Arielle Cruz
Alcohol-based skin antiseptics are crucial in preventing surgical site infections (SSIs). The two most common antiseptics are alcohol-based chlorhexidine gluconate (CHG) and aqueous-based povidone-iodine (PVI). Alcohol-based CHG has been shown to reduce postoperative SSIs more effectively than aqueous-based PVI. Randomized controlled trials (RCTs) have compared the effectiveness of alcohol-based chlorhexidine and alcohol-based iodophor in preventing SSIs, with some studies combining chlorhexidine gluconate with isopropyl alcohol to enhance antiseptic benefits. While alcohol offers a rapid microbial kill, it lacks residual activity and can cause skin dryness and corneal and nerve damage.
| Characteristics | Values |
|---|---|
| Alcohol-based solutions | Chlorhexidine gluconate (CHG) |
| Chlorhexidine | |
| Iodophor | |
| Povidone-iodine (PVP-I) | |
| Iodine | |
| Ethanol | |
| Aqueous-based solutions | Povidone-iodine (PVI) |
| Chlorhexidine-gluconate in aqueous solutions |
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What You'll Learn
Chlorhexidine gluconate (CHG) and isopropyl alcohol (IPA)
CHG is a broad-spectrum antimicrobial that is effective against Gram-positive and Gram-negative bacteria and exhibits fair fungicidal activity. It works by binding to and compromising the outer membrane integrity of microbes, leading to the precipitation of cytoplasmic contents and eventual cell death. CHG has been used in surgical skin preparation for over 50 years, and its effectiveness has been supported by numerous studies and clinical trials.
IPA, on the other hand, is a well-known topical antiseptic with a long history of use. It is a common ingredient in many over-the-counter products such as hand sanitizers due to its immediate and broad-spectrum antimicrobial activity. IPA exerts its antimicrobial effects by coagulating and/or denaturing soluble proteins, which disrupts cytoplasmic integrity, causes cell lysis, and interferes with cellular metabolism.
When combined, CHG and IPA work synergistically to provide enhanced antimicrobial persistence. For example, a solution containing 2% CHG and 70% IPA, such as the commonly used BD ChloraPrep™, has been shown to produce a significant reduction in bacterial levels on the abdomen and groin in clinical studies. This combination has become a popular choice for skin preparation during central venous catheter insertion and surgical site preparation.
However, it is important to note that higher concentrations of CHG-alcohol combinations, such as 2% or above, may have irritating effects on the skin. Additionally, while CHG-alcohol combinations have been found to be superior to aqueous-based solutions in reducing SSIs, further randomized controlled trials are recommended to establish definitive conclusions.
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CHG's antimicrobial activity
The two most common skin antiseptics used today are alcohol-based chlorhexidine gluconate (CHG) and aqueous-based povidone-iodine (PVI). Alcohol-based CHG has been shown to successfully reduce postoperative surgical site infections (SSIs) compared to aqueous-based PVI solutions.
CHG is an antimicrobial agent with a broad spectrum of activity against Gram-positive and Gram-negative bacteria and fair fungicidal activity. Its mechanism of action involves binding to and compromising the outer membrane integrity of bacteria, leading to the precipitation of cytoplasmic contents and cell death.
One of the key advantages of CHG is its ability to bind to proteins in the skin, resulting in a slow release of the active ingredient and prolonged antimicrobial activity. This phenomenon, known as substantivity, allows for extended protection against bacteria and fungi. In fact, CHG's antimicrobial activity has been documented to last at least 48 hours on the skin.
While CHG has demonstrated effectiveness, there are concerns about the development of bacterial resistance to this agent. Some bacterial species, such as Enterobacter spp., Pseudomonas spp., and Enterococcus spp., have shown isolates that are more frequently CHG-resistant. Additionally, there have been reports of outbreaks caused by contaminated CHG solutions, which further emphasizes the need to address the issue of CHG resistance.
