Surgical hand antisepsis to reduce surgical site infection

Improving Quality and Compliance of Surgical Hand Scrubbing Practices: A Clinical Audit

Background Surgical site infections (SSIs) are a critical concern in healthcare, particularly in developing countries, where they are among the most prevalent and challenging hospital-acquired infections. Adherence to proper hand hygiene practices is essential to prevent SSIs. However, compliance among surgical teams remains suboptimal due to factors such as time constraints, lack of training, and resource limitations. This study evaluates and enhances adherence to surgical hand scrubbing protocols at Osman Degna Teaching Hospital using World Health Organization (WHO) guidelines. Methods An observational cross-sectional audit was conducted in two cycles between August and October 2024, with 54 observations per cycle. Baseline adherence was assessed in the first cycle. Targeted interventions, including video demonstrations, hands-on training, and feedback, were implemented before the second cycle. Data were collected using a structured checklist and analyzed quantitatively to compare compliance rates and qualitatively to identify barriers to adherence. Results Compliance with hand scrubbing protocols improved significantly from 63.1% in the first cycle to 94.3% in the second. The most notable improvement (51.5%) was observed in rotational rubbing with clasped fingers. Other areas, including scrubbing palms and rinsing hands, showed substantial increases (30.3-42%). These findings highlight the effectiveness of structured training and feedback in enhancing adherence. Conclusion Targeted educational interventions significantly improved compliance with surgical hand scrubbing protocols, contributing to better infection control practices. While these improvements demonstrate the potential of training programs, continued efforts and long-term strategies are necessary to sustain progress and further reduce the risk of SSIs.

Evaluation of the efficacy of chlorhexidine-alcohol vs. aqueous/alcoholic iodine solutions for the prevention of surgical site infections: a systematic review and meta-analysis

BACKGROUND

Surgical site infection (SSI) is the prevailing complication that occurs after surgery and significantly escalates healthcare expenses. Published meta-analyses and international standards vary in their recommendations for the most effective preoperative skin antiseptic solution and concentration.

OBJECTIVE

The aim of this systematic review and meta-analysis is to assess the effectiveness of chlorhexidine-alcohol compared to aqueous/alcoholic iodine solutions in preventing postoperative surgical site infections.

METHODS

A systematic search was conducted using four electronic databases (PubMed, Embase, Scopus, and Cochrane Library) to select publications published in peer-reviewed journals. The risk ratio (RR) was calculated, along with their 95% confidence intervals. We assessed heterogeneity using Cochrane Q and I2 statistics and the appropriate P value. The analysis used RevMan 5.4.

RESULTS

The current meta-analysis includes 14 randomized controlled trials (RCTs) comparing either 2-2.5% chlorhexidine-alcohol with aqueous/alcoholic iodine. It was demonstrated that the CAG-using group had an overall lower incidence of postoperative surgical site infections compared to the iodine-using group (RR=0.30, 95% CI=0.20-0.46, I2 =95%, P <0.00001). It exhibits comparable efficacy across various surgical procedures, as evidenced by its RR of 0.25 [95% CI 0.15-0.41], I2 =51%, and P <0.0001 for general surgery, RR=0.47 [95% CI 0.32-0.67], I2 =82%, P =0.0002 for cesarean section and RR of 0.47 [95% CI 0.34-0.65], I2 =76% and P <0.00001 for additional surgical procedures, including neurosurgery, orthopedic surgery, etc.

CONCLUSION

This meta-analysis suggests using either 2.0-2.5% chlorhexidine in alcohol instead of aqueous, alcoholic iodine to prevent SSIs in adult patients undergoing surgery. Chlorhexidine in alcohol worked effectively for general surgery, cesarean sections, and other surgeries. Thus, preoperative skin cleansing with chlorhexidine-alcohol minimizes postoperative SSIs and bacterial colonization in diverse procedures.

