PSJT

Original Article

Debate: Surgical Skin Preparations

Chlorhexidine and Iodophors
Yayganeh Chiang, Francesca Kum (Co-Author)
Princess Royal Hospital, London
Correspondence:

Its main use within hospitals is for cleaning of the skin

of the hands before performing a surgical procedure
and cleaning patients skin at the operative site prior
to a procedure or operation (3,4).

yayganeh@doctors.org.uk
francesca.kum@doctors.org.uk

There are many different types of skin preparations

used for surgery, the key purpose being to (1):

Reduce microbial counts at the surgical site prior

to surgical incision
Minimise microbial growth both intraoperative
and postoperatively
Reduce risk of surgical site infection post
operatively

Skin preparation agents should be chosen based on

efAicacy of the agent, user choice and knowledge of the
mechanisms of action of each agents (1). Surgical skin
preparations exist as either aqueous-based or alcohol-
based solutions (2).

Figure 1 Chlorhexidine Gluconate, Hibiscruib (5)

Chlorhexidine works by binding strongly to molecules

with opposing charge, which includes most bacteria.

In current surgical practice, chlorhexidine and iodine

are the most frequently used active agents in surgical
skin preparations and hand scrubs. This article
endeavours to provide an introduction to these agents,
their background mechanisms of action and provide
scope for comparison of agents.

Chlorhexidine binds to the microbial cell walls,

disrupting cell membranes, inducing certain changes
to take place and thus damaging the surface structure
of the cell, which denatures proteins and causes
precipitation of the cytoplasm and cell death.
Chlorhexidine is a relatively safe antimicrobial agent
and has the added advantage of not producing

Chlorhexidine Gluconate
(Chlorhexidine, Hibiscrub)

resistant micro-organisms despite repetitive usage

(1,3,4).

Chlorhexidine Gluconate (Figure 1), is an antiseptic

antibacterial agent used for skin preparation in

Chlorhexidine with alcohol (also known as

numerous different circumstances, including before

Chloraprep) works very effectively against both

surgery, before an injection, after an injury and as a

gram-positive and gram-negative micro-organisms as

mouthwash for dental use. It is a broad-spectrum

well as viruses. It works extremely rapidly and has an

antimicrobial agent that is effective against all

excellent residual activity. It should be allowed to dry

categories of microbes, namely bacteria, viruses and

completely prior to draping the patient and not

yeasts (3,4).

dabbed dry (1).

Chiang, Kum.PSJT. 2012 Oct;1(1): 19-22

19

including oxidation of cytoplasmic and membrane

Polyvinylpyrrolidone-Iodine(PVP-I, Povidone-Iodine,

compounds and iodination of lipids to disrupt cell

Betadine)

metabolism. There are various antimicrobial effects of

iodine, thus providing less scope for development of

Iodine based products (Figure 4) have been used in

bacterial resistance (8).

surgical practice for wound disinfection for over 150

years (7).
Iodine products may delay wound healing when in
Clinical applications of povidone-iodine complexes

contact with blood products due to free iodine binding to

(known as iodophors) are comparable to those of

organic substances (7); therefore, research recommends

chlorhexidine. The US Food and Drug Administration

removal of such organic products (blood, fat, and pus) if

(FDA) recommend povidone-iodine as an approved

possible to improve outcomes.

product for intraoperative skin preparation (7).

Complexing iodine with the inert polymer povidone

Povidone-iodine has a wide range of proven efficacies

greatly reduces the undesirable effects of unbound

against all pathogenic classes including bacteria (both

iodine, such as staining, irritation and excessive

gram-positive, gram-negative and MRSA), mycobacteria,

sensitization of the skin (8). However, occasional mild

fungi, protozoa and viruses (8). Furthermore, povidone-

burning and stinging with topical application remain due

iodine exhibits a very rapid onset of action, killing 90% of

to osmotic changes and acidic pH (7,8).

