Editor's Note
June 17, 2024
Skin Antisepsis to Prevent Surgical Site Infections: Implications for Global Surgery
Anthony Charles, Preeti N. Malani
JAMA. Published online June 17, 2024. doi:10.1001/jama.2024.9622
Surgical site infections (SSIs) are the most common health care–associated infection. Often preventable, SSIs are associated with substantial morbidity and mortality as well as prolonged hospitalizations and readmissions, and these infections remain a vital challenge globally.1,2 Among the millions of patients undergoing surgical procedures annually in the US, an estimated 3% will develop SSIs,3 compared with nearly a quarter of patients in low- and middle-income countries.4 SSIs are well established as a key quality metric in health care, but also can be the difference between having a successful postoperative outcome or not. Thus, efforts to prevent SSIs through the standardization of perioperative processes and evidence-based preventive measures represent an important goal for health care institutions worldwide. Although the efficacy of preoperative skin antiseptics for preventing SSIs is well established, there is ongoing debate about which antiseptic is most effective for preventing SSIs.
In this issue of JAMA, Widmer and colleagues5 report the results of their study that sought to determine whether povidone iodine in alcohol is noninferior to chlorhexidine gluconate in alcohol to prevent SSIs after cardiac or abdominal surgery. This multicenter, cluster-randomized, investigator-masked, crossover, noninferiority trial enrolled 3360 patients undergoing cardiac (65%) or abdominal (35%) operations across 3 tertiary care hospitals in Switzerland. The primary outcome was the development of an SSI within 30 days after abdominal surgery and up to 1 year after cardiac surgery.
Overall, SSIs were identified among 80 patients (5.1%) in the povidone iodine group vs 97 (5.5%) in the chlorhexidine gluconate group, an absolute difference of 0.4% (95% CI, −1.0% to 2.0%), not exceeding the predefined noninferiority margin of −2.5%. The authors conclude that povidone iodine in alcohol as preoperative skin antisepsis was noninferior to chlorhexidine gluconate in alcohol in preventing SSIs after cardiac or abdominal surgery, a finding consistent with the prior SKINFECT trial that demonstrated that preoperative skin disinfection with chlorhexidine-alcohol is similar to iodine-alcohol in reducing SSI risk.6
Initiatives to improve surgical outcomes have been developed, especially focused on low- and middle-income countries, including guidelines from the World Health Organization (WHO) that include the WHO Surgical Safety Checklist. The most recent WHO guidelines on the prevention of SSIs published in 2016 strongly recommend chlorhexidine-alcohol rather than aqueous povidone iodine or povidone iodine with alcohol for surgical skin preparation based on “low to moderate” quality of evidence.7 The current study by Widmer and colleagues provides evidence to the contrary and should prompt a change in the WHO guidance. In addition to other evidence-based perioperative measures,1 the results of the study by Widmer et al provide more options for skin antisepsis, particularly in resource-limited settings given the large cost differential between povidone iodine and chlorhexidine gluconate in alcohol and the limited commercial availability of chlorhexidine gluconate–based antiseptics in some settings. Additional studies (including observational cohorts) performed in low- and middle-income countries and other resource-limited settings should build on the work of Widmer and colleagues, especially because the reported SSI rate of 5% among Swiss tertiary care hospitals may not be broadly representative.
Randomized clinical trials are essential for advancing surgical knowledge, optimizing patient care, and guiding evidence-based surgical practice. JAMA welcomes additional studies like the one by Widmer and colleagues that provide robust evidence on the effectiveness, safety, and comparative benefits of different surgical interventions, leading to improved outcomes for patients worldwide.
