra R , Sher M , Thomas M , Morgan S D J , Hwang B , Santucci W , Tran P , Kopp L , Kunc V , Hamdi A , Grieve P P , Mukhaizeem S A , Blake K , Cuggy C , Dolan R , Downes E , Geary E , Ghadge A , Gorman P , Jonson M , Jumper N , Kelly S , Leddy L , McMahon M E , McNamee C , Miller P , Murphy B , O'Halloran L , O’Shea K , Skeens J , Staunton S , Timon F , Woods J , Cortinovis U , Sala L , Zingarello V , Jusoh M H , Sadagatullah A N , Georgieva G , Pejkova S , Nikolovska B , Srbov B , Hamid H K S , Mustafa M , Abdelrahman M , Amin S M M , Bhatti D , Rahman K M A , Jumabhoy I , Kiely J , Kieran I , Lo A C Q , Wong K Y , Allan A Y , Armes H , Horwitz M D , Ioannidi L , Masterton G , Chu H , Talawadekar G D , Tong K S , Chan M , Tredgett M , Hardie C , Powell-Smith E , Gilham N , Prokopenko M , Ahmad R , Davies J , Zhen S , Dargan D , Pinder R M , Koziara M , Martin R , Reay E , Cochrane E , Elbatawy A , Green F , Griffiths T , Higginbotham G , Louette S , McCauley G , Natalwala I , Salt E , Ahmed R , Goon P , Manton R , Segaren N , Cheung G , Mahoney R , Sen S , Clarkson D , Collins M , Bolt A , Lokanathan P , Ng A , Jones G , Jones J W M , Kabariti R , Rhee S J , Herron J , Kay A , Cheung L K , Thomson D , Jugdey R S , Yoon H , L Z , Southgate J , Brennan C , Kiani S , Zabaglo M , Haider Z A , Poulter R , Sheik-Ali A , Watts A , Jemec B , Redgrave N , Dupley L , Greenhalgh M , Vella J , Harris H , Robinson A V , Dupre S , Teelucksingh S , Gargan A , Hettiaratchy S , Jain A , Kwasnicki R , Lee A , Thakkar M , Berwick D , Ismail N , Mahdi M , Rodrigues J , Liew C , Saadya A , Clarkson M , Brady C , Harrison R , Rayner A , Nolan G , Phillips B , Madhusudan N 
Published: October 2021

Abstract

Introduction
Surgical site infection (SSI) is the most common and costly complication of surgery. International guidelines recommend topical alcoholic chlorhexidine (CHX) before surgery. However, upper limb surgeons continue to use other antiseptics, citing a lack of applicable evidence, and concerns related to open wounds and tourniquets. This study aimed to evaluate the safety and effectiveness of different topical antiseptics before upper limb surgery.

Methods
This international multicentre prospective cohort study recruited consecutive adults and children who underwent surgery distal to the shoulder joint. The intervention was use of CHX or povidone–iodine (PVI) antiseptics in either aqueous or alcoholic form. The primary outcome was SSI within 90 days. Mixed-effects time-to-event models were used to estimate the risk (hazard ratio (HR)) of SSI for patients undergoing elective and emergency upper limb surgery.

Results
A total of 2454 patients were included. The overall risk of SSI was 3.5 per cent. For elective upper limb surgery (1018 patients), alcoholic CHX appeared to be the most effective antiseptic, reducing the risk of SSI by 70 per cent (adjusted HR 0.30, 95 per cent c.i. 0.11 to 0.84), when compared with aqueous PVI. Concerning emergency upper limb surgery (1436 patients), aqueous PVI appeared to be the least effective antiseptic for preventing SSI; however, there was uncertainty in the estimates. No adverse events were reported.

Conclusion
The findings align with the global evidence base and international guidance, suggesting that alcoholic CHX should be used for skin antisepsis before clean (elective upper limb) surgery. For emergency (contaminated or dirty) upper limb surgery, the findings of this study were unclear and contradict the available evidence, concluding that further research is necessary.