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.

Tear cytokine levels are reduced in patients treated with intravitreal injections

PURPOSE

To investigate cytokine levels in the tear fluid of patients receiving serial intravitreal injections (IVI) with anti-vascular endothelial growth factor (anti-VEGF) for neovascular age-related macular degeneration (nAMD).

METHODS

Concentrations of six cytokines (IFN-γ, IL-1β, IL-6, IL-8, TNF and VEGF) in tears of patients receiving anti-VEGF in one eye were assayed using multiplex cytometric bead array. The fellow untreated eye served as control. Tear sampling was performed on a single occasion at a minimum of four weeks after IVI. Patients underwent a pre-IVI antisepsis protocol with povidone-iodine.

RESULTS

Tear fluid from thirty patients with a mean age of 78.8 years (range 58-90) was assayed. Subjects received a median of 43.5 (range 22-106) IVI in one eye. The median level of IFN-γ was 0.33 (interquartile range (IQR) 0.22-0.52) pg/mg of total protein in injected eyes versus 0.41 (IQR 0.21-1.05) pg/mg in fellow eyes (p = 0.017). For TNF, a median level of 0.12 (IQR 0.08-0.18) pg/mg of total protein was found in injected eyes versus 0.14 (IQR 0.07-0.33) pg/mg of total protein in fellow eyes (p = 0.019). There were no differences between injected and fellow eyes regarding the levels of IL-1β, IL-6, IL-8 and VEGF.

CONCLUSION

Tear fluid in eyes receiving serial IVI with anti-VEGF and preoperative povidone-iodine antisepsis constitutes lower levels of the pro-inflammatory cytokines IFN-γ and TNF compared to fellow eyes. This provides biochemical support of previous findings of reduced signs of inflammation and healthier tear film parameters in patients treated with serial IVI.

[Quality of life survey of 3,738 patients treated with intravitreal injections for age-related macular degeneration]

PURPOSE

To evaluate the peri- and post-intravitreal injection (IVI) symptoms reported by patients who have been repeatedly injected for age-related macular degeneration (AMD) and to analyze these according to the protocols of the injector.

MATERIALS AND METHODS

Multi-center, cross-sectional, consecutive, analytical survey.

RESULTS

The IVI protocols of 106 injectors differed in terms of the number of instillations of povidone-iodine, its contact time, and rinsing of the ocular surface post-injection. In total, 3,738 patients responded to the survey, 60.1% of whom were women; 36.4% had received more than 20 IVIs; 50.7% of patients reported irritation upon application of povidone-iodine. Post-IVI, depending on the symptom in question, between 44.8% and 57.4% of patients reported symptoms of ocular surface change. The number of instillations of povidone-iodine, its contact time with the ocular surface, and abundant rinsing post-IVI increased the immediate symptoms. Patients who received more IVIs were more prone to experiencing gritty eyes, and the incidence of acute pain increased in patients who had previously received over 20 IVIs. Women and patients previously treated for dry eye or glaucoma were at greater risk of worse symptoms.

CONCLUSION

Comparing injecting centers' practices with patients' self-assessments showed an aggravation of symptoms of ocular surface changes related to povidone-iodine. This survey contributes to providing data for the implementation of a protocol to improve the quality of life of patients injected repeatedly for AMD.

In situ and in vitro evaluation of two antiseptics for blood bank based on chlorhexidine gluconate/isopropyl alcohol and povidone-iodine

BACKGROUND

Poor disinfection is the main cause of blood contamination, so its elimination is key to limiting the entry of bacteria into the collection system. With the advancement of antiseptic technology, antiseptics with sterile, disposable applicators are now available.

AIM

To evaluate in situ two antiseptics (with and without applicators) for blood banks and to demonstrate in vitro antiseptic activity on bacterial biofilms of importance in transfusion medicine.

METHODS

Antiseptic A (2% sterile solution of chlorhexidine gluconate/70% isopropyl alcohol provided with applicator) and bulk antiseptic B (10% povidone-iodine) were evaluated. The deferred blood donor arms were subjected to disinfection with antiseptics A and B and the contralateral arms were cultured to determine the baseline bacterial load (control). Antiseptic activity was assessed by ANOVA and logaritmic reduction values (LRV) and percentage reduction values (PRV) were calculated. Finally, the in vitro activity of antiseptic A was analyzed by confocal laser scanning microscopy (CLSM) on biofilm models.

RESULTS

Prior to disinfection tests, commensal and clinically important bacteria were identified; antiseptic A showed post-disinfection bacterial growth rates of zero compared to controls (p < 0.0001). The frequency of bacterial growth with antiseptic B was 74%. A significant difference was identified between both antiseptics, where antiseptic A showed higher activity (p < 0.5468). LRV and PRV were 0.6-2.5/100% and 0.3-1.7/66.7-99.7% for antiseptics A and B, respectively. Through CLSM, disinfectant A (without applicator) showed lower in vitro antiseptic activity on the tested biofilms at the exposure times recommended by the manufacturer.

CONCLUSIONS

Sterile solution of chlorhexidine gluconate/isopropyl alcohol with applicator showed advantages disinfection in deferred blood donors over povidone-iodine.

Association between vaginal microbiome alteration and povidone iodine use during delivery

BACKGROUND

The vaginal microbiome is a dynamic community of microorganisms in the vagina. Its alteration may be influenced by multiple factors, including gestational status, menstrual cycle, sexual intercourse, hormone levels, hormonal contraceptives, and vaginal drug administration. Povidone iodine has been used before delivery to reduce infection that may be caused by the ascendance of pathogenic and opportunistic bacteria from the vagina to the uterus. This study aimed to elucidate the impact of povidone iodine use during delivery on the vaginal microbiome.

METHODS

This study enrolled a total of 67 women from maternity services in three hospitals. During the delivery process, we have applied povidone iodine in three doses such as low dose, medium dose, and high dose based on the amount of povidone iodine administered, thus, we studied the three groups of women based on the doses applied. Vaginal swab samples were collected both before and immediately after delivery, and the microbial communities were characterized using 16 S rRNA sequencing. The identification of differentially abundant microbial taxa was performed using ZicoSeq software.

RESULTS

Before delivery, the vaginal microbiome was dominated by the genus Lactobacillus, with different percentage observed (86.06%, 85.24%, and 73.42% for the low, medium, and high dose groups, respectively). After delivery, the vaginal microbial community was restructured, with a significant decrease in the relative abundance of Lactobacillus in all three groups (68.06%, 50.08%, and 25.89%), and a significant increase in alpha diversity across all 3 groups (P < 0.01). Furthermore, as the dose of povidone iodine used during delivery increased, there was a corresponding decrease in the relative abundance of Lactobacillus (P < 0.01). Contrary, there was an increase in microbial diversity and the relative abundances of Pseudomonas (0.13%, 0.26%, and 13.04%, P < 0.01) and Ralstonia (0.01%, 0.02%, and 16.07%, P < 0.01) across the groups. Notably, some functional metabolic pathways related to sugar degradation were observed to have significant change with increasing use of povidone iodine.

CONCLUSION

Povidone iodine was associated with the vaginal microbiome alterations after parturition, and its significant change was associated to the dosage of povidone iodine administered. The escalation in iodine dosage was linked to a decrease in Lactobacilli abundance, and elevated prevalence of Pseudomonas and Ralstonia. There is a need for longitudinal studies to clearly understanding the effect of povidone iodine use on maternal and infant microbiome.

A systematic review and meta-analysis on the efficacy of topical povidone iodine in adenoviral conjunctivitis

PURPOSE

To evaluate if topical povidone iodine (alone (PI) or combined with dexamethasone (PI-DXM)) is superior to placebo for treating adenoviral conjunctivitis (AC).

METHODS

A systematic review was performed according to Preferred Reporting Items for the Systematic Review and Meta-Analyses (PRISMA) Statement. An electronic search was made on PubMed, Embase and Cochrane Library. Randomized control studies that compared PI or PI-DXM with placebo were included. At least three researchers were involved in all phases. Primary outcomes were AC duration and the number of clinical resolutions during the first week. Secondary outcomes were conjunctival redness and serous discharge one week after starting treatment and the rate of AC complications.

RESULTS

Only five studies met the inclusion criteria. PI-DXM reduced the duration of the disease by 2.4 days (IC95% 4.09-0.71), however this result was based only in one study. PI and PI-DXM did not modify the probability of clinical resolution during the first week; relative risk (RR) = 1.77 (IC95% 0.63-4.96) and 1.70 (IC95% 0.67-4.36). The impact of PI on the probability of pseudomembranes could not be estimated. PI-DXM did not influence the risk of developing subepithelial infiltrates RR = 0.73 (IC95% 0.02-33.38).

CONCLUSIONS

At this time there is great uncertainty about the usefulness of PI on the course of adenoviral conjunctivitis. PI-DXM may have a small effect on AC duration. To make future reviews possible, it is important to standardize the way in which these results are reported. Futures studies should include etiological confirmation, unit of study (eyes vs patients) and report on those aspects that are more relevant for patient quality of life (duration of the disease, development of complications: pseudomembranes and subepithelial infiltrates).

