For the 1.3 million women who deliver their babies by Cesarean section each year, tougher skin-prep guidelines could cut the rate of surgical site infection in half.
Researchers at Washington University School of Medicine in St. Louis recently showed that by using a chlorhexidine-alcohol antiseptic, as opposed to one with iodine-alcohol, they were able to lower the rate of surgical site infection from 7 to 4 percent, bringing it more in line with the average rate of infection for surgeries overall.
The research comes out as officials at the Centers for Disease Control and Prevention prepare to update their guidelines for preventing surgical site infections, which haven’t been revised since 1999.
As it stands, surgeons are required to apply an antiseptic, but which one they choose is up to them. Hospitals in the U.S. currently use chlorhexidine-based and iodine-based antiseptics in equal amounts, according to Methodius Tuuli, lead author of the paper published last month in the New England Journal of Medicine.
“It is clear that the choice of antiseptics at hospitals in the U.S. is mixed,” Tuuli said.
Tuuli explained that C-sections tend to have higher rates of infection than other surgeries because bacteria can come from two different sources — the skin and the vagina. In addition, doctors sometimes decide to perform an emergency procedure if the fetus is in a dangerous position during delivery — decreasing the amount of time available for cleaning and prepping the surgery site. All of this leads to a rate of infection for C-sections between 5 and 12 percent, which is greater than the general surgery rate of 2 to 5 percent.
In a double-blind study — meaning that neither doctors nor patients knew which treatment group they were in — the researchers tested both chlorhexidine-alcohol and iodine-alcohol for C-sections. Patients prepped with iodine-alcohol developed surgical site infections at the higher rate typical for C-sections. But the chlorhexidine-alcohol treatment lowered the rate closer to the average rate of infection for all surgeries.
Though these results are promising, the study only took place at a single hospital. In addition, chlorhexidine-alcohol is about four times as expensive as alternative chemicals, making it a less practical option.
Still, a 2010 study with general surgery patients in six hospitals also showed that chlorhexidine-alcohol performed better than alternatives.
This study “finally proves” that chlorhexidine-alcohol is the right choice for preventing infection during C-sections, said Deverick Anderson, an infectious disease specialist at Duke University School of Medicine. “We’ve been waiting for this study,” he said.
While Anderson is convinced that chlorhexidine-alcohol is the better antiseptic, the CDC’s process for updating guidelines is long and cumbersome, he said.
“It will likely be some time before their recommendations are changed,” Anderson said.
Though the official revision process could take a while, Kim Boggess, a professor of maternal-fetal medicine at the University of North Carolina, said that doctors have taken notice of the new evidence for chlorhexidine antiseptics.
“I’ve already had people asking me if we should be using chlorhexidine,” she said. “I imagine that some will adopt it into their practice if they have access to it and if they can afford it.”
Boggess pointed out that while the study was done well, other factors, like the type of antibiotics put into a patient’s blood before surgery, are also important for preventing infection — especially during emergency C-sections.