Main Operating Room Versus Field Sterility in Hand Surgery: A Review of the Evidence

Introduction: Many of the guidelines that are generally accepted as main operating room best practices are not evidence based. They are based on the concept that if some sterility is good, more must be better. They are not derived from evidence-based sterility. Evidence-based sterility is the study of which of our various sterility practices increase or decrease our infection rates, as opposed to guidelines based on how many bacteria are in the operating room. Methods: This article adds the most important evidence we could find that is not included in the first paper on evidence-based sterility in hand surgery published in 2019. In this review, we also balance the evidence with common sense opinion. Results: The 21st century has seen a rapid rise in the number and reports of hand surgery procedures performed with field sterility outside the main operating room. There is now an abundance of good evidence to support that the rate of infection is not higher when many hand operations are performed with field sterility in minor procedure rooms. Conclusion: Moving hand surgery out of the main operating room to minor procedure rooms should be supported by healthcare providers. The higher cost, increased solid waste, and inconvenience of main operating room surgery are not justifiable for many procedures because it does not reduce the risk of postoperative infection.

Greener intravitreal injections: a narrative review

Healthcare services are significant contributors to climate change. Ophthalmology, by virtue of the volume of appointments and procedures it generates, is thought to play a major role in this regard. Intravitreal injections (IVI) are a commonly performed ophthalmological procedure to treat patients with conditions such as macular neovascularisation secondary to neovascular age-related macular disease or myopia, diabetic macular oedema, and retinal vein occlusions. As IVIs become more ubiquitous, addressing their environmental impact and sustainability will become increasingly important. Strategies to tackle carbon emissions from IVIs may target the following areas which align with the Greenhouse Gas Protocol scopes: building energy; water consumption; travel to appointments; manufacture and procurement of the drug and other necessary materials; and waste disposal. We propose a path towards a more sustainable approach for IVIs, and discuss its potential safety as well as the patient experience.

Hygiene practices and antibiotic resistance among dental and medical students: a comparative study

PURPOSE

Healthcare students' hand and smartphone hygiene is critical due to potential pathogenic and antibiotic-resistant bacteria transmission. This study evaluates hygiene practices in medical and dental students at Kuwait University, exploring antibiotic resistance gene prevalence.

METHODS

Swab samples were collected from the hands and smartphones of 32 medical and 30 dental students. These samples were cultured on Columbia Blood Agar and McConkey Agar plates to quantify bacterial colony-forming units (CFUs). The extracted DNA from these colonies underwent RT-PCR to identify antibiotic resistance genes, including tem-1, shv, blaZ, and mecA. Additionally, a questionnaire addressing hygiene practices was distributed post-sample collection.

RESULTS

Medical students exhibited more frequent hand hygiene compared to dental students (P ≤ 0.0001). Although significantly fewer bacterial CFUs were found on medical students' smartphones (mean = 35 ± 53) than dental students' (mean = 89 ± 129) (P ≤ 0.05), no significant differences were observed in CFU counts on their hands (medical: mean = 17 ± 37; dental: mean = 96 ± 229). Detection of at least one of the targeted antibiotic resistance genes on medical (89% hands, 52% smartphones) and dental students' (79% hands, 63% smartphones) was not statistically significant. However, the prevalence of two genes, tem-1 and shv, was significantly higher on medical students' hands (78% and 65%, respectively) than on dental students' hands (32% and 28%, respectively).

CONCLUSION

Clinically significant prevalence of antibiotic resistance genes were found on medical and dental students' hands and smartphones, emphasizing the importance of ongoing education regarding hand hygiene and smartphone disinfection. This continuous reinforcement in the curriculum is crucial to minimizing the risk of cross-contamination.

Implementing an Internal Audit: Evaluating Hand Scrub Compliance in a Tertiary Care Hospital

Background Aseptic protocol adherence and sterilization are the most important factors in a patient's satisfactory recovery after surgery. The standard hand scrubbing procedure helps control infection and keeps the surgical site clean by adhering to aseptic principles. Methods Thirty-six young residents and house officers participated in this prospective audit after ethical clearance was obtained. The World Health Organization (WHO) standard criteria were adhered to both before and after the intervention. Participants were observed in the surgical operation theatre (OT) without prior notice to ensure hand hygiene compliance before surgical procedures. The intervention included a video presentation as well as a live demonstration. Results Only 64.41% (n=23) of residents and house officers followed the recommended standard hand hygiene procedures before the intervention. This percentage rose to 93.92% (n=33) following the intervention, suggesting a noteworthy improvement. Conclusion Significant changes in the acceptance rates for the essential requirements of hand hygiene were observed after the evaluation in the second cycle. Adhering to WHO guidelines for procedures will help reduce the risk of infections and promote awareness of asepsis in practice.

