Efficacy and safety of chlorhexidine vs. povidone-iodine for vaginal antisepsis in surgery: an updated systematic review and meta-analysis.

Background: Surgical site infections (SSIs) are significant postoperative complications in gynecologic and obstetric surgeries. Preoperative vaginal antisepsis is vital for prevention. This review compares the efficacy and safety of chlorhexidine gluconate (CHG) vs. povidone-iodine (PI) for vaginal antisepsis in preventing postoperative infections. Materials and Methods: A systematic search of major databases was conducted through 8 Ja-nuary 2025. Randomized controlled trials (RCTs) comparing CHG and PI for vaginal antisepsis during urogynecologic procedures were included. Meta-analyses were performed using random-effects models to estimate risk ratios (RRs) with 95% confidence intervals (CIs). The GRADE approach assessed the certainty of evidence. The primary outcome was SSIs; secondary outcomes included febrile morbidity, hospital stay, antiseptic-related side effects, and wound complications. Results: Twelve RCTs, including 4936 participants, were analyzed. The results showed that CHG significantly reduced compared to PI (RR: 1.71; 95% CI: 1.30-2.26; I 2 = 17%; high-certainty evidence). Subgroup analyses showed higher SSI risk with PI in upper/lower-middle-income countries (RR: 1.79; 95% CI: 1.17-2.74) and high-income countries (RR: 1.66; 95% CI: 1.08-2.56). PI was also associated with increased risks of superficial SSIs (RR: 1.57), deep SSIs (RR: 2.35), and readmissions (RR: 1.59). Conclusion: CHG was superior to PI in preventing SSIs in gynecologic and obstetric surgeries. With high-quality evidence supporting its use, CHG is recommended for vaginal preparation. Future research should explore cost-effectiveness and long-term outcomes.