Chlorhexidine vs Povidone-Iodine and Incidence of Catheter-Related Infections: A Systematic Review and Meta-Analysis.

Summary

This PRISMA-compliant network meta-analysis of 16 RCTs (7803 patients; 11,985 catheters) shows that alcohol-based skin antisepsis, particularly high-concentration chlorhexidine in isopropyl alcohol, minimizes catheter-related infections. Chlorhexidine outperformed povidone-iodine across several outcomes, with uncommon local adverse events.

Key Findings

• Alcohol-based antisepsis reduced infections versus aqueous formulations; isopropyl alcohol outperformed ethanol.
• Alcoholic chlorhexidine reduced catheter tip colonization (RR 0.42, 95% CI 0.37–0.48) and local infections (RR 0.40, 95% CI 0.23–0.70) versus alcoholic povidone-iodine.
• High-concentration chlorhexidine (≥1%) further lowered CRBSI risk (RR 0.31, 95% CI 0.19–0.52) compared to lower concentrations.
• Local adverse events were uncommon and similar between chlorhexidine and povidone-iodine, slightly higher with alcohol-based formulations overall.

Clinical Implications

Adopt high-concentration chlorhexidine gluconate in isopropyl alcohol for catheter insertion skin prep; reserve povidone-iodine or aqueous formulations only when chlorhexidine or alcohol is contraindicated (e.g., allergy). Applies to perioperative antisepsis in plastic and cosmetic procedures using invasive lines.

Limitations

• Heterogeneity across trials in catheter types, settings, and outcome definitions
• For CRBSI, some comparisons had wide CIs crossing 1.0, limiting certainty of effect size

Future Directions

Head-to-head RCTs comparing high-concentration chlorhexidine in isopropyl alcohol with standardized CRBSI definitions, stratified by catheter type and patient risk, and evaluation of skin tolerability in sensitive populations.