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

Betadine®)

Iodine based products (Figure 4 ) have been used in

surgical practice for wound disinfection for over 150years (7).

Clinical applications of povidone-iodine complexes

(known as iodophors) are comparable to those of

chlorhexidine. The US Food and Drug Administration

(FDA) recommend povidone-iodine as an approved

product for intraoperative skin preparation (7).

Complexing iodine with the inert polymer povidone

greatly reduces the undesirable effects of unbound

iodine, such as staining, irritation and excessive

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

burning and stinging with topical application remain due

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

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

The mechanism of action of povidone-iodine relies on

release of iodine molecules from the complex and

subsequent activation by exposure to water molecules

from the surrounding environment, to form active H2OI+.

Dry iodine powders therefore require availability of

adequate tissue moisture for activation (8). Free iodine

subsequently binds to bacterial surface amino acids

(particularly tyrosine and histidine). The other direct

cytotoxic effects of iodine are shown in Figure 4 below,

including oxidation of cytoplasmic and membrane

compounds and iodination of lipids to disrupt cell

metabolism. There are various antimicrobial effects of

iodine, thus providing less scope for development of

bacterial resistance (8).

Iodine products may delay wound healing when in

contact with blood products due to free iodine binding to

organic substances (7); therefore, research recommends

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

possible to improve outcomes.

Povidone-iodine has a wide range of proven efficacies

against all pathogenic classes including bacteria (bothgram-positive, gram-negative and MRSA), mycobacteria,

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

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

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

remain important antimicrobial products for management

of surgical patients and wounds; however, comparison of

superiority and choice of one product over another is a

topic of progressing discussion.

Discussion

Direct comparison of povidone-iodine and chlorhexidine

suggest chlorhexidine as the superior agent to achieve

reduction in bacterial colony counts immediately and at

later time intervals. Reports of minimal persistent activity

20

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of povidone-iodine after initial application present a

challenge for procedures which require a longer duration

of antimicrobial activity (7,11,12).

A recent systematic review and meta-analysis by Noorani

et al. 2010, of preoperative antisepsis with chlorhexidine

versus povidone–iodine concluded that chlorhexidine

was the superior agent for use in preparation for clean

contaminated surgery (operative access requiring entry

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

significant proportion of surgical site infections can be

avoided by following evidence-based infection control

measures. These include tight glucose control in

diabetics, hair removal if appropriate, prophylactic

antibiotic administration prior to a procedure and

adequate preparation of the surgical skin site with an

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

limited evidence that chlorhexidine reduces surgical site

infection, therefore most recent guidance from the World

Health Organization (WHO), the Centers for Disease

Control and prevention (CDC) and the Association for

Perioperative Practice do not directly recommend one

antimicrobial product over the other (12).

Many recent studies have explored the use of alcohol in

combination of chlorhexidine and povidone-iodine. A

recent review by Hemani and Lepor, 2009, showed that

although aqueous-based solutions and iodine can be

used safely on mucous membranes, alcohol-based

solutions act more quickly on the skin and have a lasting

effect with a broader spectrum of antimicrobial activity

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

different types of alcoholic active agents also alter the

effectiveness of the skin antisepsis. An 89.5%

concentration of n-propanol combined with 0.5%

chlorhexidine slowed down re-colonisation of skin flora.

(16).

Results from a Cochrane Review by Tanner et al.

concluded that the general consensus on hand

disinfection is that alcohol rubs are as effective, if not

more effective than aqueous scrubs (i.e. chlorhexidine

and povidone-iodine) at reducing the incidence of

surgical site infections and the number of colony forming

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

the effects of scrubbing duration on colony formation.

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

povidone-iodine was shown to be significantly superior to

chlorhexidine-alcohol in reducing bacterial counts

immediately after brushless surgical scrubbing.

However, differences in counts were non-significant after

2 hours from scrubbing (17).

Following review of several articles comparing

chlorhexidine and povidone-iodine and different

preparations of each, it can be concluded that alcohol-

based preparations for both agents are far more effective

antiseptic agents that provide “greater efficacy, easier

application, improved durability, and a superior cost

profile when compared with traditional aqueous-based

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

is safe for use on mucous membranes, chlorhexidine has

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

provide excellent asepsis against a wider range of micro-

organisms, its speed of action as well as its sustainability

of action. Unlike povidone-iodine, chlorhexidine does not

become inactivated when exposed to blood and debris,

which is a major factor during surgical procedures in

aiding the prevention of surgical site infections. Findings

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

be significantly more protective and overall rate of

surgical site infections statistically lower than for

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

chlorhexidine-alcohol should be and often is the agent of

choice (1).