bacteria on the skin within 90 seconds of contact, most

being killed within the first 15-30 secs (8,10).
The pharmaceutical industry considers iodine to have
potential for application of its antibiotic and antifungal
properties. However, this has been minimally explored at
present due to scepticism over ingesting iodine products
(aside from already proven indications, such as thyroid
conditions) (10). Iodine dressings are indicated for wound
care particularly when healing is delayed (8).
In summary, both chlorhexidine and povidone-iodine

Figure 3 Povidone-iodine, Betadine surgical scrub (9)

remain important antimicrobial products for management

of surgical patients and wounds; however, comparison of
superiority and choice of one product over another is a

The mechanism of action of povidone-iodine relies on

topic of progressing discussion.

release of iodine molecules from the complex and

subsequent activation by exposure to water molecules

Discussion

from the surrounding environment, to form active H2OI+.

Dry iodine powders therefore require availability of
adequate tissue moisture for activation (8). Free iodine

Direct comparison of povidone-iodine and chlorhexidine

subsequently binds to bacterial surface amino acids

suggest chlorhexidine as the superior agent to achieve

(particularly tyrosine and histidine). The other direct

reduction in bacterial colony counts immediately and at

cytotoxic effects of iodine are shown in Figure 4 below,

later time intervals. Reports of minimal persistent activity

Chiang, Kum.PSJT. 2012 Oct;1(1): 19-22

20

of povidone-iodine after initial application present a

and povidone-iodine) at reducing the incidence of

challenge for procedures which require a longer duration

surgical site infections and the number of colony forming

of antimicrobial activity (7,11,12).

units (11). However, limited evidence was presented for

the effects of scrubbing duration on colony formation.

A recent systematic review and meta-analysis by Noorani

et al. 2010, of preoperative antisepsis with chlorhexidine

In a recent study in Japan, when combined with alcohol,

versus povidoneiodine concluded that chlorhexidine

povidone-iodine was shown to be significantly superior to

was the superior agent for use in preparation for clean

chlorhexidine-alcohol in reducing bacterial counts

contaminated surgery (operative access requiring entry

immediately after brushless surgical scrubbing.

to a colonized viscus or body cavity). Furthermore, a

However, differences in counts were non-significant after

significant proportion of surgical site infections can be

2 hours from scrubbing (17).

avoided by following evidence-based infection control

measures. These include tight glucose control in

Following review of several articles comparing

diabetics, hair removal if appropriate, prophylactic

chlorhexidine and povidone-iodine and different

antibiotic administration prior to a procedure and

preparations of each, it can be concluded that alcohol-

adequate preparation of the surgical skin site with an

based preparations for both agents are far more effective

aseptic agent (15). In contrast, another review reports

antiseptic agents that provide greater efficacy, easier

limited evidence that chlorhexidine reduces surgical site

application, improved durability, and a superior cost

infection, therefore most recent guidance from the World

profile when compared with traditional aqueous-based

Health Organization (WHO), the Centers for Disease

solutions (2). Alongside this, although povidone-iodine

Control and prevention

(CDC) and the Association for

is safe for use on mucous membranes, chlorhexidine has

Perioperative Practice do not directly recommend one

been shown to be superior in action due to its ability to

antimicrobial product over the other (12).

provide excellent asepsis against a wider range of microorganisms, its speed of action as well as its sustainability

Many recent studies have explored the use of alcohol in

of action. Unlike povidone-iodine, chlorhexidine does not

combination of chlorhexidine and povidone-iodine. A

become inactivated when exposed to blood and debris,

recent review by Hemani and Lepor, 2009, showed that

which is a major factor during surgical procedures in

although aqueous-based solutions and iodine can be

aiding the prevention of surgical site infections. Findings

used safely on mucous membranes, alcohol-based

by Darouiche et al., 2010 found chlorhexidine-alcohol to

solutions act more quickly on the skin and have a lasting

be significantly more protective and overall rate of

effect with a broader spectrum of antimicrobial activity

surgical site infections statistically lower than for

(2). Another study by Reichel et al. 2009, showed that

povidone-iodine (14). Thus, it can be said that

different types of alcoholic active agents also alter the

chlorhexidine-alcohol should be and often is the agent of

effectiveness of the skin antisepsis. An 89.5%

choice (1).

concentration of n-propanol combined with 0.5%

chlorhexidine slowed down re-colonisation of skin flora.