Associations between Serial Intravitreal Injections and Dry Eye

PURPOSE

To investigate the effects of serial intravitreal injections (IVIs) on the ocular surface and meibomian glands (MGs) in patients treated with anti-vascular endothelial growth factor (anti-VEGF) for neovascular age-related macular degeneration (nAMD).

DESIGN

Retrospective, controlled, observational study.

PARTICIPANTS

Patients with nAMD receiving unilateral IVIs with anti-VEGF agents. The fellow eye was used as control.

METHODS

Tear film and ocular surface examinations were performed on a single occasion at a minimum of 4 weeks after IVI. A pre-IVI asepsis protocol with povidone-iodine (PVP-I) was applied.

MAIN OUTCOME MEASURES

Upper and lower MG loss, tear meniscus height (TMH), bulbar redness (BR) score, noninvasive tear break-up time (NIBUT), tear film osmolarity (TOsm), Schirmer test, corneal staining, fluorescein tear film break-up time (TBUT), meibomian gland expressibility (ME), and meibum quality.

RESULTS

Ninety patients with a mean age of 77.5 years (standard deviation [SD], 8.4; range 54-95) were included. The median number of IVIs in treated eyes was 19.5 (range, 2-132). Mean MG loss in the upper eyelid was 19.1% (SD, 11.3) in treated eyes and 25.5% (SD, 14.6) in untreated fellow eyes (P = 0.001). For the lower eyelid, median MG loss was 17.4% (interquartile range [IQR], 9.4-29.9) in treated eyes and 24.5% (IQR, 14.2-35.2) in fellow eyes (P < 0.001). Mean BR was 1.32 (SD, 0.46) in treated eyes versus 1.44 (SD, 0.45) in fellow eyes (P = 0.017). Median TMH was 0.36 mm (IQR, 0.28-0.52) in treated eyes and 0.32 mm (IQR, 0.24-0.49) in fellow eyes (P = 0.02). There were no differences between treated and fellow eyes regarding NIBUT, TOsm, Schirmer test, corneal staining, fluorescein TBUT, ME, or meibum quality.

CONCLUSIONS

Repeated IVIs with anti-VEGF with preoperative PVP-I application was associated with reduced MG loss, increased tear volume, and reduced signs of inflammation compared with fellow nontreated eyes in patients with nAMD. This regimen may thus have a beneficial effect on the ocular surface.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Comparison of different concentrations of a povidone iodine-diluted sitz bath in the prevention of perianal infection in patients undergoing chemotherapy for hematological malignancy: study protocol for a randomized controlled trial

Background

Infection is one of the most common causes of death in patients with hematological malignancies during chemotherapy. Due to its special location, local warmth and humidity, repeated pollution with stool and urine, and characteristically wrinkled anatomical structure within which bacteria can hide, the perianal becomes a site with a high incidence of infection. Such infection also has a high recurrence rate and high mortality, increasing the economic burden of patients, delaying the time of treatment and reducing the quality of life. In severe cases, sepsis occurs and endangers the patient’s life. Previous studies have confirmed the effectiveness of povidone iodine (PI) in the prevention of perianal infection in patients with hematological malignancies during chemotherapy, but these reports have not documented in detail the adverse events associated with sitz bathing and the lack of randomized controlled trials of different concentrations of dilute povidone iodine sitz bathing. Therefore, the evidence is insufficient. Hence, the objective of this paper is to determine whether a povidone iodine diluent sitz bath can reduce the incidence of perianal infection compared with conventional perianal cleaning care and to observe the incidence of perianal infection, the severity of perianal infection, and the complications related to the sitz bath among groups treated with different concentrations of povidone iodine diluent, especially in high-risk patients prone to perianal infection, to screen for the optimal concentration.

Methods

The trial is designed as a single-center, parallel, randomized, controlled and intervention trial with four parallel groups, and a primary endpoint of perianal infection occurred after this hospitalization chemotherapy. Randomization will be performed as simple randomization with a 1:1:1:1 allocation. This study received full ethics committee approval. The first patient was enrolled on May 1, 2021. A total of 268 patients with hematological malignancies undergoing chemotherapy who have risk factors for perianal infection will be enrolled with informed consent and randomly allocated to one of the four arms receiving (1) perianal cleaning care (control group D), (2) 1:100 PI diluted sitz bath (intervention group A), (3) 1:200 PI diluted sitz bath (intervention group B), and (4) 1:300 PI diluted sitz bath (intervention group C). The primary endpoint of the trial was the incidence of perianal infection. The secondary endpoints of the study will be the results of anal swab bacterial culture, the severity of perianal infection, the incidence of perianal adverse events (dryness, peeling, pigmentation, burning sensation), and pain scores. The length of hospitalization in days and hospitalization expenses will be recorded. Safety will be assessed with consideration of all adverse and severe adverse events related to the study treatment.

Discussion

We hypothesized that patients with hematological malignancies during chemotherapy would benefit from a povidone iodine diluted sitz bath. This study will provide evidence-based recommendations for clinicians and nurses.

Trial registration

Chinese Clinical Trial Registry (registration ID: ChiCTR2000041073). Registered on December 17, 2020. The protocol version number is V1.0,20201217. http://www.chictr.org.cn/edit.aspx?pid=66044&htm=4

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06721-y.

Efficiency of hypericum perforatum, povidone iodine, tincture benzoin and tretinoin on wound healing

Different topical agents have been used to accelerate wound healing. The purpose of this study is to compare the safety and efficacy of topical application of the extract of Hypericum perforatum (HPE), povidone iodine (PI), tincture benzoin (TB) and tretinoin (T) on surgical wound healing. Ten adult female, Wistar albino rats were included in the study. HPE, PI, TB and T solutions were applied on the wounds. After seven days, tissue samples were collected and inflammatory cells, re-epithelialization, granulation tissue, angiogenesis, collagen accumulation, hemorrhage and lysis of cells were investigated histopathologically. No dermal toxicity was noted. HPE, TB, PI have all showed good epithelialization and granulation, but HPE showed the most advanced stage of healing within a short period of time. HPE had significantly higher values of re-epithelialization and collagen accumulation, but lower inflammatory cell count and granulation tissue. TB had the second best in re-epithelialization, collagen accumulation and the highest granulation tissue. PI induced better reepithelialization and granulation than the control group with remarkable cell lysis. As a result, HPE can be a safe, effective, and cheap agent that can be used for surgical wounds.

Randomized Study on Postoperative Intra-alveolar Betadine Irrigation Versus Chlorhexidine Irrigation on the Incidence of Occurrence of Alveolar Osteitis After Mandibular Third Molar Surgery

Purpose

To compare the effectiveness of two different antiseptic solutions for irrigation of the extraction socket and the incidence of occurrence of dry socket in the sample population in Bhubaneswar, Odisha.

Patients and Methods

A prospective and randomized study among the patients reporting to the department of oral and maxillofacial surgery for surgical removal of impacted mandibular third molars under local anesthesia was done in a group of 100 patients meeting the inclusion and exclusion criteria. Two different intervention groups (groups A and B) were allocated which comprised irrigation of the extraction sockets continuously up to 7 postoperative days with chlorhexidine (hexidine 0.2% ICPA) and povidone iodine (Betadine^® mouthwash 1%), respectively. Pain, edema, trismus, alveolar osteitis, infection, wound dehiscence and food debris impaction were the various outcome variables.

Results

A total of 100 patients participated in this study, while there was a loss in the follow-up of 5 patients. Pain scores, edema and the incidence of occurrence of alveolar osteitis were significantly reduced in group A (p < 0.05). The effect on trismus was statistically insignificant. Pain scores had reduced significantly on the 7th-day follow-up in group A as compared to group B (p < 0.05).

Conclusion

Chlorhexidine is therefore a good option for irrigation of the surgical site. There is also a decrease in incidence of occurrence of AO with chlorhexidine irrigation than with that of povidone iodine irrigation. Hence, chlorhexidine can be preferred over betadine for the routine preparation and irrigation of the surgical site.

Histological microaggregates as a sign of systemic dissemination due to oral ingestion of povidone-iodine (Betadine®)

Povidone-iodine (PVP-I) in the formulation of Betadine® is widely used in several medical fields, whereas its suicidal ingestion is an unusual occurrence. Therefore, the biological signs of this fatal poisoning remain unclear and elusive, similarly to the histological lesions induced by PVP-I. In fact, there are no forensic articles concerning the histological signs of PVP-I acute poisoning. Specifically, this short communication reports the unique case of a man who ingested 125 ml of Betadine® 10% to commit suicide, for which he died three days later. The autopsy examination showed either local or systemic signs of caustic ingestion; moreover, the histological analysis showed both intra- and extra-cytoplasmic amorphous and brownish microaggregates in almost all the organs. Histological and histochemical techniques resulted to be negative for the detection of physiological and known pigments (e.g., formalin, lipofuscin, hemosiderin). Likewise, such pigments were not associated neither with the man's diseases nor with his medications. Therefore, the authors supposed that they were povidone-iodine microaggregates, which have been deposited in the organs through the blood circulation. In conclusion, the complete postmortem histological examination could allow the identification and the characterization of PVP-I microaggregates as evidence of systemic toxicity from Betadine®, when dealing with a forensic case of ingestion of povidone-iodine.