"Water or not water: That is the question." Analysis of costs and consumption of the operating theaters in a greener perspective

OBJECTIVE

To compare the amounts of water and plastic used in surgical hand washing with medicated soaps and with alcohol-based products and to compare costs and consumption in a year, based on scheduled surgical activity.

METHOD

This retrospective study was carried out at Udine's Gynecology Operating Block from October to November 2022. We estimated the average amount of water with a graduated cylinder and the total cost of water usage based on euros/m3 indicated by the supplier; for each antiseptic agent we collected the data relevant to wash time, amount of water and product used per scrub, number of handscrubs made with every 500 mL bottle and cost of a single bottle. We put data into two hypothetical contexts, namely WHO guidelines and manufacturers' recommendations. Data were subjected to statistical analysis.

RESULTS

The daily amount of water using povidone-iodine, chlorhexidine-gluconate and alcohol-based antiseptic agents was 187.6, 140.7 and 0 L/day (P value = 0.001), respectively; A total of 69 000 L/year of water would be saved if alcohol-based products were routinely used. A single unit of an alcohol-based product allows three times as many handscrubs as any other product (P value = 0.001) with consequent reduction in plastic packaging.

CONCLUSION

Despite the cost saving being negligible, choosing alcohol-based handrub over medicated soap handrub - on equal antiseptic efficacy grounds - could lead to a significant saving of water and plastic, thus making our operating theaters more environmentally friendly.

Cell Phones in the OR: A Cross-Sectional Study of Norwegian Perioperative Nurses' Knowledge, Practice, and Attitudes

Few studies have focused on the use of cell phones in the OR. In Norway, researchers sought to assess perioperative nurses' knowledge, practice, and attitudes associated with cell phone use in the OR and distributed a nationwide questionnaire via a social media platform. More than 80% of the 332 respondents thought that cell phones were contaminated and that pathogens could contaminate hands. Almost all respondents brought their phone to work; approximately 61% of respondents carried it in their pocket in the OR. Responses to questions about phone cleaning showed that 39 (11.7%) of the respondents routinely cleaned their phone before entering the OR and 33 (9.9%) of the respondents cleaned it when leaving the OR. Less than 20% of respondents indicated their facility had guidelines for cleaning personal cell phones. Opportunities for improvement in cell phone cleaning in ORs exist and additional research involving all perioperative team members is needed.

[Bacterial contamination of autologous blood in reinfusion in neurosurgery: a phenomenon or a problem?]

There is a problem of bacterial contamination of autologous blood despite long-term experience of intraoperative blood salvage and reinfusion.

OBJECTIVE

To analyze safety of blood reinfusion with white blood cell filtration and X-ray irradiation for blood decontamination in neurosurgery.

MATERIAL AND METHODS

The study included 57 patients with various neurosurgical diseases. We used intraoperative blood reinfusion in all patients considering high predictable risk of major blood loss due to neurosurgical diseases, features of neoplasm topography, anamnesis and examination data. Microbiological examination of autologous blood was carried out at different stages before reinfusion.

RESULTS

Bacterial contamination of autologous blood samples was observed in 42% of patients. Enlargement of surgical access to paranasal sinuses in patients with craniofacial lesions poses a potential risk of bacterial contamination of autologous blood. Additional methods of decontamination including white blood cell filtration and X-ray irradiation reduced bacterial load. The above-mentioned methods were less effective for decontamination of microflora not typical for human skin compared to saprophytic ones. There were no postoperative infectious complications.

CONCLUSION

Combination of white blood cell filtration and X-ray irradiation reduces bacterial contamination and increases safety of reinfusion although these methods do not completely free autologous blood from opportunistic microorganisms. Decontamination quality significantly depended on microflora and surgical approach.

Hand Scrubbing and Donning of Sterile Surgical Gloves: An Observational Clinical Audit of Novice Dental Surgeons