In summary, both chlorhexidine and povidone-iodine are

effective antimicrobial agents. Current literature indicates

that chlorhexidine-alcohol is the most efficacious and

superior agent of choice. However, in clinical practice the

agent used often remains surgeon choice.

21

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References

7B Best Practice Guidelines, Surgical Skin Preparation, 2011

May: 1-13.

FB 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.

HB Chlorhexidine (Topical Application Route), online:

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

01/10/2012.

IB Kaplowitz GJ, Cortell M. Chlorhexidine: A Multifunctional

Antimicrobial Drug. PENWELL, online: www.ineedce.com,

accessed 01/10/2012.

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

original/hibiscrub.jpg

KB Image from: http://www.dentist-charlotte-north-carolina-

nc.com/chlorhexidine-gluconate.html

LB 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.

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

Wounds International 2011; 2(2): Available from http://

www.woundsinternational.com, accessed 03/10/2012.

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

ProductID/695/videne-surgical-scrub.htm

7OB Sekhon B. Iodine: A support against infections and emerging

as an antibiotic. Pharm Educ Res. 2012 June;3(1):35-39.

77B Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to

reduce surgicalsite infection. Cochrane Database Syst Rev.

2008 Jan 23;(1):CD004288.

7FB 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.

7HB 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.

7IB Darouiche RO,

Wall MJ Jr,

Itani KM,

Otterson MF,

WebbAL,

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.

7JB Reduction of Surgical Site Infections (A Continuing

Educational Self-Study Activity). Activity Number: 1136.

Pfiedler Enterprises, 2011.

7KB 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.

7LB Nishimura C. Comparison of the antimicrobial efficacy of

pov idone- iod ine, pov idone- i od ine-ethanol and

chlorhexidin e gluconate-ethanol surgical scrubs.