Yogic Neti-Kriya Using Povidone Iodine: Can it have a Preventive Role Against SARS-CoV-2 Infection Gateway?

During this COVID-19 pandemic, except steroid, none of the therapeutic measures have showed any evidence of efficacy. Traditionally jala-neti using lukewarm salted water remains a yogic way of maintaining upper airway hygiene. Saline irrigation decreases the concentration of inflammatory mediators (e.g. histamine, leukotriene etc.) in nasal secretions, reduces the severity and frequency of sinusitis, reduce need of antibiotic therapy and restores competency of nasal mucosa. Jala-neti is an integral part of six cleansing techniques of yogic kriyas practised in India since thousands of years. Jala-neti can clean the upper airways, prevents colonization of infectious agents, removes foreign bodies, prevents stasis of mucous and subsequently enhances the drainage of paranasal sinuses and maintain health. Regular practice of Jala neti improves nasal symptoms and overall health status of patients with sinusitis. Jala-neti sample can even be used for COVID-19 diagnosis. Povidone iodine (PVP-I) has been utilized as a time tested antimicrobial agent with broad spectrum coverage against wide range of bacteria and viruses. Anti-SARS-CoV-2 action of PVP-I was seen at a concentration as low as 0.45%. PVP-I is generally well tolerated upto 5%, however nasal ciliotoxicity is reported at this concentration, however, this toxicity is not reported with lower concentrations(1.25% and 0.5%). So, theoretically, by using neti-kriya with povidone iodine (0.5–1%) as irrigation solution can combine and enhance the protection against COVID-19 and this can be an important armor in the fight against COVID-19. However, this hypothesis needs to be validated in real life clinical trial scenario before implementing.

Adjunctive dental therapies in caries-active children: Shifting the cariogenic salivary microbiome from dysbiosis towards non-cariogenic health

Background:

The oral microbiome is a complex assembly of microbial species, whose constituents can tilt the balance towards progression of oral disease or sustained health. Recently we identified sex-specific differences in the salivary microbiome contained within caries-active and caries-free children. In this study, we sought to ascertain if adjunctive dental therapies, including povidone iodine and chlorhexidine, were effective in shifting the cariogenic microbiome from dysbiosis to non-cariogenic health.

Design:

We recruited young children (ages 2–12 years) to enter five enrollment groups, with each group (N = 9–30 participants/group) receiving caries restorative and/or adjunctive therapies, either singularly or in combination (OHSU IRB #6535). Saliva specimens were collected pre- and post-treatment (4–8 weeks) of caries preventive measures, and oral microbiota were identified using next generation sequencing (HOMINGS, Forsyth Institute, Cambridge, MA).

Results:

With the use of multi-dimensional scaling plots, support vector machine learning, odds ratio analysis, and other statistical methods, we have determined that treatment with povidone iodine can shift the composition of the salivary cariogenic microbiome to include higher proportions of aerobic microorganisms, such as Stentrophomonas maltophila, as well as non-cariogenic, anaerobic microorganisms including Poryphyromonas and Fusobacterium species.

Conclusion:

We have identified microorganisms that are associated with caries-active children and have determined that povidone iodine is an effective adjunctive therapy that has the potential to shift the composition of the cariogenic microbiome to one more closely aligned with non-cariogenic health.

Comparison of 0.5% chlorhexidine gluconate alcohol with 10% povidone-iodine for skin disinfection in children to prevent blood culture contamination

INTRODUCTION

Various disinfectants, such as povidone iodine (PVI)¹, alcohol preparations, and chlorhexidine gluconate ethanol (CHG-ALC), are used for disinfection prior to blood sampling for culture.

METHODS

This retrospective cohort study compared the usefulness and effectiveness of CHG-ALC and PVI in pediatric venipuncture. We applied 0.5% w/v CHG-ALC or 10% PVI as an antiseptic for phlebotomies on pediatric outpatients and inpatients with suspected bacterial infection between November 2017 and April 2019. We conducted logistic regression analysis to define the differences associated with the choice of disinfectant, collection site, and the staff member collecting the blood sample (explanatory variables) and the presence of contamination (objective variable). Based on these results, we performed propensity score matching.

RESULTS

The total number of specimens was 1460. The propensity score matching indicated that CHG-ALC reduced the incidence of blood culture contamination more effectively than PVI (0.4%, 2/479 cultures versus 2.5%, 12/479 cultures; relative risk, 0.163 [95% confidence interval, 0.036 to 0.733]; P = 0.012). There were no differences in the contamination rates between cultures of blood drawn from a vascular catheter and those of blood obtained percutaneously. Higher contamination rates were found when junior residents performed the venipuncture.

CONCLUSIONS

Compared with PVI, CHG-ALC dries rapidly with no pigmentation and has a long-lasting antiseptic effect. Overall, CHG-ALC skin preparations were more efficacious than the PVI preparations for blood sampling in children.

Tolerability and usability of 0.5% PVP-I gargles and nasal drops in 6692 patients: Observational study

Objectives

1.

To assess the feasibility and usability of 0.5% PVP-I gargles and nasal drops in patients attending ENT consultations for a period of 5 months as a pre requisite prior to ENT examination.

2.

To assess the tolerance of 0.5% PVP-I in these patients for regular use for a period of 8 days.

Study design

Observational study.

Setting

Secondary care ENT Centre.

Methods

All patients attending the hospital for office ENT consultations from 15th April 2020 to 15th September 2020 were included in the study. A total of 6692 office patients were evaluated for feasibility, usability and tolerability of the 0.5% PVP-I gargles and nasal drops.

Results

Overall practicability of using 0.5% PVP-I gargles and nasal drops at office level was assessed in terms of feasibility and usability. Feasibility and usability was considered in terms of the ease of the dispensing method of the 0.5% PVP-I gargles and nasal drops by the health care workers to the patients prior to ENT examination. Tolerance was assessed in terms of altered taste, staining of teeth or nasal skin or irritation in the nose. None reported any serious reactions or adverse effects following use of 0.5% PVP-I.

Conclusion

The study reports the successful feasibility and usability of 0.5% PVP-I gargles and nasal drops and bears the potential to provide benefits in preventing transmission from the patients to the health care workers and vice versa.

Level of evidence

4.

Effect of povidone iodine contact lens disinfecting solution on orthokeratology lens and lens case contamination and organisms in the microbiome of the conjunctiva

PURPOSE

To compare lens cleaning routines using a povidone iodine-based rigid lens disinfecting solution and its effect on conjunctival colonisation, and lens and lens case contamination.

METHODS

Participants, aged 6-10 years, receiving orthokeratology treatment were randomised to four lens cleaning routines: with and without the use of daily and/or weekly cleaners, which were performed by their parents. Conjunctival colonisation was compared before lens wear and at 1-, 3-, and 6-month after commencement of lens wear. Contamination of lenses and lens cases was investigated at these times. Organisms were identified using MALDI-TOF mass spectrometry.

RESULTS

Of the 76 participants who completed the study, conjunctival colonization was present in 24 (32 %) at baseline. Of the remaining 52 participants, 34 consistently yielded no growth. Participants positive at baseline were statistically more likely to be colonized after commencement of lens wear (p = 0.020). Overall, colonization rate was reduced to 15 % (11/72) after 6-month lens wear, which reached significance for initially colonized participants (p < 0.001). Few cultures yielded potential ocular pathogens, with notably no Pseudomonas aeruginosa. Contamination rates of both lenses and lens cases were also low, with few isolations of ocular pathogens. No significant differences were observed between cleaning regimes for conjunctival colonization or contamination of lenses or cases.

CONCLUSIONS

Disinfection for rigid and ortho-k lens wearers may be effectively achieved with the use of povidone iodine-based solution, apparently regardless of cleaning routine adopted in the current study. The absence of pathogens in the conjunctiva, lenses, and lens cases in the great majority of samples indicates that it can improve the safety of overnight lens wear.

Recurrent Morel-Lavallée lesion obliterated with povidone iodine, a case report

INTRODUCTION AND IMPORTANCE

A Morel-Lavallee lesion is a closed degloving injury due to traumatic separation of the hypodermis from underlying fascia. Accumulation of hemolymphatic fluid that occurs is a potential habitat for bacteria. Management options include percutaneous aspiration, open debridement, or a non-surgical approach, each with recurrence risk. In the event of recurrence, sclerotherapy is used. In this case report, after reviewing povidone iodine's efficacy in treating seromas, we used it as a sclerosant for recurrent Morel-Lavallee lesion as the more established options were unavailable in our setting.

