Hadiati Diah R, Hakimi Mohammad, Nurdiati Detty S, Ota Erika
Department of Obstetrics and Gynaecology, Faculty of Medicine, Universitas Gadjah Mada, DR.Sardjito Hospital, Jl. Kesehatan No.1, Sekip, Yogyakarta, Daerah Istimewa Yogyakarta, Indonesia, 55281.
Cochrane Database Syst Rev. 2014 Sep 17(9):CD007462. doi: 10.1002/14651858.CD007462.pub3.
The risk of maternal mortality and morbidity (particularly postoperative infection) is higher for caesarean section than for vaginal birth. With the increasing rate of caesarean section, it is important that the risks to the mother are minimised as far as possible. This review focuses on different forms and methods for preoperative skin preparation to prevent infection.
To compare the effects of different agent forms and methods of preoperative skin preparation for preventing postcaesarean infection.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (26 June 2014) and the reference lists of all included studies and review articles.
Randomised and quasi-randomised trials, including cluster-randomised trials, evaluating any type of preoperative skin preparation agents, forms and methods of application for caesarean section.
Three review authors independently assessed all potential studies for inclusion, assessed risk of bias and extracted the data using a predesigned form. Data were checked for accuracy.
We included six trials with a total of 1522 women. No difference was found in the primary outcomes of either wound infection or endometritis. Two trials of 1294 women, compared drape with no drape (one trial using iodine and the other using chlorhexidine) and found no significant difference in wound infection (risk ratio (RR) 1.29; 95% confidence interval (CI) 0.97 to 1.71). One trial of 79 women comparing alcohol scrub and iodophor drape with iodophor scrub without drape reported no wound infection in either group. One trial of 50 women comparing parachlorometaxylenol plus iodine with iodine alone reported no significant difference in wound infection (RR 0.33; 95% CI 0.04 to 2.99).Two trials reported endometritis, one trial comparing alcohol scrub and iodophor drape with iodophor scrub only found no significant difference (RR 1.62; 95% CI 0.29 to 9.16). The other trial of 50 women comparing parachlorometaxylenol plus iodine with iodine alone reported no significant difference in endometritis (RR 0.88; 95% CI 0.56 to 1.38). One trial of 60 women comparing chlorhexidine gluconate with povidone-iodine reported significant lower rates of bacterial growth at 18 hours after caesarean section (RR 0.23, 95% CI 0.07 to 0.70). No difference was found in the secondary outcome of either length of stay or reduction of skin bacteria colony count. No trial reported other maternal outcomes, i.e. maternal mortality, repeat surgery and re-admission resulting from infection. One trial, which was only available as an abstract, investigated the effect of skin preparation on neonatal adverse events and found cord blood iodine concentration to be significantly higher in the iodine group.Most of the risk of bias in the included studies was unclear in selection bias and attrition bias. The quality of the evidence using GRADE was low for wound infection comparing drape versus no drape, one-minute alcohol scrub with iodophor drape versus five-minute iodophor scrub without drape, and parachlorometaxylenol with iodine versus iodine alone. The quality of the evidence for wound infection comparing chlorhexidine gluconate with povidone-iodine was very low.
AUTHORS' CONCLUSIONS: This review found that chlorhexidine gluconate compared with iodine alone was associated with lower rates of bacterial growth at 18 hours after caesarean section. However, this outcome was judged as very low quality of evidence. Little evidence is available from the included randomised controlled trials to evaluate different agent forms, concentrations and methods of skin preparation for preventing infection following caesarean section. Therefore, it is not yet clear what sort of skin preparation may be most efficient for preventing postcaesarean wound and surgical site infection.There is a need for high-quality, properly designed randomised controlled trials with larger sample sizes in this field. High priority questions include comparing types of antiseptic (especially iodine versus chlorhexidine), the timing and duration of applying the antiseptic (especially previous night versus day of surgery, and application methods (scrubbing, swabbing and draping).
剖宫产的孕产妇死亡和发病风险（尤其是术后感染）高于阴道分娩。随着剖宫产率的上升，尽可能降低对母亲的风险非常重要。本综述重点关注术前皮肤准备预防感染的不同形式和方法。
比较不同剂型和术前皮肤准备方法预防剖宫产术后感染的效果。
我们检索了Cochrane妊娠与分娩组试验注册库（2014年6月26日）以及所有纳入研究和综述文章的参考文献列表。
随机和半随机试验，包括整群随机试验，评估剖宫产术前皮肤准备的任何类型的制剂、剂型和应用方法。
三位综述作者独立评估所有潜在研究是否纳入，评估偏倚风险并使用预先设计的表格提取数据。检查数据的准确性。
我们纳入了6项试验，共1522名女性。在伤口感染或子宫内膜炎的主要结局方面未发现差异。两项涉及1294名女性的试验，比较了使用手术单与不使用手术单（一项试验使用碘，另一项使用氯己定），发现伤口感染无显著差异（风险比（RR）1.29；95%置信区间（CI）0.97至1.71）。一项涉及79名女性的试验比较了酒精擦浴加碘伏手术单与无手术单的碘伏擦洗，两组均未报告伤口感染。一项涉及50名女性的试验比较了对氯间二甲苯酚加碘与单独使用碘，发现伤口感染无显著差异（RR 0.33；95%CI 0.04至2.99）。两项试验报告了子宫内膜炎，一项试验比较了酒精擦浴加碘伏手术单与仅碘伏擦洗，未发现显著差异（RR 1.62；95%CI 0.29至9.16）。另一项涉及50名女性的试验比较了对氯间二甲苯酚加碘与单独使用碘，发现子宫内膜炎无显著差异（RR 0.88；95%CI 0.56至1.38）。一项涉及60名女性的试验比较了葡萄糖酸氯己定与聚维酮碘，报告剖宫产术后18小时细菌生长率显著降低（RR 0.23，95%CI 0.07至0.70）。在住院时间或皮肤细菌菌落计数减少的次要结局方面未发现差异。没有试验报告其他孕产妇结局，即孕产妇死亡、再次手术和因感染再次入院。一项仅以摘要形式提供的试验研究了皮肤准备对新生儿不良事件的影响，发现碘组脐带血碘浓度显著更高。纳入研究中的大多数偏倚风险在选择偏倚和失访偏倚方面尚不清楚。使用GRADE评估，比较使用手术单与不使用手术单、一分钟酒精擦浴加碘伏手术单与五分钟无手术单碘伏擦洗以及对氯间二甲苯酚加碘与单独使用碘的伤口感染证据质量较低。比较葡萄糖酸氯己定与聚维酮碘的伤口感染证据质量非常低。
本综述发现，与单独使用碘相比，葡萄糖酸氯己定与剖宫产术后18小时较低的细菌生长率相关。然而，这一结局被判定为证据质量非常低。纳入的随机对照试验几乎没有证据可用于评估不同的制剂形式、浓度和皮肤准备方法预防剖宫产术后感染。因此，目前尚不清楚哪种皮肤准备可能对预防剖宫产伤口和手术部位感染最有效。该领域需要高质量、设计合理且样本量更大的随机对照试验。高度优先的问题包括比较防腐剂类型（尤其是碘与氯己定）、防腐剂应用的时间和持续时间（尤其是前一晚与手术当天）以及应用方法（擦洗、擦拭和铺单）。
