Recommendation ID

What is the clinical and cost effectiveness of chlorhexidine in alcohol at different concentrations in the prevention of surgical site infection when applied to the skin before incision?

Any explanatory notes
(if applicable)

Why the committee made the recommendations

Based on their knowledge and experience, the committee agreed that an antiseptic should be used for skin preparation before surgery. Overall, the evidence showed that chlorhexidine in alcohol was associated with the lowest incidence of surgical site infections, whereas aqueous povidone-iodine was associated with the highest incidence. An economic analysis also showed that chlorhexidine in alcohol is likely to be cost effective. Based on the evidence, the committee agreed that an alcohol-based solution of chlorhexidine should usually be the first choice when deciding which antiseptic preparation to use. However, the quality of the studies was not good enough for the committee to make a strong recommendation for the choice of antiseptic preparation.

The committee discussed that alcohol-based solutions should not be applied to mucous membranes because of the risk of burns. For surgical procedures next to mucous membranes, they agreed to recommend an aqueous solution of chlorhexidine as an option for skin preparation. Because of the limited evidence, the committee were unable to make a strong recommendation.

There was little evidence to support the use of povidone-iodine, but based on their clinical experience the committee agreed that it should be an option when chlorhexidine is contraindicated, for example, in people with hypersensitivity to chlorhexidine.

There was no evidence on the use of skin antiseptics in babies. However, the committee were aware of risks, such as burns, associated with their use in this population, and wished to highlight this. The committee noted that the MHRA has published advice on the use of chlorhexidine for skin disinfection in premature babies.

The committee also discussed that some operative procedures may require diathermy. This means that precautions must be taken when using alcohol-based antiseptic solutions because they are flammable and can result in burns. Along with using evaporation to dry antiseptic skin preparations and avoiding pooling, the committee also agreed that soaked materials, drapes or gowns should be removed before diathermy, excessive quantities of alcohol antiseptics should not be used and no excess product should be present before applying an occlusive dressing.

The committee agreed that further research is needed to establish the effectiveness of different concentrations of chlorhexidine in reducing the risk of surgical site infections. Therefore the committee made a research recommendation to examine this further.

How the recommendations might affect practice

Antiseptic skin preparation before skin incision is standard practice although the type of antiseptic used varies depending on the type of surgery.

The recommendations follow current trends in practice and should reduce variation.

Full details of the evidence and the committee's discussion are in evidence review B: skin antiseptics in the prevention of surgical site infection.

Source guidance details

Comes from guidance
Surgical site infections: prevention and treatment
Date issued
April 2019

Other details

Is this a recommendation for the use of a technology only in the context of research? No  
Is it a recommendation that suggests collection of data or the establishment of a register?   No  
Last Reviewed 11/04/2019