CASE PRESENTATION

A 49-year-old with no known comorbid presented following a motor traffic accident, with left lateral thigh swelling. He was stable systematically, with a tense, tender left lateral thigh swelling and intact neurovascular assessment distally. X-ray and computed tomography ruled out skeletal and vascular injuries. Magnetic resonance imaging revealed a 580 ml type 1 Morell-Lavallee lesion. Open surgical debridement was done to drain and debride the lesion. He developed two recurrences that necessitated percutaneous aspiration. Doxycycline and talc sclerosants were considered; however, due to their unavailability, povidone iodine was used. It is now five months post-intervention without increased pain, recurrence, or wound complications.

CLINICAL DISCUSSION

Recurrence is hypothesized to be due to the persistence of fluid loculations, unobliterated dead space, and pseudocyst formation. Sclerotherapy stimulates inflammation that results in fibrosis of the cavity walls causing its obliteration. Doxycycline, the most studied sclerosant in Morel-Lavallée lesion has an efficacy of 95.7%.

CONCLUSION

The current report is the first successful use of povidone iodine for sclerotherapy of recurring Morel-Lavallée lesions. Based on povidone iodine experiences as a sclerosant, it is associated with increased analgesic requirements. We cautiously propose its use as an alternative in settings where talc powder and doxycycline powder are unavailable.

Repurposing 0.5% povidone iodine solution in otorhinolaryngology practice in Covid 19 pandemic

SARS CoV 2 is very much homologous in structure to SARS CoV. Review of literature suggests the in-vitro virucidal action of povidone iodine in SARS CoV and MERS. The oropharynx and nasopharynx are target sites of SARS CoV 2. A significant proportion of COVID 19 sufferers are asymptomatic, but shedding these viral particles, PVP-I has been shown to be a safe therapy when used as a mouthwash or taken nasally or used during ophthalmic surgeries.

AIMS

MATERIALS AND METHODS: 0.5% PVP-I solution is prepared from commercially available 10% PVP-I solution. Patients were instructed to put 0.5% PVP-I drops in nose and rinse mouth with gargle prior examinations for 30 s. For endoscopic procedure (nasal and throat) nasal douching and gargling to be started one day prior. Douching and rinsing to be repeated just before procedures. Nasal packing with 0.5% PVP-I along with 4% xylocaine/adrenaline solution, tolerability and any allergic reaction noted.

RESULTS

The patient and health care workers tolerated the 0.5%. No allergy was noted.

CONCLUSION

We propose the use of 0.5% PVP-I in healthcare workers and their patients to minimise the risk of spread of the disease in addition to the recommended PPE.

Endogenous Endophthalmitis successfully treated with Intravitreal Povidone-iodine injection: a case report

BACKGROUND

The usefulness of povidone-iodine as an alternative to antimicrobial agents, for endophthalmitis, has recently been documented. We report a case of endogenous endophthalmitis successfully treated with intravitreal injection of povidone-iodine.

CASE PRESENTATION

An 88-year-old woman underwent small bowel bypass surgery for postoperative ileus following rectal cancer resection. She developed a fever during total parenteral nutrition and was diagnosed with gram-positive cocci bacteremia of central venous catheter origin. The patient was referred to our department with chief complaints of ocular pain, hyperemia and decreased vision in the right eye, which had manifested during the febrile period. The initial examination revealed the visual acuity in her right eye to be finger counting and that in her left eye 0.2. The right eye showed a severe inflammatory reaction in the anterior chamber, fibrin deposition, and hypopyon. The fundus was difficult to visualize. Endogenous endophthalmitis due to bacteria was diagnosed. Surgical treatment was judged to be difficult based on the patient's poor general condition and mental status, and intravitreal injection of 0.1 ml of 1.25% povidone-iodine was performed on the same day. The inflammation rapidly diminished, and the hypopyon had disappeared 4 days after treatment. The fundus became visible 7 days after treatment and there was no recurrence of endophthalmitis findings. The visual acuity in her right eye recovered to that in the left eye (0.2).

CONCLUSION

Intravitreal injection of povidone-iodine is potentially useful and effective as an alternative treatment of antibiotics for endogenous endophthalmitis patients, especially in whom surgical therapy is difficult.

Topical povidone iodine inhibits bacterial growth in the oral cavity of patients on mechanical ventilation: a randomized controlled study

Background

Topical 0.12% chlorhexidine has been used widely to prevent ventilator-associated pneumonia in patients undergoing mechanical ventilation. However, it is not approved for mucosal application in Japan. The aims of this study were to investigate if topical povidone iodine (i) inhibits bacterial growth and (ii) disrupts the balance of the oral microbiota.

Methods

This randomized controlled clinical trial included 23 patients who underwent mechanical ventilation in the intensive care unit. The patients were divided randomly into two groups: the intervention group (n = 16) and the control group (n = 7). All patients received oral cleaning with 3% hydrogen peroxide, followed by irrigation with tap water. The patients in the intervention group received 10% povidone iodine applied topically to the oral cavity. The concentration of total bacteria in the oropharyngeal fluid were determined before, immediately after, 1 h, 2 h, and 3 h after oral care using the Rapid Oral Bacteria Quantification System, which is based on dielectrophoresis and impedance measurements. The number of streptococci, methicillin-resistant Staphylococcus aureus, Streptococcus pneumoniae, Pseudomonas aeruginosa, Porphyromonas gingivalis, and Candida albicans before, immediately after, 1 h, and 3 h after oral care were estimated based on real-time polymerase chain reaction data.

Results

After irrigation of the oral cavity, the number of bacteria decreased, but increased again at 1 h after oral care in the control group; however, in the intervention group, the concentration of bacteria was significantly lower than that in the control group at 1 hour (p = 0.009), 2 h (p = 0.001), and 3 h (p = 0.001) after oral care. The growth of all bacterial species tested was inhibited in the intervention group at 3 h after oral care, suggesting that povidone iodine did not disturb the balance of the oral microbiota.

Conclusions

Topical application of povidone iodine after cleaning and irrigation of the oral cavity inhibited bacterial growth in the oropharyngeal fluid of patients on mechanical ventilation while not disrupting the balance of the oral microbiota.

Trial registration

University Hospitals Medical Information Network Clinical Trials Registry (UMIN-CTR), UMIN000028307. Registered 1 September 2017.

Preoperative topical liposomal ozone dispersion to reduce bacterial colonization in conjunctival sac and periocular skin: Preliminary study in dogs

Prophylaxis represents a keystone to reduce periocular skin and ocular conjunctiva bacterial load before surgical procedures. Despite many prophylactic agents are available the preferred perioperative ocular surface antimicrobial is still unknown. The purpose of this study was to assess the effectiveness of preoperative liposomal ozone dispersion in reducing bacterial colonization from the conjunctival sac and periocular skin in dogs, in comparison with povidone-iodine and fluoroquinolone. Twenty-two owned dogs consisting with 44 eyes in total scheduled for ophthalmic surgical procedure were enrolled for the study and divided in four groups receiving either ozone dispersion or povidone iodine in eyelid and conjunctiva, fluoroquinolone or placebo. A swab was taken before and after the antisepsis protocol evaluating total microbial count, coagulase positive and negative staphylococci. Statistical analysis revealed a significant decrease in colony forming units (CFU) for total microbial count, coagulase positive and negative staphylococci both for liposomal ozone dispersion and povidone iodine. No statistical differences were detected in median CFU for both one-day placebo and fluoroquinolone preoperative prophylactic topical therapy. The results of this preliminary study demonstrate that liposomal ozone-dispersion is as effective as povidone iodine to reduce preoperative bacterial load in ocular surface.

Comparison of disinfection effect between benzalkonium chloride and povidone iodine in nasotracheal intubation: a randomized trial

Background

Nasotracheal intubation can potentially result in microbial contamination from the upper respiratory tract to the lower respiratory tracts. However, an ideal nasotracheal disinfection method is yet to be determined. Therefore, we compared the disinfection effects between benzalkonium chloride and povidone iodine in nasotracheal intubation.

Methods

Overall, this study enrolled 53 patients aged 20–70 years who were classified into classes 1 and 2 as per American Society of Anesthesiologists-physical status and were scheduled to undergo general anesthesia with NTI. Patients who did not give consent (n = 2) and who has an allergy for BZK or PVI were excluded from the study. The patients were randomly divided into two groups on the basis of the disinfection method: BZK (n = 26, one patient was discontinued intervention) and PVI (n = 25). 50 patients were assessed finally.

The subjects’ nasal cavities were swabbed both before (A) and after disinfection (B), and the internal surface of the endotracheal tube was swabbed after extubation (C). The swabs were cultured on Brain heart infusion agar and Mannitol salt agar. The number of bacteria per swab was determined and the rates of change in bacterial count (B/A, C/B) were calculated. The growth inhibitory activity of the disinfectants on Staphylococcus aureus were also investigated in vitro.

Results

Although the initial disinfection effects (B/A) were inferior for benzalkonium chloride compared with those for povidone iodine, the effects were sustained for benzalkonium chloride (C/B). In the in vitro growth inhibitory assay against S. aureus, benzalkonium chloride showed higher inhibitory activity than povidone iodine.