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

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http://www.ncbi.nlm.nih.gov/pubmed?term=alcohols%20for%20skin%20antisepsis%20at%20clinically%20relevant%20skin%20siteshttp://www.ncbi.nlm.nih.gov/pubmed?term=Reichel%20M%5BAuthor%5D&cauthor=true&cauthor_uid=19738017http://www.ncbi.nlm.nih.gov/pubmed?term=Heisig%20P%5BAuthor%5D&cauthor=true&cauthor_uid=19738017http://www.ncbi.nlm.nih.gov/pubmed?term=Kohlmann%20T%5BAuthor%5D&cauthor=true&cauthor_uid=19738017http://www.ncbi.nlm.nih.gov/pubmed?term=Kampf%20G%5BAuthor%5D&cauthor=true&cauthor_uid=19738017http://www.ncbi.nlm.nih.gov/pubmed?term=chlorhexidine-alcohol%20versus%20povidone-iodine%20for%20surgical-site%20antisepsishttp://www.ncbi.nlm.nih.gov/pubmed?term=Mosier%20MC%5BAuthor%5D&cauthor=true&cauthor_uid=20054046http://www.ncbi.nlm.nih.gov/pubmed?term=Alsharif%20A%5BAuthor%5D&cauthor=true&cauthor_uid=20054046http://www.ncbi.nlm.nih.gov/pubmed?term=Berger%20DH%5BAuthor%5D&cauthor=true&cauthor_uid=20054046http://www.ncbi.nlm.nih.gov/pubmed?term=Webb%20AL%5BAuthor%5D&cauthor=true&cauthor_uid=20054046http://www.ncbi.nlm.nih.gov/pubmed?term=Carrick%20MM%5BAuthor%5D&cauthor=true&cauthor_uid=20054046http://www.ncbi.nlm.nih.gov/pubmed?term=Darouiche%20RO%5BAuthor%5D&cauthor=true&cauthor_uid=20054046http://www.ncbi.nlm.nih.gov/pubmed?term=Darouiche%20RO%5BAuthor%5D&cauthor=true&cauthor_uid=20054046http://www.ncbi.nlm.nih.gov/pubmed?term=Wall%20MJ%20Jr%5BAuthor%5D&cauthor=true&cauthor_uid=20054046http://www.ncbi.nlm.nih.gov/pubmed?term=Itani%20KM%5BAuthor%5D&cauthor=true&cauthor_uid=20054046http://www.ncbi.nlm.nih.gov/pubmed?term=Otterson%20MF%5BAuthor%5D&cauthor=true&cauthor_uid=20054046http://www.dltchiropody.co.uk/details1.asp/ProductID/695/videne-surgical-scrub.htmhttp://www.dltchiropody.co.uk/details1.asp/ProductID/695/videne-surgical-scrub.htmhttp://www.woundsinternational.com/http://www.dentist-charlotte-north-carolina-nc.com/chlorhexidine-gluconate.htmlhttp://www.dentist-charlotte-north-carolina-nc.com/chlorhexidine-gluconate.htmlhttp://www.dentist-charlotte-north-carolina-nc.com/chlorhexidine-gluconate.htmlhttp://www.dentist-charlotte-north-carolina-nc.com/chlorhexidine-gluconate.htmlhttp://www.dentist-charlotte-north-carolina-nc.com/chlorhexidine-gluconate.htmlhttp://www.dentist-charlotte-north-carolina-nc.com/chlorhexidine-gluconate.htmlhttp://www.dentist-charlotte-north-carolina-nc.com/chlorhexidine-gluconate.htmlhttp://www.dentist-charlotte-north-carolina-nc.com/chlorhexidine-gluconate.htmlhttp://www.broschdirect.com/images/uploads/original/hibiscrub.jpghttp://www.broschdirect.com/images/uploads/original/hibiscrub.jpghttp://www.broschdirect.com/images/uploads/original/hibiscrub.jpghttp://www.broschdirect.com/images/uploads/original/hibiscrub.jpghttp://www.broschdirect.com/images/uploads/original/hibiscrub.jpghttp://www.mayoclinic.com/http://www.ncbi.nlm.nih.gov/pubmed/20111631http://www.ncbi.nlm.nih.gov/pubmed?term=alcohols%20for%20skin%20antisepsis%20at%20clinically%20relevant%20skin%20siteshttp://www.ncbi.nlm.nih.gov/pubmed?term=alcohols%20for%20skin%20antisepsis%20at%20clinically%20relevant%20skin%20siteshttp://www.ncbi.nlm.nih.gov/pubmed?term=alcohols%20for%20skin%20antisepsis%20at%20clinically%20relevant%20skin%20siteshttp://www.ncbi.nlm.nih.gov/pubmed?term=alcohols%20for%20skin%20antisepsis%20at%20clinically%20relevant%20skin%20siteshttp://www.ncbi.nlm.nih.gov/pubmed?term=Kampf%20G%5BAuthor%5D&cauthor=true&cauthor_uid=19738017http://www.ncbi.nlm.nih.gov/pubmed?term=Kampf%20G%5BAuthor%5D&cauthor=true&cauthor_uid=19738017http://www.ncbi.nlm.nih.gov/pubmed?term=Kohlmann%20T%5BAuthor%5D&cauthor=true&cauthor_uid=19738017http://www.ncbi.nlm.nih.gov/pubmed?term=Kohlmann%20T%5BAuthor%5D&cauthor=true&cauthor_uid=19738017http://www.ncbi.nlm.nih.gov/pubmed?term=Heisig%20P%5BAuthor%5D&cauthor=true&cauthor_uid=19738017http://www.ncbi.nlm.nih.gov/pubmed?term=Heisig%20P%5BAuthor%5D&cauthor=true&cauthor_uid=19738017http://www.ncbi.nlm.nih.gov/pubmed?term=Reichel%20M%5BAuthor%5D&cauthor=true&cauthor_uid=19738017http://www.ncbi.nlm.nih.gov/pubmed?term=Reichel%20M%5BAuthor%5D&cauthor=true&cauthor_uid=19738017http://www.ncbi.nlm.nih.gov/pubmed?term=chlorhexidine-alcohol%20versus%20povidone-iodine%20for%20surgical-site%20antisepsishttp://www.ncbi.nlm.nih.gov/pubmed?term=chlorhexidine-alcohol%20versus%20povidone-iodine%20for%20surgical-site%20antisepsishttp://www.ncbi.nlm.nih.gov/pubmed?term=chlorhexidine-alcohol%20versus%20povidone-iodine%20for%20surgical-site%20antisepsishttp://www.ncbi.nlm.nih.gov/pubmed?term=chlorhexidine-alcohol%20versus%20povidone-iodine%20for%20surgical-site%20antisepsishttp://www.ncbi.nlm.nih.gov/pubmed?term=Berger%20DH%5BAuthor%5D&cauthor=true&cauthor_uid=20054046http://www.ncbi.nlm.nih.gov/pubmed?term=Berger%20DH%5BAuthor%5D&cauthor=true&cauthor_uid=20054046http://www.ncbi.nlm.nih.gov/pubmed?term=Alsharif%20A%5BAuthor%5D&cauthor=true&cauthor_uid=20054046http://www.ncbi.nlm.nih.gov/pubmed?term=Alsharif%20A%5BAuthor%5D&cauthor=true&cauthor_uid=20054046http://www.ncbi.nlm.nih.gov/pubmed?term=Mo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