In summary, both chlorhexidine and povidone-iodine are

(16).

effective antimicrobial agents. Current literature indicates

that chlorhexidine-alcohol is the most efficacious and

Results from a Cochrane Review by Tanner et al.

superior agent of choice. However, in clinical practice the

concluded that the general consensus on hand

agent used often remains surgeon choice.

disinfection is that alcohol rubs are as effective, if not

more effective than aqueous scrubs (i.e. chlorhexidine

Chiang, Kum.PSJT. 2012 Oct;1(1): 19-22

21

17. Nishimura C. Comparison of the antimicrobial efficacy of

povidone-iodine, povidone-iodine-ethanol and

References

chlorhexidine gluconate-ethanol surgical scrubs.

Dermatology. 2006;212 Suppl 1:21-5.
1.

Best Practice Guidelines, Surgical Skin Preparation, 2011

May: 1-13.

2.

Hemani ML and Lepor H. Skin Preparation for the Prevention

of Surgical Site Infection: Which Agent is Best? Rev
Urol.2009 Fall;11(4):190-5.

3.

Chlorhexidine (Topical Application Route), online:

www.mayoclinic.com, last updated 01/11/2011, accessed
01/10/2012.

4.

Kaplowitz GJ, Cortell M. Chlorhexidine: A Multifunctional

Antimicrobial Drug. PENWELL, online: www.ineedce.com,
accessed 01/10/2012.

5.

Image from: http://www.broschdirect.com/images/uploads/

original/hibiscrub.jpg

6.

Image from: http://www.dentist-charlotte-north-carolinanc.com/chlorhexidine-gluconate.html

7.

Zinn J, Jenkins JB, Swofford V, Harrelson B, McCarter S.

Intraoperative patient skin prep agents: is there a difference?
AORN J. 2010 Dec;92(6):662-74.

8.

SibbaldRG, Leaoer DJ, Queen D. Iodine Made Easy.

Wounds International 2011; 2(2): Available from http://
www.woundsinternational.com, accessed 03/10/2012.

9.

Image from: http://www.dltchiropody.co.uk/details1.asp/

ProductID/695/videne-surgical-scrub.htm

10. Sekhon B. Iodine: A support against infections and emerging

as an antibiotic. Pharm Educ Res. 2012 June;3(1):35-39.
11. Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to
reduce surgicalsite infection. Cochrane Database Syst Rev.
2008 Jan 23;(1):CD004288.
12. Jarral OA, McCormack DJ, Ibrahim S, Shipolini AR. Should
surgeons scrub with chlorhexidine or iodine prior to surgery?
Interact Cardiovasc Thorac Surg. 2011 Jun;12(6):1017-21.
13. Noorani A, Rabey N, Walsh SR, Davies RJ. Systematic
review and meta-analysis of preoperative antisepsis with
chlorhexidine versus povidone-iodine in clean-contaminated
surgery. Br J Surg. 2010 Nov;97(11):1614-20.
14. Darouiche RO, Wall MJ Jr, Itani KM, Otterson MF, Webb
AL, Carrick MM, Miller HJ, Awad SS, Crosby CT, Mosier
MC, Alsharif A, Berger DH. Chlorhexidine-Alcohol versus
Povidone-Iodine for Surgical-Site Antisepsis. N Engl J
Med.2010 Jan 7;362(1):18-26.
15. Reduction of Surgical Site Infections (A Continuing
Educational Self-Study Activity). Activity Number: 1136.
Pfiedler Enterprises, 2011.
16. Reichel M,Heisig P,Kohlmann T,Kampf G. Alcohols for Skin
Antisepsis at Clinically Relevant Skin Sites. Antimicrob
Agents Chemother.2009 Nov;53(11):4778-82.

Chiang, Kum.PSJT. 2012 Oct;1(1): 19-22

22