Conclusion

Although both disinfectants were inactivated or diffused/diluted over time, benzalkonium chloride maintained the threshold concentration and displayed antimicrobial effects longer than povidone iodine; therefore, benzalkonium chloride appeared to show a better sustained effect. Benzalkonium chloride can be used for creating a hygienic nasotracheal intubation environment with sustained sterilizing effects.

Trial registration

UMIN-CTR (Registration No. UMIN000029645). Registered 21 Oct 2017.

Evaluation of prevention and disruption of biofilm in contact lens cases

PURPOSE

The presence of biofilm in the lens case has been shown to be a risk factor for contamination of lenses and consequently microbial keratitis. This study aimed to evaluate effectiveness of solutions for rigid contact lenses in prevention and disruption of biofilm in lens cases and methods for biofilm detection.

METHOD

This study adopted a stepwise approach to evaluate effectiveness of four rigid lens disinfecting solutions against biofilm. These included two polyhexamethylene bigiuanide (PHMB) solutions and a chlorhexidine/PHMB-based solution, as well as a novel povidone-iodine formulation. The presence of biofilm following exposure to the solutions was assessed using both crystal violet (CV) staining and MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide) viability assay, taking into account the effect of lens case design. Three lens case designs, conventional flat, large bucket type, and cylindrical cases, were investigated for the ability to trap stain and allow biofilm formation.

RESULTS

Considerable differences were noted between solutions in their ability to prevent and disrupt biofilm (p < 0.001). Lens case design greatly influenced optical density (OD) measurements even in negative controls, as cylindrical cases trapped more stain, increasing OD readings. Correcting for this factor reduced variations, but could not differentiate between residues and biofilm. MTT assay revealed that both povidone-iodine and chlorhexidine-containing solutions could effectively kill > 95% of organisms, whilst PHMB-based solutions were less effective with up to 55% of staphylococci and 41% of Pseudomonas surviving at 24 h.

CONCLUSION

Biofilm can rapidly form in lens cases and may not be killed by disinfecting solutions. Of the solutions tested, none were able to prevent biofilm formation or disrupt established biofilm, but those containing chlorhexidine or povidone iodine were able to penetrate the biofilm and kill organisms. Assessment of biofilm by CV assay may be confounded by lens case design. Whilst CV assay can demonstrate presence of biofilm, this technique should be accompanied by viability assay to determine bactericidal activity.

Infectious Disease Management and Control with Povidone Iodine

With reports of vancomycin-resistant enterococci recently emerging in hospital settings, renewed focus is turning to the importance of multifaceted infection prevention efforts. Careful compliance with established hygiene practices by healthcare workers together with effective antiseptic options is essential for the protection of patients from infectious agents. For over 60 years, povidone iodine (PVP-I) formulations have been shown to limit the impact and spread of infectious diseases with potent antiviral, antibacterial and antifungal effects. In addition to a lack of reported resistance, the benefits of PVP-I include an excellent safety profile and a broad spectrum of effect due to its multimodal action. Studies have shown that hand washing with PVP-I-based antiseptics is effective for the decontamination of skin, while PVP-I mouthwashes and gargles significantly reduce viral load in the oral cavity and the oropharynx. The importance of PVP-I has been emphasised by its inclusion in the World Health Organization’s list of essential medicines, and high potency for virucidal activity has been observed against viruses of significant global concern, including hepatitis A and influenza, as well as the Middle-East Respiratory Syndrome and Sudden Acute Respiratory Syndrome coronaviruses. Together with its diverse applications in antimicrobial control, broad accessibility across the globe, and outstanding safety and tolerability profile, PVP-I offers an affordable, potent, and widely available antiseptic option.

Funding Mundipharma Singapore Holding Pte Limited.

The effects of perineal disinfection on infant's oral microflora after transvaginal examination during delivery

BACKGROUND

Early life microflora is an important determinant of immune and metabolic development and may have lasting consequences. However, the mode of delivery and the effect of povidone iodine disinfection on neonatal oral microflora colonization are still unclear. The objective of the study was to understand the effects of the use of polyvidone iodine on infant's oral microflora after transvaginal examination during delivery, provided data support for the establishment of neonatal oral microflora health.

METHODS

A total of 20 cases of full-term neonatal delivered in October 2017 in Shenzhen Bao'an Maternity and Child Health Hospital through vaginal delivery. These neonates were randomly divided into two groups, the conventional disinfection group and the non-disinfection group. Simultaneously, 10 infants with elective cesarean section were taken as comparison. With Illumina MiSeq platform, 16S rRNA V3-V4 sequencing method was used to analyze bacterial DNA of oral secretions.

RESULTS

At the phylum level, compared to the non-disinfection group, higher relative abundance of Bacteroidetes and Proteobacteria, and lower proportion of Firmicutes were observed in the cesarean section group and the disinfection group. As main composition of phylum Firmicutes, genus Lactobacillus presented extremely low in the cesarean section group and the disinfection group, whereas it was the absolute dominant bacteria in the non-disinfection group. Compared with the caesarean section group, only Lactobacillus increased in majority of the non-disinfection group. There was no increase in Lactobacillus in the disinfection group, but Prevotella, Escherichia-Shigella, Staphyloccus, and Klebsiella increased significantly. Through KEGG pathway analysis, we found that there were more harmful pathways such as staphylococcus aureus infection, viral myocarditis and sporulation in the disinfection group.

CONCLUSIONS

The mode of delivery affects the infant's Lactobacillus obtained from the mother. Moreover, vulvar disinfection played an important part in the colonization of neonatal oral microbiota. And the impact of the first oral colonizers on infant health needs further follow-up investigations.

In vitro evaluation of the protoscolicidal effect of Eucalyptus globulus essential oil on protoscolices of hydatid cyst compared with hypertonic saline, povidone iodine and silver nitrate

OBJECTIVE

There are various protoscolicidal agents for inactivation of protoscoleces of hydatid cysts before and during surgical operation. The present study was aimed to evaluate the protoscolicidal effect of two concentrations of Eucalyptus globulus on protoscoleces of Echinococcus granulosus sensu lato under in vitro condition and to compare its efficacy with hypertonic saline, povidone iodine and silver nitrate.

METHODS

Live protoscoleces obtained from the liver of naturally infected sheep were exposed to 0.5% and 1% of Eucalyptus globulus essential oil, 5% hypertonic saline, 10% povidone iodine and 0.5% silver nitrate for 1 and 3minutes. Phosphate buffered saline was used as a negative control. One percent eosin staining method was used to test the viability of protoscoleces in different groups.

RESULTS

While the mean percentage of dead protoscoleces was 6.08% in the control group, the scolicidal power of 5% hypertonic saline was only 6.54% and 6.60% after 1 and 3min respectively. 0.5% E. globulus EO demonstrated 97.38% and 100% scolicidal activity after 1 and 3min respectively. The mean protoscolicidal power of 1% E. globulus EO, 10% povidone iodine and 0.5% silver nitrate was 100% after one minute.

CONCLUSIONS

According to the results of this study, E. globulus EO demonstrated high scolicidal power in a short period of time. Hence, this herbal product could be considered as a potent natural scolicidal agent that could be used before and during surgery of hydatid disease.

Current preoperative antisepsis in neurosurgery: an example of the challenges in implementing evidence-based medicine to surgical practice

INTRODUCTION

Surgical site infection is associated with significant morbidity and mortality. Effective preoperative skin decolonisation is an important preventative strategy. The National Institute for Health and Care Excellence clinical guidelines recommend decolonisation using chlorhexidine gluconate (CHG) or povidone iodine (PVI). Current evidence indicates that CHG is more effective, while the combination of CHG and PVI is greater still. This study describes current practice among neurosurgeons in the UK, including differences between trainees and consultants, to review compliance with the latest evidence.

MATERIALS AND METHODS

A Society of British Neurosurgical Surgeons approved national, multicentre questionnaire was circulated online. A total of 74 complete responses were obtained from 27 trainees and 47 consultants, representing 28 of 37 neurosurgical centres.

RESULTS

Of the total responding centres, 36 (49%) used a single agent and 38 (51%) used a dual-agent preparation. One respondent used Tisept®. Seventy (95%) used alcohol in some form and none used aqueous CHG. Trainees were more likely to use a dual-agent preparation (P = 0.025). Forty-seven (63%) prepared the skin three or more times, with trainees preparing the skin more times than consultants (P = 0.002).

CONCLUSION

Neurosurgical practice adheres to national clinical guidelines but not the latest evidence from the literature. Given the weighting placed on randomised controlled trials, such a trial may be required to standardise practice that is likely to reduce surgical site infection.

