A comparison of pre-operative bathing with chlorhexidine-detergent and non-medicated soap in the prevention of wound infection

Prevention of intraoperative wound contamination with chlorhexidine shower and scrub

In a prospective, controlled, clinical trial, we found that preoperative showering and scrubbing with 4% chlorhexidine gluconate was more effective than povidone-iodine or triclocarban medicated soap in reducing skin colonization at the site of surgical incision. Mean log colony counts of the incision site were one half to one log lower for patients who showered with chlorhexidine compared to those who showered with the other regimens. No growth was observed on 43% of the post shower skin cultures from patients in the chlorhexidine group compared with 16% of the cultures from patients who had povidone-iodine showers and 5% of those from patients who used medicated soap and water. The frequency of positive intraoperative wound cultures was 4% with chlorhexidine, 9% with povidone-iodine and 14% with medicated soap and water. This study demonstrates that chlorhexidine gluconate is a more effective skin disinfectant than either povidone-iodine or triclocarban soap and water and that its use is associated with lower rates of intraoperative wound contamination.

Preoperative whole body disinfection--a controlled clinical study

Preoperative whole body washing with chlorhexidine scrub was compared with soap for its effect on prevention of wound infection in clean surgery. Two thousand and fifteen patients were studied using chlorhexidine scrub, placebo or plain soap. The overall infection rate in the control and placebo groups was 12.8% (p less than 0.05) and 11.7% as opposed to 9% (p less than 0.05) in the treated group. Three per cent fewer infections were found in treated 'clean surgery' patients, and the incidence of Staphylococcus aureus infections was reduced from 6% (bar soap) to 3% (chlorhexidine). The saving in bed occupancy from prevention of infection is a significant cost-saving.

Preoperative skin preparation and surgical outcome

The use of antiseptics in surgery from Lister to the present day is described. A review of current procedures for preoperative preparation for surgery is given; and some data showing that the effect of chlorhexidine on skin flora is persistent is recorded.

Studies on perioperative skin flora

Chlorhexidine in spirit is used to reduce the skin bacterial load before surgery; and recently prewashing with chlorhexidine scrub has been advocated. We describe three studies on cardio-thoracic surgical patients--particularly those having coronary artery grafts with long leg and sternal wounds. Two studies compared prewashes with chlorhexidine scrub (Hibiscrub-ICI) or soap. Study Number One (250 patients per group) was of wound infections; and Number Two (25 patients per group) was of alterations in skin flora for 10 days postoperation. Chlorhexidine scrub failed to reduce overall wound infection rates in Study 1, although leg wounds healed more quickly with less inflammation. Study Two showed that the scrub had a significant effect on skin flora that lasted at least 3 days postoperation. Study Number Three was of 100 patients (no chlorhexidine scrub) examined for methicillin-resistant coagulase-negative staphylococci (MRSE) by cultures of swabs from the leg, sternum and chest drain site before and after operation on methicillin agar. Three per cent of patients had MRSE preoperation (1 doctor) and 23% postoperation. One thousand strains were tested by agar dilution against methicillin and chlorhexidine. MRSE had a 2-8-fold increased resistance to chlorhexidine compared to a greater than 256-fold to methicillin. Thus although chlorhexidine has a marked persistent effect on skin flora, emergence of major resistance is unlikely. Use of postoperative chlorhexidine should be investigated further.

Current thoughts on Staphylococcus epidermidis in vascular surgery

Staphylococcus epidermidis (CNS) is a major cause of infection in peripheral vascular surgery. It occurs as commonly in vascular prostheses as in orthopaedic, cardiac and neurosurgical implants. Greater awareness of the possible presence of CNS in initially indolent infections, particularly in the groin, is necessary. More rapid isolation and identification techniques to separate the contaminant from the pathogenic CNS are needed. It seems that better preoperative antiseptic care of vascular patients may reduce the tendency for even 24 h cephalosporin prophylaxis to encourage the emergence of resistant CNS strains.

