Chlorhexidine-Alcohol Versus Povidone-Iodine for Surgical Site Infection Prevention in Abdominal Surgery in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.

BACKGROUND

Surgical site infections remain disproportionately common in low- and middle-income countries (LMICs). We systematically reviewed and meta-analyzed evidence comparing chlorhexidine-alcohol (CHG-ALC) and povidone-iodine (PI) for preoperative skin antisepsis in abdominal surgery in LMICs.

METHODS

Following PRISMA guidelines, we searched PubMed, Scopus, Web of Science, and Lens.org from January 2015 to October 2025 for randomized trials and prospective cohort studies conducted in LMICs that compared CHG-ALC with PI and reported SSI outcomes after abdominal surgery. Because some eligible studies included mixed wound classifications, we performed a primary pooled analysis across eligible abdominal procedures and a pre-specified sensitivity analysis restricted to studies limited to clean-contaminated wounds. Study-level risk ratios (RRs) were pooled using a random effects model, and heterogeneity and publication bias were assessed using I2, τ2, Cochran's Q statistics, Egger's regression, and funnel plot-based methods.

RESULTS

Fifteen studies including 7459 patients were analyzed. Overall, CHG-ALC was associated with a lower risk of SSI than PI (RR = 0.61, 95% CI 0.46-0.80; p < 0.001; and I2 = 0%). This effect remained significant when the largest trial was excluded (RR = 0.58, 95% CI 0.46-0.71) and when analysis was restricted to studies enrolling only clean-contaminated wounds (RR = 0.59, 95% CI 0.45-0.77; I2 = 0%). Regional subgroup analysis showed consistent benefit in South Asia (RR = 0.58, 95% CI 0.46-0.71; I2 = 0%), whereas evidence in sub-Saharan Africa was inconclusive (RR = 0.88, 95% CI 0.35-2.21; I2 = 90.8%).

CONCLUSION

CHG-ALC appears more effective than PI for reducing SSI after abdominal surgery in LMICs overall, with the most consistent evidence observed in South Asia. However, evidence from sub-Saharan Africa remains limited and heterogeneous. These findings support context-specific implementation and the need for additional African trials focused on abdominal procedures and clearly defined wound classes.