In vitro efficacy of povidone iodine and hydroxyethyl cellulose, alone and in combination, against common feline ocular pathogens

Infectious ocular disease, such as conjunctivitis, is common in cats and can be caused by several viruses and bacteria, either as a single infection or as co-infections. In this study, povidone-iodine (PVP-I), alone or compounded with hydroxyethyl cellulose (HEC), was investigated for its efficacy against these pathogens in vitro. Whilst PVP-I alone was effective at inhibiting feline herpesvirus type 1 (FHV-1), Chlamydia felis, and Mycoplasma felis, PVP-I with HEC exerted a synergistic inhibitory effect against FHV-1 and C. felis. In contrast, only minimal inhibition of feline calicivirus was observed. These results demonstrate that PVP-I, alone and in combination with HEC, is effective against some feline ocular pathogens when tested in cell lines in vitro. In vivo studies investigating the systemic safety, ocular tolerance, and clinical efficacy of this combination in cats would be necessary before it could be recommended as a therapy in affected cats.

In vitro comparative cytotoxicity study of a novel biocidal iodo-thiocyanate complex

Novel biocides, which avoid the induction of cross-resistance to antibiotics, are an urgent societal requirement. Here, we compared the cytotoxic and bactericidal effects of a new antimicrobial agent, the iodo-thiocyanate complex (ITC), with those of the common antiseptics, hydrogen peroxide (H₂O₂), povidone iodine (PVP-I) and Lugol's iodine (Lugol). The antimicrobials were co-incubated for 10 min with HeLa and Escherichia coli cells in the presence and absence of organic matter (Dulbecco's modified Eagle's medium, supplemented with 10% fetal bovine serum). The cytotoxic concentrations of ITC were equivalent to its bactericidal concentrations (7.8 μg ml^-1). By contrast, cytotoxic effects of H₂O₂, PVP-I and Lugol were apparent at concentrations lower than their bactericidal concentrations (250, 250 and 125 μg ml^-1, respectively). The cellular effects of ITC were not quenched by organic matter, unlike the other antiseptics. ITC, PVP-I and Lugol had hemolytic effect on horse erythrocytes at high concentrations, while H₂O₂ showed no hemolysis. ITC, at 30 or 300 μg ml^-1, did not cause DNA breakage in HeLa cells as assessed by an in vitro comet assay in the absence of S9 metabolic activation, whereas H₂O₂ caused extensive single-strand DNA breaks. The pronounced antimicrobial potency of ITC and its favorable cytotoxicity profile suggests that ITC should be considered for antiseptic applications.

Factors Affecting the Incidence and Severity of Oral Mucositis Following Hematopoietic Stem Cell Transplantation

Background: Patients who receive hematopoietic stem cell transplantation (HSCT) experience several complications that oral mucositis (OM) is a frequent symptom. This study was designed to evaluate the incidence, risk factors, prophylaxis and treatment strategies for established OM. Materials and Methods: We included 173 adult patients who received autologous or allogeneic hematopoietic stem cell transplantation in this study. The World Health Organization oral toxicity scale was used to assess the severity of OM. Patients received two prophylactic regimens: regimen 1 contained nystatin, chlorhexidine, povidone iodine and amphotericin B. Regimen 2 contained nystatin and povidone iodine. 70 patients (40.5%) received the first prophylaxis regimen, 89 patients (51.4%) received the second prophylaxis regimen and the remaining 14 patients (8.1%) were not adherence to the use of the mouthwashes and were excluded from the analysis. Results: OM was detected in 60.7% of patients with mean (SD) age of 38.1±14.6 years. Multivariate analysis showed that only the female gender and the prophylactic regimen were the significant predictors of OM. Conclusion: We found that addition of amphotericin B and chlorhexidine, to the nystatin and povidone iodine resulted in a significant beneficial effect in prevention OM.

Evaluation of the Role of Novel Aprotic Dimethyl Sulfoxide in Cutaneous Antisepsis Protocols Prior to Blood Donor Phlebotomy with Isopropyl Alcohol, Povidone Iodine or Chlorhexidine

The study was planned to measure the reduction of the load of bacterial flora on the blood donor's arm quantitatively using a three step protocol of donor arm cleansing incorporating either 70% isopropyl alcohol (IPA) or 5% w/v povidone iodine (PVI, 0.5% w/v available iodine) or 4% chlorhexidine gluconate (CHG) with or without the addition of 5% dimethyl sufloxide (DMSO). Single blind randomized study after obtaining ethical clearance, using the Miles and Misra technique for quantification and matrix assisted laser desorption ionization-mass spectrometry for identification of colony morphotypes on blood donor's skin. The mean pre-cleansing colony forming units (CFUs) was 89,318 and mean post-cleansing CFUs was 132, with a mean reduction of 99.85% with a mean log reduction of 3.24 (95% CI 2.01-4.47) at a P value of <0.0001. The post-cleansing CFUs was reduced to zero in all 34 samples in the protocol using CHG with DMSO, in 23 of 31 samples in the protocol using PVI with DMSO and 19 of 29 samples in the protocol using IPA with DMSO. The difference in means of the reduction of CFUs in protocols using CHG with DMSO compared with protocols using PVI or IPA with DMSO and PVI or IPA without DMSO was statistically significant with P value of 0.006, 0.0009, 0.015 and 0.05 respectively. The enhanced cutaneous antisepsis effect of CHG when complimented with DMSO in presence of IPA using the three step protocol of donor arm cleansing could stimulate more research and utilization of this as an additional safety towards the prevention of the problem of bacterial contamination of blood and blood components.

Antimicrobial efficacy of a novel povidone iodine contact lens disinfection system

PURPOSE

Contact lens (CL) wear is a risk factor for the acquisition of microbial keratitis. Accordingly, compliance to manufacturers' recommended hygiene and disinfection procedures are vital to safe (CL) use. In this study we evaluated a novel povidone-iodine (PI) (CL) disinfection system (cleadew, Ophtecs Corporation, Japan) against a range of bacterial, fungal and Acanthamoeba.

METHODS

Antimicrobial assays were conducted according to ISO 14729 using the recommended strains of bacteria and fungi, with and without the presence of organic soil. Regrowth of bacteria and fungi in the disinfection system was also examined. The activity on biofilms formed from Stenotrophomonas maltophilia and Achromobacter sp. was evaluated. Efficacy against A. castellanii trophozoites and cysts was also investigated.

RESULTS

The PI system gave >4 log₁₀ kill of all bacteria and fungi following the manufacturer's recommended disinfection and cleaning time of 4h, with or without the presence of organic soil. No regrowth of organisms was found after 14days in the neutralized solution. In the biofilm studies the system resulted in at least a 7 log₁₀ reduction in viability of bacteria. For Acanthamoeba, >3 log₁₀ kill of trophozoites and 1.1-2.8 log₁₀ kill for the cyst stage was obtained.

CONCLUSIONS

The PI system effective against a variety of pathogenic microorganisms under a range of test conditions. Strict compliance to recommended CL hygiene procedures is essential for safe CL wear. The use of care systems such as PI, with broad spectrum antimicrobial activity, may aid in the prevention of potentially sight threatening microbial keratitis.

Povidone iodine soaked gelfoam for the treatment of recalcitrant otomycosis - Our experiences at a tertiary care teaching hospital of eastern India

INTRODUCTION

Otomycosis is a common clinical condition seen in outpatient department of otorhinolaryngology. The treatment of the otomycosis is also very simple. However, sometime it is difficult to treat otomycosis along with mastoid cavity, chronic suppurative otitis media, immunocompromised patient, etc. with conventional treatment, called recalcitrant otomycosis. Here, we describe a technique of treatment for recalcitrant otomycosis.

MATERIALS AND METHODS

This is a prospective observational study/clinical trial carried out on 44 patients of recalcitrant otomycosis. They are divided into two groups, each of 22. One group treated with routine clotrimazole topical eardrops whereas other group treated with povidone iodine soaked gelfoam, placed in the external auditory canal.

RESULTS

There was no significance difference according to the age (P=0.134), gender (P=0.760) and causative agents (P=0.750) between treatment groups. The resolution of the symptoms showed statistically significant on itching (P=0.0001), otorrhoea (P=0.0033), fullness (P=0.0432) and earache (P=0.0259), whereas no statistical significant on hearing loss (P=0.0683), when treating with povidone iodine soaked gelfoam as compared to routine (clotrimazole) treatment. Resolution of signs like canal wall erythema (P=0.0045), tragal tenderness (P=0.0012) and congestion of tympanic membrane (P=0.0088) is statistically significant when comparing clotrimazole with povidone iodine. Apart from these, we did not reveal any adverse effects from the study populations treated with povidone iodine soaked gelfoam.

CONCLUSION

Use of the povidone iodine soaked gelfoam at the external auditory canal in recalcitrant otomycosis is an effective and well-tolerated treatment.

Povidone-iodine for the management of oral mucositis during cancer therapy

Oral mucositis (OM) is a common and often dose-limiting side effect of cancer therapy. Povidone iodine (PVP-I) formulations have been shown to decrease the incidence and severity of OM, but the relevance of these findings remains unclear. The objective of the present study was to review evidence for the use of PVP-I for OM management. An algorithm identified relevant articles published online, and a panel of experts with experience in the management of OM reviewed the findings. Six studies fulfilled the criteria for full review. Two studies provided evidence of moderate quality. Two of the studies with negative findings were confounded by the use of PVP-I concentrations that are too low to be efficacious. The remaining two studies were found to have design flaws. There exists reasonable evidence to support a recommendation for the use of PVP-I in the management of cancer therapy-related OM.

