Does the kind of disinfectant that surgeons apply to the skin before surgery affect the likelihood of an infection at the surgical site? Yes, it does, according to recent findings from a global experiment that McMaster University and the University of Maryland School of Medicine co-led.
Researchers discovered that using iodine povacrylex in alcohol to disinfect a patient’s skin could prevent surgical site infection in thousands of patients having surgery for a closed fracture every year. The PREPARE trial enrolled nearly 8,500 participants at 25 hospitals in Canada and the United States.
A policy change regarding the use of iodine povacrylex in alcohol for fracture procedures is about to happen in several hospitals because of the findings, which were reported in The New England Journal of Medicine.
“This trial is the result of a very fruitful partnership between McMaster University, the University of Maryland School of Medicine, and twenty-five trauma clinics from both the US and Canada. With the help of this multi-center approach, we were able to promptly and effectively address a significant clinical research question that will help prevent thousands of infections annually,” says Sheila Sprague, an associate professor in the McMaster Department of Surgery and one of the trial’s co-principal investigators.
“Importantly, our collaborations will continue to grow to address other unanswered questions in orthopedic trauma surgery.”
In this trial, 1,700 patients had surgery for an open fracture, and 6,785 patients had surgery for a closed pelvic or lower extremity fracture. When the skin is unbroken, but the bone is broken, this is known as a closed fracture. Open fractures are particularly prone to infection because, in the hours leading up to surgery, the exposed bone and open wound are left to linger in the environment.
Researchers compared the two antiseptic products that are most frequently used in Canada and the United States. People who were randomly assigned to receive 2% chlorhexidine gluconate in 70% isopropyl alcohol for skin antisepsis (0.7% iodine povacrylex in 74% isopropyl alcohol) were less likely to get surgical site infections after having a fracture heal. The two distinct antiseptic skin preparation solutions did not significantly differ in terms of infection risk for individuals with open fractures.
“Although some guidelines propose using chlorhexidine gluconate for antisepsis rather than an iodophor, all recommendations have acknowledged that there is no agreement on the best agent. Our findings imply that thousands of patients with closed fractures could avoid surgical-site infections every year by using iodine povacrylex in alcohol as preoperative skin antisepsis,” says Gerard Slobogean, co-principal investigator of the trial and orthopedic trauma surgeon at the University of Maryland’s R. Adams Cowley Shock Trauma Center.
“As a patient involved in the trial, it was my job to ensure that the voice of trauma patients was heard in the design, implementation, and dissemination of the trial,” says trial executive committee member and patient partner Jeffrey Wells.
According to the authors, this randomized controlled trial is far larger than previous trials that they are aware of, which helped them identify significant variations in infection. Even though only patients undergoing fracture surgery were included in the trial, the results may still apply to other surgical specialties, according to the researchers.
Journal Reference
Skin Antisepsis before Surgical Fixation of Extremity Fractures, New England Journal of Medicine (2024). DOI: 10.1056/NEJMoa2307679.