Background The most critical factors in the satisfactory recovery of a patient post-surgery are obedience to sterilization and aseptic protocol. Using aseptic principles, the standard hand scrubbing and gloving procedure prevents contamination of the surgical site and aids in infection control.  Methods Eighty dental interns were observed during minor oral surgical procedures for hand scrubbing and donning sterile surgical gloves, following the steps and guidelines provided by World Health Organization (WHO). The dental interns were evaluated, and in order to enhance their understanding of hand scrubbing and donning surgical gloves, desensitization programs were conducted through lectures using PowerPoint presentations. After one week, the participants were observed and evaluated again. This program made the participants aware of asepsis and infection control in clinical practice. Results Prior to intervention, only 37.14% of young dental surgeons performed proper conventional hand hygiene practices. After the intervention, this percentage increased to 62.142%, indicating a significant improvement. Regarding the donning of sterile surgical gloves, 43.75% of participants followed the standard steps before the intervention. After the intervention, the percentage raised to 86.25% indicating substantial growth. Conclusion Observations before and after the evaluation demonstrated significant changes in the acceptance rates for the fundamental criteria of hand hygiene and donning sterile surgical gloves. Adhering to both procedures according to WHO guidelines will help to reduce the risk of infections and raise awareness about asepsis in the practice among young dental surgeons.

Surgical site infection trends in community hospitals from 2013 to 2018

OBJECTIVE

Sparse recent data are available on the epidemiology of surgical site infections (SSIs) in community hospitals. Our objective was to provide updated epidemiology data on complex SSIs in community hospitals and to characterize trends of SSI prevalence rates over time.

DESIGN

Retrospective cohort study.

METHODS

SSI data were collected from patients undergoing 26 commonly performed surgical procedures at 32 community hospitals in the southeastern United States from 2013 to 2018. SSI prevalence rates were calculated for each year and were stratified by procedure and causative pathogen.

RESULTS

Over the 6-year study period, 3,561 complex (deep incisional or organ-space) SSIs occurred following 669,467 total surgeries (prevalence rate, 0.53 infections per 100 procedures). The overall complex SSI prevalence rate did not change significantly during the study period: 0.58 of 100 procedures in 2013 versus 0.53 of 100 procedures in 2018 (prevalence rate ratio [PRR], 0.84; 95% CI, 0.66-1.08; P = .16). Methicillin-sensitive Staphylococcus aureus (MSSA) complex SSIs (n = 480, 13.5%) were more common than complex SSIs caused by methicillin-resistant S. aureus (MRSA; n = 363, 10.2%).

CONCLUSIONS

The complex SSI rate did not decrease in our cohort of community hospitals from 2013 to 2018, which is a change from prior comparisons. The reason for this stagnation is unclear. Additional research is needed to determine the proportion of or remaining SSIs that are preventable and what measures would be effective to further reduce SSI rates.

Sustainable Hand Surgery: Incorporating Water Efficiency Into Clinical Practice

Introduction Public health and well-being outcomes are intimately connected with the health of our planet. Climate change has numerous far-reaching effects. Managing and mitigating these risks to human health presents one of the next challenges to global healthcare. The current usage of planetary resources is unsustainable. Surgical procedures are particularly resource-intensive, often utilising vast amounts of single-use consumables, like water. In the last 100 years global usage of fresh water has increased six-fold and continues to rise by 1% year on year. It is well established that initial hand sterilization and maintenance of hand sterility during the surgical list are essential for preventing hospital-acquired infections and associated morbidity and mortality. This study aims to estimate the current daily water usage of two typical hand surgery lists from a District General Hospital in North Wales, to determine potential water savings by switching exclusively to an alcohol-based hand rub for subsequent scrubs, in line with current national guidelines. Methods Observational study estimation of water consumption from a temperature-controlled manual tap required using a 1 litre volumetric jug where the time taken to fill was recorded. Three separate observational samples were taken, and a mean was calculated. This mean determined the amount of water dispensed from the tap in a standard 3 min scrub and subsequent 1 min scrub. Two different theatre schedules were analysed: 1. A trauma list (five cases) and 2. A higher volume minor elective procedure schedule (16 cases), in this case a wide-awake local anaesthetic no tourniquet (WALANT) carpal tunnel release (CTR). Results Each case regardless of procedure had approximately three persons scrubbed. 20.57L of water is used for one person to scrub for 3 mins and an extra 6.8574L for each subsequent 1 min scrub. Therefore, current daily water consumption could reach 143.99L during the major hand trauma list and 411.4L during a high-volume carpal tunnel release list. Conclusion Simply following current guidelines by switching to alcohol-based hand rub just for subsequent scrubs could reduce water consumption by 57.2% for hand trauma lists and 70.2% for high-volume CTR lists.