An Asian Perspective on Povidone Iodine in Wound Healing

Antiseptics, with a broader spectrum of antimicrobial efficacy, lower risk of antibiotic resistance development, and minimal collateral damage to host tissues, are important alternatives to control the bioburden in wounds. Povidone iodine (PVP-I), in use for several decades, has the broadest spectrum of activity, a persistent antimicrobial effect, an ability to penetrate biofilms, and a lack of acquired or cross-resistance. It demonstrates good skin tolerance and low cytotoxicity. However, some reports on PVP-I have raised concerns over allergy, ineffective penetration, and toxic effects on host cells. The majority of these concerns are based on in vitro or rodent wound studies with diverse study designs and outcomes; these results may not be directly applicable in the clinical reality in humans. In this paper, we discuss the efficacy and safety of PVP-I and outline its place in wound healing in Asia, based on an appraisal of recent literature and clinical practice across the region.

Evaluation of Post-surgical Bacteremia with Use of Povidone-Iodine and Chlorhexidine During Mandibular Third Molar Surgery

BACKGROUND

Microorganisms may invade the blood stream by oral routes through surgical procedures like extractions, fractured teeth and periodontal pockets. The incidence of bacteremia is 70-80 % following tooth extraction, sub gingival scaling and intra ligament injection.

AIMS AND OBJECTIVES

Aim of study was to evaluate and compare the efficacy of two topical antimicrobial agents for the prevention of post-surgical bacteremia during mandibular third molar surgery. And objectives were to suggest need of proper topical antimicrobial agents and select proper antibiotics before oral surgical procedures in high risk cardiac patients.

MATERIALS AND METHODS

Thirty patients with Class 1, Position B mesioangular impacted mandibular third molar were randomly included in study and divided into 3 groups, each group containing 10 patients. Group I; sterile water group, Group II: povidone-iodine (5 %) group, Group III: chlorhexidine (Q, 2 %) group, pre and post-surgical blood samples were collected and Microbiological analyses of the blood samples were done. The organisms were identified by standard method on grams staining and identification of bacterial species by biochemical tests.

RESULTS

The clinical parameters like oral hygiene index simplified and periodontal index of Russel showed that all patients in three groups had fair oral hygiene with simple gingivitis on mean. In some individuals with slightly higher OHIS and PI scores, bacteremia was noted. All the pre surgical blood samples were negative for the growth of bacteria after 7 days of culture. In total 30 patients, 12 subjects had postoperative bacteremia. Out of those 12 patients 6 cases (60 %) of group I showed positive bacterial growth in the post surgical blood sample, while 4 cases in group III and 2 cases (20 %) in group II showed the same.

CONCLUSION

Use of povidone-iodine and chlorhexidine prior to the oral surgical procedures decreases the incidence of bacteremia as compared to sterile water irrigation. Povidone-iodine significantly reduces the incidence bacteremia and number of organisms compared to chlorhexidine and sterile water.

A Randomized Controlled Study to Compare Conventional and Evidence Based Treatment Protocols in Fresh Compound Fractures

INTRODUCTION

A recent concept review in Journal of Bone and Joint Surgery (JBJS) outlines evidence to control peri-operative infections in compound fractures. However, evidence for impact of adopting a protocol combining measures that have some evidence is lacking in literature. The present method of treatment at King George's Medical University (KGMU) is representative of the conventional practice of managing compound fractures in India and is an appropriate control for trial against the Experimental Evidence Based Protocol (EBP).

AIM

To study the additional impact of adopting Evidence Based Protocol on parameters defining infection rate and bone union.

MATERIALS AND METHODS

This randomized controlled study was conducted at the orthopaedics department of KGMU. Two hundred and twenty six patients of compound fractures of both bone leg, age > 12y were randomized to two groups. One group received standard treatment and the experimental group received treatment as per JBJS review.

STATISTICAL ANALYSIS

Random allocation was tested by comparing baseline characteristics of the two groups. The two groups were compared for all the outcome variables in terms of time to a negative wound culture, time to wound healing, time to union at fracture site and time to achieve complete range of motion at knee joint.

RESULTS

Random allocation was successful. EBP group reported significantly lesser time to a negative culture report from wound (mean in conventional=4.619, experimental=1.9146, p=0.0006), lesser time to bony union (mean in conventional=23.8427 weeks, experimental=22.8125 weeks, p=0.0027), lesser time to wound healing (mean in conventional=14.4425 weeks experimental=10.4513 weeks, p=0.0032), and a lesser duration of hospital stay (mean in conventional=6.5982 days, experimental=4.5000 days, p=0.0343).

CONCLUSION

EBP based on the guidelines suggested by Fletcher et al., significantly shorten the time taken for achieving a negative culture and hasten wound and fracture healing. Therefore EBP is recommended for use in settings like the KGMU trauma center.

Single versus multiple instillation of povidone iodine and urographin in the treatment of chyluria: A prospective randomised study

Objective

To compare the safety, efficacy and complications of single vs multiple instillations of povidone iodine (PI) and urographin as a sclerosing agent in the treatment of chyluria.

Patients and methods

The study included 58 patients diagnosed with chyluria between March 2006 and January 2013. The inclusion criteria were either severe attacks of chyluria or patients with mild-to-moderate chyluria who had failed conservative treatment. The patients were randomly allocated to one of two groups: those in Group A had a single instillation of a combination of PI 0.2% plus the contrast-agent urographin 76%, while those in Group B had multiple instillations of the same combination twice daily for 3 successive days.

Results

The mean (SD) age of the patients in Groups A and B was 38.22 (10.67) and 37.9 (10.86) years, respectively. Chyluria was severe in eight patients (14.8%), moderate in 25 (46.3%) and mild in 21 (38.9%). The success rate in Group A (single instillation) was 85.2% and in Group B (multiple instillation) was 88.9%. The recurrence rate in Group A was 14.8% with a disease-free duration (DFD) of 4–15 weeks, while in group B it was 11.1% with a DFD of 6–18 weeks.

Conclusion

There was no significant difference between a single instillation of a combination of PI 0.2% and urographin 76% as a sclerosing agent in the treatment of chyluria and multiple instillations. However, the single instillation protocol is more cost effective with a shorter hospital stay.

Accidental oral administration of povidone iodine in a newborn: case report

Iodine solutions are widely used as antiseptic for treating and preventing wound infections. Povidone iodine, one of the most common topical iodine solutions in emergency kits, can lead to several abnormalities as thyroid dysfunction. Povidone iodine poisoning is unusual and previously reported effects are mainly complications of topical usage during surgical procedures. Here we present the case of a newborn that was accidentally given oral povidone iodine, showing no signs or symptoms of toxicity after ingestion.

[Keratomycosis due to Fusarium oxysporum treated with the combination povidone iodine eye drops and oral fluconazole]

In developing countries where systemic antifungal are often unavailable, treatment of filamentous fungi infection as Fusarium is sometimes very difficult to treat. We report the case of a keratomycosis due to Fusarium oxysporum treated by povidone iodine eye drops and oral fluconazole. The diagnosis of abscess in the cornea was retained after ophthalmological examination for a 28-year-old man with no previous ophthalmological disease, addressed to the Ophthalmological clinic at the University Hospital Le Dantec in Dakar for a left painful red eye with decreased visual acuity lasting for 15 days. The patient did not receive any foreign body into the eye. Samples by corneal scraping were made for microbiological analysis and the patient was hospitalized and treated with a reinforced eye drops based treatment (ceftriaxone+gentamicin). The mycological diagnosis revealed the presence of a mold: F. oxysporum, which motivated the replacement of the initial treatment by eye drops containing iodized povidone solution at 1% because of the amphotericin B unavailability. Due to the threat of visual loss, oral fluconazole was added to the local treatment with eye drops povidone iodine. The outcome was favorable with a healing abscess and visual acuity amounted to 1/200th. Furthermore, we noted sequels such as pannus and pillowcase. The vulgarization of efficient topical antifungal in developing countries would be necessary to optimize fungal infection treatment.

Rosacea Blepharoconjunctivitis Treated with a Novel Preparation of Dilute Povidone Iodine and Dimethylsulfoxide: a Case Report and Review of the Literature

Introduction

Povidone iodine (PVP-I) 10% aqueous solution is a commonly utilized anti-septic employed for sterilization of the ocular surface prior to interventional procedures. Dimethylsulfoxide (DMSO) is a well-known skin penetration agent scarcely utilized in ophthalmic drug formulations. We describe here a low-dose formulation of 1% PVP-I (w/w) in a gel containing DMSO for use in the setting of recalcitrant rosacea blepharoconjunctivitis. A review of the ocular uses of dimethylsulfoxide is also presented.