The impact of preoperative skin disinfection on preventing intraoperative wound contamination

The efficacy of total body showering and incision site scrub with disinfectant agents was evaluated in a randomized, prospective study of 575 patients undergoing selected surgical procedures. Patients who showered twice with 4% chlorhexidine gluconate had lower mean colony counts of skin bacteria at the surgical incision site in the operating room prior to the final scrub than patients who showered twice with povidone-iodine solution or medicated bar soap. Patients in the chlorhexidine group had no growth on 43% of the incision site skin cultures compared with 16% in the povidone-iodine group and 6% in the soap and water group. Patients who showered and who were scrubbed with chlorhexidine also had lower rates of intraoperative wound contamination. Bacteria were recovered from the wounds of 4% of patients using this regimen compared with 9% for patients who used povidone-iodine and 15% for patients who showered with medicated soap and water and were scrubbed with povidone-iodine. We noted no difference in surgery-specific infection rates among patients in the three treatment groups; however, our sample sizes were too small to evaluate this outcome parameter adequately. These data suggest that preoperative showering and scrubbing with chlorhexidine is an effective regimen to reduce extrinsic intraoperative contamination of the surgical wound from skin bacteria. The efficacy of this regimen to prevent postoperative wound infection needs to be evaluated in a well-designed, carefully controlled prospective trial with adequate numbers of patients to achieve statistically valid conclusions.

A placebo-controlled trial of the effect of two preoperative baths or showers with chlorhexidine detergent on postoperative wound infection rates

The effect of preoperative whole-body washing with chlorhexidine detergent on the incidence of postoperative wound infection was assessed in a placebo-controlled trial of 1989 patients. Patients bathed or showered with chlorhexidine, placebo, or conventional bar soap, on two occasions in the 24 h before operation. The overall infection rate for patients treated with chlorhexidine was 9%, against 12.8% in the bar soap and 11.7% in the placebo groups; in the 'clean' surgery group infections were 7.2% against 10.2% and 10%, respectively. The Staphylococcus aureus infection rate in the 'clean' group was 3% for chlorhexidine against 6% for bar soap.

Skin as a source of nosocomial infection: directions for future research

Whereas infections of the skin per se comprise only a fraction of all institutionally-acquired infections, the skin has become one of the most important reservoirs of nosocomial pathogens in the hospital. Professor Noble has provided a scholarly review of the increasing importance of the major constituents of the cutaneous microflora as nosocomial pathogens and what we know of their epidemiology. Unfortunately, the empiricism and limited scientific data which underlie essential infection control measures in this area, particularly in regard to cutaneous antisepsis and handwashing, is almost incongruous in an era in which controlled clinical trials have dominated most other areas of medicine. The numerous outbreaks traced to contaminated antiseptics and disinfectants over the past two decades, stand as mute testimony to the inadequate investigative attention this area has received.

Prevention of wound infection following vasectomy

A prospective study on 90 patients undergoing vasectomy as day cases is reported. The use of a chlorhexidine gluconate bath or shower on day 1 and day 2 post-operatively reduced the wound infection rate from 37.8 to 6.7%. It is suggested, therefore, that this technique is an economical and successful way of reducing the incidence of infection in these patients.

Surgical scrub and skin disinfection

The role of pre-operative disinfection of the surgeon's hands and the skin of the operative site in the prevention of wound infection remains uncertain. The normal resident skin flora, consisting mainly of coagulase-negative staphylococci and aerobic and anaerobic diphtheroids, is an uncommon cause of infection except in prosthetic operations. Staphylococcus aureus is rarely a resident on normal skin other than the perineum, and is mostly present on the hands as a transient acquired from the nose. Nevertheless, it seems rational to kill or remove all transients on the hands of the surgeon and reduce residents to low levels. Surgical skin disinfection is usually assessed by measuring the reduction in organisms on the hands immediately after disinfection, after repeated applications of the disinfectant and after wearing gloves for two to three hours. The hands are commonly sampled in a bowl or plastic bag containing Ringer's or a similar solution and relevant neutralizers, or by the use of glove washings. A standardized technique is necessary to provide a statistical comparison between agents. Antiseptic detergents, chlorhexidine or povidone iodine show immediate reductions in bacterial counts of 70% to 80%, increasing to 99% after repeated application. Hexachloraphene and triclosan detergents show a lower immediate reduction but a good residual effect. Seventy percent ethyl or 60% propyl alcohol, with or without an antiseptic, show an immediate reduction of over 95%, and in excess of 99% on repeated application. Residual levels of organisms tend to be lower after repeated alcohol treatment than following the use of antiseptic detergents.(ABSTRACT TRUNCATED AT 250 WORDS)