Vaginal cleansing with antiseptic solution before cesarean section brings down postoperative infection: Cochrane review

A simple and inexpensive intervention of vaginal cleaning with the chlorhexidine-based or iodine-based solution immediately before cesarean section probably reduces the risk of endometritis after the procedure. The benefit could be more for women who underwent cesarean section while in labor or after rupture of membranes reports the results of a Cochrane review published 17 July 2018.

The current review is the fifth update on vaginal preparation before cesarean section and risk of subsequent infection by Cochrane; the first review was published in 2010 and subsequently updated in 2012, and twice in 2014.

Cesarean section is the most commonly performed operation in obstetrics, with 1 in 3 babies being born by cesarean section. Nearly 25% of women have endometritis and 10% of women develop skin infection after C-section.

Pre-op or intra-op antibiotic prophylaxis has not been able to bring down the rate considerably.

The Cochrane researchers searched the Cochrane Pregnancy and Childbirth’s Trials Register, the WHO International Clinical Trials Registry Platform (ICTRP) (10 July 2017), ClinicalTrials.gov, and reference lists of retrieved studies.

The review included 11 trials with a total of 3403 women in whom vaginal preparation was done immediately before the start of the cesarean section. Most of the trials used Povidone-iodine (n=8), while the rest used chlorhexidine (n=2) and benzalkonium chloride (n=1).

The control group included women with no vaginal antisepsis preparation (eight trials) or those in whom saline vaginal preparation (three trials) was used.

Vaginal preparation with the antiseptic solution immediately before cesarean delivery probably reduced the risk of endometritis by 64% (average risk ratio (RR) 0.36, 95% confidence interval (CI) 0.20 to 0.63).

It was not possible to separately analyze the risk reduction in a subgroup of women who were in labor or in women whose membranes had ruptured when antiseptics were used. 

Risk of postoperative fever or surgical wound complications may also be brought down by the use of vaginal antisepsis, but the confidence interval around the effects for both outcomes was very wide consistent with insufficient data.

Composite outcome of wound complication or endometritis was reduced by 54% in two trials consisting of 499 women (RR 0.46, 95% CI 0.26 to 0.82).

No adverse effects were reported with either the povidone-iodine or chlorhexidine vaginal cleansing.

The quality of evidence using GRADE was moderate for all reported outcomes. The authors downgraded the outcome for post-cesarean endometritis and composite of wound complications or endometritis because of bias in the involved study and broader CI.

The recommend that healthcare providers may continue using vaginal antisepsis preparation by either using povidone-iodine or chlorhexidine before performing a cesarean delivery.

Abstract

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What is best for Cesarean Antisepsis? Chlorhexidine-Alcohol versus Povidone-Iodine.

Chlorhexidine-Alcohol is not superior to Povidone-Iodine in reducing the rate of surgical site infection in Cesarean section reports the results of Chlorhexidine-Alcohol Versus Povidone-Iodine for Cesarean Antisepsis (CAPICA) Trial published ahead of print in American Journal of Obstetrics and Gynecology.

Wound infection after a cesarean section (CS) is a major cause of maternal morbidity, lengthy hospital stays and increased medical cost. The rate of surgical site infection after cesarean section range from 3% to 15%.

Researchers and investigators are always looking at ways to minimize the surgical site infection in cesarean section. Numerous interventions have been proposed from changing gloves at timeof abdominal closure to preoperative antibiotic prophylaxis.

But, no previous randomized control trial has compared chlorhexidine-alcohol to povidone-iodine aqueous scrub and paint in reduction of cesarean-related surgical site infections (SSIs).

The CAPICA Trial is the first single center pragmatic randomized trial conducted at urban tertiary care center over a period of 3+ years. The trial compared efficacy of 26ml chlorhexidine-alcohol applied as single step versus 236mL povidone-iodine aqueous scrub as preoperative skin preparation in cesarean section in reducing the SSIs.

The trial recruited 932 study participants, who were 18 years or older, with no chorioamnionitis, non-allergic to povidone iodine or alcohol and who were ready to be compliant with the follow up protocols.

Women who had elective cesarean section as well as those who had emergency cesarean sections were included in the study. 

Statistical analysis was performed to look at categorical and continuous outcomes in comparing incidence of superficial or deep SSIs or endometritis as defined by CDC, including allergic skin reactions, hematomas, wound separation, dehiscence.

461 women were assigned to chlorhexidine-alcohol, and 471 assigned to povidone-iodine group. About 97% to 99% women came for follow up at 30 days. SSIs occurred in 7% of women in the povidone-iodine group vs 6.3% chlorhexidine-alcohol group(p=0.38).

Individually the difference in sub-component of infections are: superficial surgical site infection (4.6% v 5.5%, p=0.55), deep surgical site infection (0.0% v 0.4%; p=0.50), and endometritis (1.7% v 1.1%; p=0.42) in chlorhexidine-alcohol versus povidone-iodine arms respectively.

The authors concluded that use of chlorhexidine-alcohol does not results in less frequent infections as compared to using povidone-iodine.