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Grand Rounds

Chlorhexidine or Povidone-Iodine for Vaginal Cleansing Prior to Cesarean Delivery?

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BACKGROUND AND PURPOSE:

  • Lakhi et al. (AJOG MFM, 2019) compared vaginal cleansing with chlorhexidine gluconate (4%) vs povidone-iodine prior to cesarean section to
    • Determine whether chlorhexidine reduces wound infection rates
    • Assess patient-reported side effects

METHODS:

  • Block randomized, comparator-controlled, open-label trial (RCT)
  • Participants
    • Undergoing nonemergent cesarean delivery, including
    • Arrest | Maternal request | Category II tracings | Failed TOLAC
  • Randomized to receive vaginal cleansing prior to incision (3 passes) with either
    • 4% chlorhexidine solution
    • 10% povidone-iodine solution
  • Prophylactic antibiotics (at least 30 minutes prior to skin incision) provided to all patients
  • Primary outcome
    • Wound site infection (superficial or deep) within 14 days of surgery
  • Secondary outcomes
    • Rates of endometritis
      • ≥100.4°F occurring 24 hours post-surgery | Uterine fundal tenderness or foul-smelling vaginal discharge
    • Postoperative fever
    • Side effects (e.g., vaginal dryness, irritation, and desquamitization) within 14 days of cesarean delivery
      • Patient reported
  • Statistical analysis
    • 1,050 patients (total) required for 80% power
    • Based on 7% rate of post-op wound infection rate at study site

RESULTS:

  • 524 patients received chlorhexidine gluconate cleansing | 590 received povidone-iodine
    • Both groups were similar with regard to age, parity, body mass index, gestational age at delivery, indication for cesarean delivery, and incidence of membrane rupture
  • Rate of wound infection was significantly lower in the chlorhexidine group (p = 0.039)
    • Chlorhexidine group: 0.6%
    • Povidone-iodine group: 2.0%
    • Odds ratio (OR) 0.28 (95% CI, 0.08–0.98)
  • Rates of endometritis and postoperative fever were similar for both groups
    • Endometritis: 0.4% chlorhexidine vs 0.5% povidone-iodine (p = 1.000)
    • Postoperative fever: 2.5% and 2.7% (P = 0.892)
  • Adverse effects: Not observed in either group

CONCLUSION:

  • Authors note overall low infection rates, particularly for endometritis
    • Standardization of vaginal prep because of this study
    • The study center has a protocol in place to reduce wound infection, including adherence to prophylactic antibiotics, skin prep, instrument glove changes etc. (see ‘Learn More – Primary Sources’ below; Table 4 in the discussion section of the paper)
    • Single site protocols may limit generalization of findings
  • Vaginal cleansing with a 4% chlorhexidine solution reduces wound infection rates vs to povidone-iodine
    • Consistent with previous studies

Learn More – Primary Sources:

Vaginal cleansing with chlorhexidine gluconate or povidone-iodine prior to cesarean delivery: a randomized comparator-controlled trial

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Related ObG Topics:

Cesarean Delivery Best Practices & Guidelines – The ERAS Committee Recommendations
Does Vaginal Cleansing Prevent Endometritis Following Cesarean Section?
What is the Best Practices Prevention Bundle for Post Cesarean Infection?
Can Evidence-Based Interventions Reduce C-section Complications?

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