The CIPHUR Collaborative Author Notes (Including:

). (2021) Chlorhexidine versus povidone–iodine skin antisepsis before upper limb surgery (CIPHUR) : an international multicentre prospective cohort study. BJS Open, 5 (6). zrab117. doi:10.1093/bjsopen/zrab117 ISSN 2474-9842.

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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.

Item Type:	Journal Article
Subjects:	R Medicine > RA Public aspects of medicine R Medicine > RD Surgery
Divisions:	Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Clinical Trials Unit Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School
Library of Congress Subject Headings (LCSH):	Surgical wound infections , Surgical wound infections -- Prevention, Chlorhexidine, Arm -- Surgery , Surgery, Aseptic and antiseptic , Preoperative Care
Journal or Publication Title:	BJS Open
Publisher:	Oxford University Press
ISSN:	2474-9842
Official Date:	15 December 2021
Dates:	Date Event 15 December 2021 Published 20 October 2021 Accepted
Volume:	5
Number:	6
Article Number:	zrab117
DOI:	10.1093/bjsopen/zrab117
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Open Access (Creative Commons)
Date of first compliant deposit:	9 March 2022
Date of first compliant Open Access:	10 March 2022
RIOXX Funder/Project Grant:	Project/Grant ID RIOXX Funder Name Funder ID DRF-2018–11-ST2-028 National Institute for Health Research http://dx.doi.org/10.13039/501100000272 UNSPECIFIED Health Education England http://viaf.org/viaf/305200827 UNSPECIFIED Royal College of Surgeons of England http://dx.doi.org/10.13039/501100000297 UNSPECIFIED British Society of Surgery for the Hand http://viaf.org/viaf/137833244

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