TABLE 3.

State of the art and perspectives: use of PVP-I, CHG, and mupirocin for the preoperative decolonization of MRSA and prevention of SSIs^a

Antiseptic	Spectrum of activity	Activity against MRSA and mupirocin-resistant S. aureus	Bacterial resistance	Efficacy in surgical site infections
PVP-I	Broad spectrum, including Gram-positive bacteria, Gram-negative bacteria, actinobacteria, antiviral, antifungal, antiprotozoal, and antispore (23, 81)	• Biocidal against MSSA/MRSA within 15 to 60 s (39, 43, 45)	• Very limited occurrence of the induction of iodine resistance (37, 57, 58)	Preoperative intranasal PVP-I in orthopedic surgery:
		• Active against S. aureus regardless of the presence of antibiotic or antiseptic resistance (28, 39, 40, 42–44, 46)	• Does not induce cross-resistance to antibiotics (57, 58)	• Significantly reduced 30-day SSI rate in combination with topical CHG (1.1%) vs controls (3.8%); P = 0.02 (71)
				• Similar efficacy (6/842) to a 5-day course of intranasal mupirocin (14/855) in reducing 90-day deep SSI rate following surgery (fraction of surgeries with presence of deep SSI) (22)
Chlorhexidine	Broad spectrum, including activity against Gram-positive bacteria and some Gram-negative bacteria and limited activity against fungi (e.g., yeasts) and enveloped viruses (81)	• Biocidal against MRSA within 2 to 30 min (45)	• Several reports of the induction of CHG resistance but a low incidence in some studies (81, 84–90)	Preoperative topical CHG in orthopedic surgery:
		• Dual CHG and mupirocin-resistant MRSA rare but has been reported to cause decolonization failure (82)	• More common in MRSA than MSSA (91)	• 2% CHG no-rinse cloth reduced SSI rates from 3.19% to 1.59% when introduced into decolonization protocol in orthopedic surgery (93)
		• One study found that in mupirocin-resistant MRSA, the rate of qacA/B gene was 65% and smr gene was 71% (83)	• Reports of cross-resistance to antibiotics (92)	• No significant difference in incidence of SSI between topical 2% CHG (36 [0.954%] of 3,774) and topical 7.5% PVP-I (33 [1.036%] of 3,185; P = 0.728) (72)
Mupirocin	Broad antibacterial spectrum, including some Gram-positive bacteria (staphylococci and streptococci) and some Gram-negative bacteria (Haemophilus influenzae, Neisseria spp., and Branhamella catarrhalis) (94)	Active against MRSA after 12 h (47)	• Several reports of resistance (95–99)	Intranasal mupirocin in orthopedic surgery:
				• No significant difference in SSI rate between nasal mupirocin (3.8%) and placebo (4.7%) (100)
			• High-level resistance (MIC ≥512 μg/ml) associated with treatment failure (95)	Intranasal mupirocin in other surgery (gynecologic, neurologic, or cardiothoracic surgery):
			• Clinical significance of low-level resistance (MIC ≥8–256 μg/ml) unknown (95)	• No significant difference in S. aureus SSI rate between nasal mupirocin (2.3%) and placebo (2.4%) (101)

^aCHG, chlorhexidine gluconate; MRSA, methicillin-resistant S. aureus; MSSA, methicillin-sensitive S. aureus; PVP-I, povidone iodine; qac, quaternary ammonium compound; smr, streptomycin resistance gene; SSI, surgical site infection.