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Prevention of Surgical Site Infection After Cesarean Delivery (CAPISSI)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT02027324
Recruitment Status : Withdrawn (Another study with similar methods was recently published)
First Posted : January 6, 2014
Last Update Posted : January 12, 2016
Information provided by (Responsible Party):
Arvind Palanisamy, MD, FRCA, Brigham and Women's Hospital

Brief Summary:
There are approximately 1.4 million cesarean deliveries in the United States each year, and an average of 1250 elective cesarean deliveries each year at the Brigham and Women's Hospital (BWH) in Boston, Massachusetts. Among cesarean deliveries performed at BWH, approximately 2% of patients are diagnosed with a surgical site infection (SSI). Because SSI is associated with significant morbidity and increased cost of care, numerous guidelines exist to guide preoperative administration of prophylactic antibiotics. However, there are no recommendations for the choice of antiseptic solution for prevention of SSI. Among the currently popular antisepsis preparations, chlorhexidine-alcohol (CA) is known to decrease SSI in non-obstetric surgeries. However, the time required for CA to dry (~ 3 min) to minimize flammability risk is disadvantageous in the setting of emergent cesarean delivery. Many institutions use povidone-iodine, another antisepsis preparation that does not require the mandatory drying time. Our randomized study aims to compare the incidence of SSI in patients receiving either CA or PI during elective cesarean delivery, and we hypothesize that CA would be associated with a lower incidence of SSI.

Condition or disease Intervention/treatment Phase
Surgical Site Infection Drug: Chlorhexidine-alcohol group Drug: Povidone-Iodine Group Not Applicable

Detailed Description:

This study will be conducted over three years with an estimated sample size of 4500 patients. Prior to enrollment of study subjects, each year will be divided into 3-month blocks and each block will be assigned one of the two study antiseptic solutions - 2% chlorhexidine gluconate in 70% isopropyl alcohol (CA) or 10% Povidone-Iodine (PI) - in an alternating manner. All patients undergoing elective cesarean deliveries during a block will receive the same preoperative skin preparation, in concordance with guidelines for its use. The block assignments will alternate within each year and the order will be reversed after one year to minimize or eliminate seasonal variation in skin infection rates. All patients will receive routine history and physical examination, blood tests, pre-procedure bathing instructions, and preoperative body hair clipping as desired by their primary obstetric provider. Age, body mass index (BMI), gestational age, history of smoking, previous abdominal surgery, number of pregnancies, and live births will be documented before entry into the study. Eligible patients will receive antibiotic prophylaxis with weight-based cefazolin within 60 min before skin incision. We will collect data on preoperative preparation of the surgical site (clipping vs. shaving), type of skin and uterine incision, method of fascia and skin closure, duration of the procedure, use of postoperative antibiotics, and adverse reactions to the skin preparation. The primary endpoint for this study will be any SSI diagnosed within 30 days of cesarean delivery. Our secondary outcomes will be the type of SSI (based on the Center for Disease Control infection classification) and the time to diagnosis of SSI.

The Infectious Disease department at BWH will perform the surveillance for SSI/endometritis. This team will be blinded to the choice of anti-sepsis preparation during the study period. Briefly, surveillance will include daily, weekly, monthly, and quarterly reviews of data. The infectious disease team will perform a daily review of microbiology results for positive wound and blood cultures, and assess whether the patient had cesarean section within 30 days prior to cultures. On a weekly basis, a report of obstetric patients readmitted within 30 days will be generated, and patients will be selected with an admitting diagnosis consistent with infection in the setting of a history of recent cesarean delivery. Each month, a report of patients will be generated with ICD-9 discharge code for cesarean section as well as ICD-9 codes for other complications of obstetrical surgical wound and major puerperal infection. Post-cesarean delivery patients receiving antibiotics for at least 2 days after the first postoperative day, and those that receive antibiotics during readmission will also be identified and recorded. During every quarter, the number of elective cesarean deliveries performed will be quantified, and the incidence of specific sub-types of SSI (superficial, deep, organ space/endometritis) will be documented. In addition to inpatient surveillance, the electronic clinic records for all patients will be reviewed, and data will be recorded for any SSI that is diagnosed and treated on an outpatient basis. Documentation from discharge to the six-week postpartum visit will be reviewed to ensure data fidelity, but only infections that occur within 30 days of cesarean delivery will be included in the final analyses. Active SSI will be treated according to prevailing guidelines.

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 0 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Prevention
Official Title: Chlorhexidine-Alcohol Vs. Povidone-Iodine for Prevention of Surgical Site Infection After Cesarean Delivery: A Randomized Trial
Study Start Date : June 2015
Estimated Primary Completion Date : February 2017
Estimated Study Completion Date : February 2017

Arm Intervention/treatment
Experimental: Chlorhexidine-alcohol group
2% chlorhexidine in 70% isopropyl alcohol in accordance with manufacturer's instructions for safe usage.
Drug: Chlorhexidine-alcohol group
2% chlorhexidine in 70% isopropyl alcohol in accordance with manufacturer's instructions for safe usage.
Other Name: Chloraprep

Experimental: Povidone-Iodine group
10% Povidone-iodine applied topically according to manufacturer's instructions
Drug: Povidone-Iodine Group
10% Povidone-Iodine for surgical antisepsis according to manufacturer's instructions.
Other Name: Betadine

Primary Outcome Measures :
  1. Incidence of Surgical Site Infection within 30 days of Cesarean Delivery [ Time Frame: At 3 years after first patient enrollment ]

Secondary Outcome Measures :
  1. Type of SSI (based on CDC classification) [ Time Frame: 3 years after initial enrollment ]
  2. Time to diagnosis of SSI [ Time Frame: 3 years after initial enrollment ]

Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years to 45 Years   (Adult)
Sexes Eligible for Study:   Female
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • All patients scheduled for elective cesarean delivery

Exclusion Criteria:

  • Allergy to either of the antiseptic preparations
  • Ongoing active skin or systemic infection
  • Pre-operative antibiotic therapy for non-surgical reasons
  • Those unable to receive antibiotic prophylaxis

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT02027324

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United States, Massachusetts
Brigham and Women's Hospital
Boston, Massachusetts, United States, 02115
Sponsors and Collaborators
Brigham and Women's Hospital
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Principal Investigator: Arvind Palanisamy, MD, FRCA Brigham and Women's Hospital
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Responsible Party: Arvind Palanisamy, MD, FRCA, Assistant Professor of Anaesthesia, Brigham and Women's Hospital Identifier: NCT02027324    
Other Study ID Numbers: 2013P002037
First Posted: January 6, 2014    Key Record Dates
Last Update Posted: January 12, 2016
Last Verified: January 2016
Keywords provided by Arvind Palanisamy, MD, FRCA, Brigham and Women's Hospital:
Surgical site infection
Cesarean delivery
Povidone iodine
Chlorhexidine alcohol
Additional relevant MeSH terms:
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Communicable Diseases
Surgical Wound Infection
Wound Infection
Postoperative Complications
Pathologic Processes
Anti-Infective Agents, Local
Anti-Infective Agents
Plasma Substitutes
Blood Substitutes