Iodine-Based Skin Prep Better for Certain Fracture Surgeries

— Large randomized trial comparing alcohol antibacterial options might alter practice

by
Crystal PhendContributing Editor, MedPage Today
January 31, 2024

Iodine-based skin antisepsis appeared much better for surgical repair work of closed limb fractures however on par with chlorhexidine-based antisepsis when the fracture broke the skin, the PREPARE trial revealed.

In closed fractures, surgical-site infection happened in 2.4% of clients prepped with a service of 0.7% iodine povacrylex in 74% isopropyl alcohol (Duraprep) compared to 3.3% amongst those prepped with 2% chlorhexidine gluconate in 70% isopropyl alcohol (BD ChloraPrep; OR 0.74, 95% CI 0.55-1.00, P=0.049)

For open fractures, surgical-site infection took place in numerically however not substantially less iodine group clients (6.5% vs 7.3%, OR 0.86, 95% CI 0.58-1.27, P=0.45).

Unintended reoperation and other results were comparable in between groups in both open and closed fractures, Sheila Sprague, PhD, of McMaster University in Hamilton, Ontario, and associates reported in the New England Journal of Medicine

“Our findings recommend that making use of iodine povacrylex in alcohol as preoperative skin antisepsis might avoid surgical-site infection in countless clients with closed fractures,” the group kept in mind.

The outright distinction in surgical-site infection for that population was nearly one infection avoided per 100 surgical treatments for closed fractures, with an upper limitation of the self-confidence period of 1.6 portion points, pointed out an accompanying editorial by Selwyn O. Rogers Jr., MD, MPH, of the University of Chicago Medicine, and Richard P. Wenzel, MD, of the Virginia Commonwealth University in Richmond.

The factor that iodine didn’t show remarkable throughout the board might have been that “skin-cleansing treatments might have less result on open fractures in which contamination might have currently happened in the field,” they kept in mind.

PREPARE was the second of 2 trials carried out under the PREP-IT master trial procedureThe very first, called Aqueous-PREPrevealed no distinction in infection threat in between 2 water-based antibacterial services– chlorhexidine and povidone-iodine– for surgical repair work of open limb fractures.

PREPARE now broadens the proof base for the 2 most typically utilized skin antisepsis services for the more than 1 million orthopedic injury surgeries done each year in the U.S.

“Although some standards prefer antisepsis with chlorhexidine gluconate over an iodophor, all suggestions have actually acknowledged an absence of agreement with regard to the most efficient representative,” stated co-author Gerard Slobogean, MD, of the University of Maryland in Baltimore, in a declaration

The iodine and chlorhexidine services have comparable rate, schedule, and instructions for usage, the scientists kept in mind. “Nevertheless, the possibility that clients will have an allergy to an active ingredient in either option indicates that health centers will require to continue to equip both interventions.”

The practical trial consisted of 25 health centers in the U.S. and Canada, cluster randomized to utilize a service of 0.7% iodine povacrylex in 74% isopropyl alcohol or 2% chlorhexidine gluconate in 70% isopropyl alcohol for preoperative antisepsis of limb or pelvic fractures. The health centers crossed over in between treatments every 2 months and had high adherence to both bactericides.

The trial population consisted of 6,785 grownups with a closed fracture and 1,700 with an open fracture. Fractures of the proximal thigh were most typical, representing around 25% of the trial population.

The main result was surgical-site infection, specified as shallow incisional infection within 30 days and deep incisional or organ-space infection within 90 days after conclusive fracture management surgical treatment. For the secondary endpoint– unexpected reoperation within 365 days after fracture– the rates in the iodine group and in the chlorhexidine group (5.5% vs 5.9%) were comparable.

Major negative occasions were likewise comparable in between groups, without any chemical burns or surgical fires reported in either antibacterial group.

One restriction of the trial was lower than anticipated standard infection threat in the open-fracture population, which decreased the analytical power for the main contrast. Even extending the security duration to 1 year did not reveal a considerable distinction in between antibacterial representatives.

Surgeons and clients understood the trial-group tasks, however as the editorialists kept in mind, “the main adjudication committee examined the trial leads to a blinded way, therefore alleviating possible evaluation predispositions of results.” In general, it was an extensive and properly designed trial, they composed.

“Given the considerable morbidity and healthcare expenses connected with surgical-site infection, we require more ingenious trials evaluating unique techniques to even more decrease the infection threat,” Rogers and Wenzel argued.

One such method may be customized interventions based upon much deeper understanding of the specific client’s microbiome, they recommended.

Lister had the ability to make a radical change to significantly decrease the threat of infection and to lower death,” they concluded. “We wait for next-generation developments to attain no surgical-site infections.”