Vaginal Antiseptic Preparation at the Time of Hysterectomy: A Systematic Review and Meta-Analysis

Objective: To compare the rates of surgical site infection (SSI) after hysterectomy using vaginal antisepsis with chlorhexidine gluconate (CHG) versus povidone-iodine (PI).

Data sources: PubMed, Embase, and Clinicaltrials.gov databases were queried from January 1, 1985 through Dec 7, 2023.

Study eligibility criteria: Randomized controlled trials (RCTs) and nonrandomized comparisons of interventions (NRCIs) of CHG and PI vaginal antiseptic preparation prior to hysterectomy were included. The primary outcome was SSI as defined by the CDC. Secondary outcomes included postoperative urinary tract infections (UTIs) and vaginal culture specimens. Large single group studies of vaginal CHG reporting adverse events and case reports of desquamation were also included.

Study appraisal and synthesis methods: Methodologic quality of each study was assessed using the original Cochrane Risk of Bias and Risk of Bias in Nonrandomized Studies Intervention tools. Restricted maximum likelihood meta-analyses of odds ratios (OR) were conducted.

Results: 5,289 abstracts were screened. 10 met inclusion with a total of 9,618 participants. The studies included 4 RCTs (n=306), 3 prospective NRCIs (n=1,089), and 3 retrospective NRCIs (n=8,223). PI was compared to 4% CHG in 4 studies (n=2,491), 2% CHG in 2 studies (n=236), 0.1% in 1 study (n=50), and both 2% and 4% CHG in 1 study (n=49). Meta-analysis revealed no statistically significant difference in SSIs, although SSIs were somewhat more common with CHG (summary OR 1.22, 95% CI 0.91-1.63). The relative effect of antiseptic preparations on UTIs was unclear, with an imprecise summary OR (1.18, 95% CI 0.65-2.12). Positive vaginal cultures were less common with CHG preparation (summary OR 0.10, 95% CI 0.04-0.27). Two studies reported no adverse events with CHG, and two found no difference in vaginal irritation when compared with PI. Two case reports described vaginal desquamation or hypersensitivity with CHG.

Conclusion: There is no evidence of a difference in postoperative infection with CHG use compared to PI, but CHG vaginal preparation results in lower rates of positive intraoperative vaginal cultures. Despite inadequate reporting, risk of adverse events appears low.