Case report

A 78-year-old male presented with chronic, long-standing blepharitis involving both the anterior and posterior lid margins. Posterior lid and skin inflammatory changes were consistent with ocular rosacea. Previous oral and topical therapies had been largely ineffective at controlling his condition.

Conclusion

The topical PVP-I/DMSO system was effective in abating the signs and symptoms of rosacea blepharoconjunctivitis. Further investigation of this novel agent is warranted.

Electronic supplementary material

The online version of this article (doi:10.1007/s40123-015-0040-4) contains supplementary material, which is available to authorized users.

Rapid and Effective Virucidal Activity of Povidone-Iodine Products Against Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and Modified Vaccinia Virus Ankara (MVA)

Introduction

Since the first case of Middle East Respiratory Syndrome coronavirus (MERS-CoV) infection was reported in 2012, the virus has infected more than 1300 individuals in 26 countries, and caused more than 480 deaths. Human-to-human transmission requires close contact, and has typically occurred in the healthcare setting. Improved global awareness, together with improved hygiene practices in healthcare facilities, has been highlighted as key strategies in controlling the spread of MERS-CoV. This study tested the in vitro efficacy of three formulations of povidone iodine (PVP-I: 4% PVP-I skin cleanser, 7.5% PVP-I surgical scrub, and 1% PVP-I gargle/mouthwash) against a reference virus (Modified vaccinia virus Ankara, MVA) and MERS-CoV.

Methods

According to EN14476, a standard suspension test was used to assess virucidal activity against MVA and large volume plating was used for MERS-CoV. All products were tested under clean (0.3 g/L bovine serum albumin, BSA) and dirty conditions (3.0 g/L BSA + 3.0 mL/L erythrocytes), with application times of 15, 30, and 60 s for MVA, and 15 s for MERS-CoV. The products were tested undiluted, 1:10 and 1:100 diluted against MVA, and undiluted against MERS-CoV.

Results

A reduction in virus titer of ≥4 log₁₀ (corresponding to an inactivation of ≥99.99%) was regarded as evidence of virucidal activity. This was achieved versus MVA and MERS-CoV, under both clean and dirty conditions, within 15 s of application of each undiluted PVP-I product.

Conclusion

These data indicate that PVP-I-based hand wash products for potentially contaminated skin, and PVP-I gargle/mouthwash for reduction of viral load in the oral cavity and the oropharynx, may help to support hygiene measures to prevent transmission of MERS-CoV.

Funding

Mundipharma Research GmbH & Co.

Electronic supplementary material

The online version of this article (doi:10.1007/s40121-015-0091-9) contains supplementary material, which is available to authorized users.

Enhancement of wound healing with roots of Ficus racemosa L. in albino rats

OBJECTIVE

To establish the wound healing activity of aqueous and ethanolic extract of roots of Ficus racemosa (F. racemosa).

METHODS

Two models were performed to evaluate the wound healing activity i.e. incision and excision models. In incision model the parameter which was carried out was breaking strength of wounded skin. In excision model percentage wound contraction and period of epithelialization were established for both the extracts. Reference standard drug was povidone iodine ointment for comparison with other groups.

RESULTS

From the observation in both two models, aqueous extract of F. racemosa was found to have greater wound healing activity in terms of breaking strength in incision model and percentage wound contraction, period of epithelialization in excision model than that of other groups.

CONCLUSIONS

In conclusion, our findings suggest that aqueous extract of F. racemosa possesses better wound healing ability than the ethanolic extract.

Bactericidal activity of 3 cutaneous/mucosal antiseptic solutions in the presence of interfering substances: Improvement of the NF EN 13727 European Standard?

OBJECTIVE

There is no standard protocol for the evaluation of antiseptics used for skin and mucous membranes in the presence of interfering substances. Our objective was to suggest trial conditions adapted from the NF EN 13727 standard, for the evaluation of antiseptics used in gynecology and dermatology.

METHODS

Three antiseptic solutions were tested in vitro: a chlorhexidine-benzalkonium (CB) combination, a hexamidine-chlorhexidine-chlorocresol (HCC) combination, and povidone iodine (P). The adaptation of trial conditions to the standard involved choosing dilutions, solvent, and interfering substances. The activity of solutions was assessed on the recommended strains at concentrations of 97% (pure solution), 50%, and 10% (diluted solution), and 1%. A logarithmic reduction ≥ 5 was expected after 60seconds of contact, to meet requirements of bactericidal activity.

RESULTS

HCC did not present any bactericidal activity except on P. aeruginosa at a concentration of 97%. P was not bactericidal on E. hirae at any concentration and on S. aureus at 97%. CB had the most homogeneous bactericidal activity with a reduction>5 log on the 4 bacterial strains at concentrations of 97%, 50% and 10%.

CONCLUSION

Adapting the NF EN 13727 standard allowed assessing the 3 tested solutions: only CB was bactericidal in dirty conditions. This study proved the possibility of validating antiseptic choice in vitro, in current practice conditions, for adjunctive treatment of skin and mucous membranes disorders, primarily of bacterial origin or with a potential of superinfection.

Efficacy and Physicochemical Evaluation of an Optimized Semisolid Formulation of Povidone Iodine Proposed by Extreme Vertices Statistical Design; a Practical Approach

One of the most significant issues in pharmaceutical industries, prior to commercialization of a pharmaceutical preparation is the "preformulation" stage. However, far too attention has been paid to verification of the software assisted statistical designs in preformulation studies. The main aim of this study was to report a step by step preformulation approach for a semisolid preparation based on a statistical mixture design and to verify the predictions made by the software with an in-vitro efficacy bioassay test. Extreme vertices mixture design (4 factors, 4 levels) was applied for preformulation of a semisolid Povidone Iodine preparation as Water removable ointment using different PolyEthylenGlycoles. Software Assisted (Minitab) analysis was then performed using four practically assessed response values including; Available iodine, viscosity (N index and yield value) and water absorption capacity. Subsequently mixture analysis was performed and finally, an optimized formulation was proposed. The efficacy of this formulation was bio-assayed using microbial tests in-vitro and MIC values were calculated for Escherichia coli, pseudomonaaeruginosa, staphylococcus aureus and Candida albicans. Results indicated the acceptable conformity of the measured responses. Thus, it can be concluded that the proposed design had an adequate power to predict the responses in practice. Stability studies, proved no significant change during the one year study for the optimized formulation. Efficacy was eligible on all tested species and in the case of staphylococcus aureus; the prepared semisolid formulation was even more effective.

Postsurgical contact dermatitis due to povidone iodine: a diagnostic dilemma

We present 7 cases of postsurgical contact dermatitis due to povidone iodine. The diagnosis was based on the clinical manifestations, the history of exposure, the site of the lesions, and the results of patch tests. This type of dermatitis can develop in the area of surgery or at distant sites exposed to povidone iodine during the surgical intervention. Patch tests with 10% povidone iodine in petrolatum were positive in all patients. Based on the results of the same tests in a control group, we recommend the use of petrolatum rather than water as the vehicle for the diagnosis of this form of contact dermatitis. Repeated open application tests with a commercially available solution of povidone iodine were negative. We conclude that the presence of the solution under occlusion during surgery is necessary both for the symptoms to develop and for the diagnosis to be made. This condition may be underdiagnosed.

Management of non-healable or maintenance wounds with topical povidone iodine

Although complete healing may appear to be the logical goal for most patients and clinicians, some wounds do not have the potential to heal due to a number of factors such as inadequate vasculature, coexisting medical conditions and medications that prohibit the healing process. Local management of wounds that are considered to have poor potential for healing remains elusive. The purpose of this article is to review the evidence that supports the use of topical antiseptic agents in non-healable wounds. Retrospective chart audit was conducted to evaluate the use of povidone iodine in the management of wounds that were deemed to have poor healing potential.

Pneumonia due to aspiration of povidine iodine after induction of general anesthesia -A case report-

Aspiration pneumonia is usually caused by aspiration of gastric contents during anesthesia. It causes severe pulmonary complications. Povidone iodine was used widely as an oral antiseptic. Although povidone iodine is thought to be a safe and effective antiseptic, severe complications from its aspiration may occur. We present a case of pneumonia secondary to aspiration of povidone iodine in a 16 year old female patient who underwent orofacial surgery. Aspiration pneumonia must be treated immediately. Mechanical ventilation with PEEP and periodical bronchial toilet with fiberoptic bronchoscopy were carried in the operating room and ICU. Bronchodilators, antibiotics, steroids and diuretics were also used to treat pneumonia. The patient was treated successfully without any complication.

Reducing surgical site infections: a review

Infection at or near surgical incisions within 30 days of an operative procedure contributes substantially to surgical morbidity and mortality each year. The prevention of surgical site infections encompasses meticulous operative technique, timely administration of appropriate preoperative antibiotics, and a variety of preventive measures aimed at neutralizing the threat of bacterial, viral, and fungal contamination posed by operative staff, the operating room environment, and the patient's endogenous skin flora. It is the latter aspect of contamination, and specifically mechanical methods of prevention, on which this review focuses.