Overall, CHG's antimicrobial activity makes it a valuable component in skin preparation solutions, contributing to its effectiveness in reducing SSIs and providing prolonged protection against microbial colonization.
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IPA's antiseptic properties
Isopropyl alcohol (IPA) is a colourless, flammable, organic compound with a pungent odour. It is widely used for its antiseptic properties, particularly in medical settings as a rubbing alcohol and hand sanitiser.
When used as an antiseptic, IPA solutions with high concentrations of alcohol, ideally 70%, are able to penetrate the cell wall of microorganisms, causing all proteins to coagulate and killing the microorganism. The presence of water in isopropyl alcohol solutions is vital for inhibiting the regrowth of pathogenic microorganisms because it helps to slow the speed of evaporation, increasing surface contact time and improving antibacterial effectiveness. Concentrations of alcohol below 50% or above 90% are not strong enough to be effective in this way.
IPA is commonly used to disinfect tools and packaging that must pass into ultra-clean spaces, such as cleanrooms in medical facilities. It is also used to clean electronic equipment, as it can thoroughly clean a component without leaving any streaks or damage.
In medical settings, IPA is used as a skin antiseptic before injections or piercings. It is also included in many over-the-counter products, such as hand sanitisers and other skin-preparation products, due to its immediate, broad-spectrum antimicrobial activity. However, IPA should only be used in small amounts on the skin to prevent skin damage, as it is classified as a skin irritant.
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Aqueous-based solutions
Overall, aqueous-based solutions are an important option for skin preparation, especially in abdominal surgery, and can be used alone or in combination with alcohol-based solutions to reduce the risk of surgical site infections.
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Preoperative skin cleansing
Alcohol-based CHG has proven to be superior to aqueous-based PVI in reducing surgical site infections (SSIs) in abdominal surgeries. A meta-analysis of 12,072 participants who underwent abdominal surgery showed that alcohol-based CHG successfully reduced postoperative SSIs compared to aqueous-based PVI solutions. This is supported by previous studies, which found that preoperative skin cleansing with chlorhexidine-based preparations was more effective than povidone-based preparations for clean and clean-contaminated surgery.
The antimicrobial efficacy of alcoholic CHG formulations has been demonstrated in multiple studies. CHG has broad-spectrum antimicrobial activity against Gram-positive and Gram-negative bacteria and exhibits fair fungicidal activity by binding to and compromising outer membrane integrity, leading to cell death. Additionally, CHG has strong binding properties to skin proteins, which contributes to its persistence on the skin.
On the other hand, povidone-iodine (PVP-I) is another commonly used skin antiseptic agent. When combined with isopropyl alcohol (IPA), it forms PVP-I+IPA, which offers both immediate and persistent antimicrobial activity against a wide range of microorganisms. This combination has been shown to be more effective than using IPA or CHG alone. PVP-I exhibits antimicrobial properties through the slow release of iodine from the povidone scaffold over time.
Randomized controlled trials (RCTs) have been conducted to evaluate the effectiveness of these skin preparation agents in preventing SSIs. These trials typically involve comparing the proportion of SSIs using risk ratios (RR) and confidence intervals. While CHG-alcohol combinations have been found to be more protective than PVP-I against superficial and deep incisional SSI, further RCTs are needed to evaluate their effectiveness in clean surgeries.
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Frequently asked questions
The two types of alcohol used for skin prep are ethanol and isopropyl alcohol.
Skin prep is the use of antiseptic agents to lower microbial counts on a patient's body before surgery to reduce the risk of post-op surgical site infection.
Alcohol-based chlorhexidine gluconate (CHG) and aqueous-based povidone-iodine (PVI) are the two most common skin antiseptics used today.
The purpose of skin prep is to prevent surgical site infections (SSIs) and reduce the risk of postoperative wound infections.
Alcohol-based skin preps have been shown to be effective in reducing SSIs. A meta-analysis of 12,072 participants found that alcohol-based CHG reduced postoperative SSIs compared to aqueous-based PVI solutions.
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