title: Skin preparation before surgery: options and evidence.
abstract: BACKGROUND
  Despite many advances in surgical asepsis, surgical site infection (SSI) remains a challenging and costly problem. Decontamination of the skin with an antiseptic agent is standard practice before any trans-cutaneous invasive procedure, but the antiseptic agent of choice to best reduce the risk of SSI remains controversial.
  
  
  METHODS
  Review of relevant literature.
  
  
  RESULTS
  Many randomized controlled trials (RCTs) have evaluated chlorhexidine-based and iodine-based preparation solutions, with and without an alcohol component. Most of these trials are underpowered to detect differences in SSI rates. The largest modern RCT showed that a chlorhexidine-isopropyl alcohol preparation reduced the risk of SSI substantially compared with a povidone-iodine preparation without alcohol in clean-contaminated surgery. Many smaller RCTs have shown that chlorhexidine-isopropyl alcohol is superior to povidone-iodine plus isopropyl alcohol or iodine povacrylex plus isopropyl alcohol in pre-operative skin decontamination; whether or not this translates into lower SSI rates is unknown. A mixed treatment comparison of 10 RCTs concluded that alcohol-based preparations have a 98% probability of reducing the risk of SSI more effectively than aqueous-based preparations. Non-randomized observational studies have generally found no difference in SSI rates among various skin antiseptic preparations.
  
  
  CONCLUSIONS
  Alcohol-based agents are likely superior to aqueous agents. Chlorhexidine may decrease SSI rates compared with povidone-iodine, and chlorhexidine-isopropyl alcohol likely offers better skin decontamination before clean surgery than povidone-iodine plus isopropyl alcohol or iodine povacrylex plus isopropyl alcohol. The quality of the available data is moderate. Rigorous, well-powered RCTs with appropriate treatment comparisons are needed to establish the optimal and most cost-effective pre-operative skin preparation in various operations and wound classifications.
authors.affiliation: 1 Boston University School of Medicine , Boston, Massachusetts.
authors.forename: Feroze
authors.initials: F
authors.lastname: Sidhwa
authors.forename: Kamal M F
authors.initials: KM
authors.lastname: Itani
mesh_terms: D004203:Disinfection / Q000379:methods*; D006801:Humans; D011300:Preoperative Care / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D012867:Skin / Q000382:microbiology*; D013530:Surgical Wound Infection / Q000517:prevention & control*