Which antiseptic to use for a Caesarean section? A systematic review and network meta-analysis of randomised controlled trials.

BACKGROUND: Guidelines for preoperative skin antisepsis recommend using chlorhexidine in an alcohol-based solution. However, other antiseptics such as aqueous povidone iodine or alcohol-based solutions are still used. Randomised controlled trials (RCTs) in Caesarean section (CS) are rare and do not include all possible comparisons of antiseptics.

AIM: To assess the efficacy (reduction of surgical site infections) of chlorhexidine at two different concentrations (0.3% and 2%) and povidone iodine in aqueous or alcohol-based solutions using a network meta-analysis, including only RCTs of caesarean sections. Fragility indexes and prediction intervals were also estimated.

METHODS: A systematic literature review and network meta-analysis (NMA) were performed. RCTs published up to February 2024 were collected from PubMed, ScienceDirect and the Cochrane Library. Interventions included alcohol-based povidone iodine; aqueous povidone iodine; alcohol-based chlorhexidine 2% and 0.3%. The primary outcome measure was surgical site infection.

RESULTS: Nine RCTs with 4915 patients and 4 interventions were included in the NMA. All credible intervals of the compared interventions overlapped. Alcohol-based 2% chlorhexidine had the highest probability of being effective in preventing surgical site infections, followed by alcohol-based povidone iodine. The fragility index ranged from 4 to 18. The prediction intervals were wide.

CONCLUSIONS: On the basis of rank probabilities, chlorhexidine 2% in an alcohol-based solution was most likely to be effective in preventing surgical site infections after CS, followed by alcohol-based povidone-iodine. Given the paucity of literature and the relatively small difference between povidone-iodine and chlorhexidine found in our meta-analysis, we suggest that either can be used in an alcohol-based solution as antisepsis for planned or emergency CS.