Donning Sterile Surgical Gloves - A Prospective Clinical Audit of Young Surgeons at a Tertiary Care Hospital of Lahore, Pakistan

Background Sterilization and aseptic surgical techniques are the most important keys to successful postoperative outcomes. The standard surgical gloving technique causes early wound healing and reduces morbidity and mortality. Objective To assess the standard technique of donning sterile surgical gloves while scrubbing among young surgeons. Material and Methods This two-week prospective audit involved 60 young residents and house officers after ensuring ethical implications. Participants were observed unannounced for donning sterile surgical gloves in the surgical operation theatre (OT) according to the standard criteria set by World Health Organization (WHO) before and after the relevant intervention. The intervention was made through a clinical lecture, live demonstration, and hands-on sessions. After a detailed literature study, a pro forma was generated to record participants' compliance with 14 steps of donning sterile surgical gloves. Data was sent to a statistician for descriptive analysis. Results About 72.14% of the participants followed the standard criteria of donning sterile surgical gloves before intervention. This percentage raised to 90.71% after the intervention, showing marked improvement. Conclusion Pre-intervention and post-intervention observations showed apparent differences in compliance rates for the standard criteria of donning sterile surgical gloves. This scientific study signifies the need for such clinical audits to boost standard surgical practices, especially among newcomers.

Pre-surgical hand preparation in veterinary practice

The objective of this paper is to review the evidence for different methods of surgical hand preparation applicable to veterinary practice. Surgical hand preparation is an essential step in performing surgery as a veterinarian. Recommended protocols and products for surgical hand preparation have varied since its inception in the late 1800s. Many factors must be considered when assessing the efficacy, safety, and users' compliance with any available product. Traditional scrub methods employing chlorhexidine gluconate or povidone-iodine have been compared to alcohol-based rub protocols with respect to immediate and prolonged efficacy, safety, compliance, requirements for theatre furniture, cost and water usage. Although much of the comparative data has been generated in human medical facilities, extrapolation of the data to veterinary surgery is appropriate. Considerations for veterinary practice are specifically discussed. Overall, the benefits of alcohol-based rubs indicate that this should be the preferred method of pre-surgical hand preparation for veterinarians in all types of practice.

Penile implant surgery-managing complications

Penile prosthesis surgery represents the end-stage treatment for erectile dysfunction. It is conventionally used only in cases of erectile dysfunction refractory to pharmacological treatments or vacuum constriction devices. Contemporary literature suggests that penile prothesis surgery is associated with a high satisfaction rate and a low complication profile. However, it must be appreciated that the complications of surgery can have devastating consequences on a patient’s quality of life and satisfaction and include infection, prosthesis malfunction, penile corporal perforation and penile length loss. Several factors – such as appropriate patient selection, methodical preoperative assessment and patient optimization, specific intraoperative protocols and postoperative recommendations – can reduce the risk of surgical complications. This narrative review discusses the diagnosis and management of both intraoperative and postoperative complications of penile prosthesis surgery.

Use of Vancomycin Mixed Bone Graft and Vancomycin Mixed Saline Wash Before Wound Closure Reduces the Rate of Infection in Lumbar Spine Fusion Surgery

This study aims to evaluate whether surgical site vancomycin mixed in bone grafts and local vancomycin mixed in normal saline wash before wound closure decrease the infection rates in patients undergoing lumbar spinal instrumentation and posterolateral fusion. A retrospective study was performed on cases between 2017 and 2019, who underwent lumbar spine instrumentation and posterolateral fusion for lumbar canal stenosis or listhesis. The routine prophylactic procedures were performed in all patients as per institutional protocol. Patients' records were analysed and categorised into two groups, the vancomycin group (VG), where vancomycin mixed in bone graft and normal saline wash was used at the surgical site, and the control group (CG), where vancomycin was not used. The study included 63 patients, 31 in VG and 32 in CG. There is no statistical difference in age, sex, and diabetes mellitus in both groups. A total of seven cases were infected, six in CG (6/32) and one in VG (1/31). Out of six infections in CG, three patients had diabetes and four infected cases underwent surgery for debridement. In VG, the only single case got infected and treated with intravenous antibiotics. We found that the use of vancomycin added to the bone graft and normal saline in posterior lumbar spinal instrumentation and posterolateral fusion is associated with significantly lower rates of infection (p value=0.049).

Surgical handwashing practices of operating room staff: An observational study

OBJECTIVE

This descriptive and cross-sectional study aims to assess the surgical handwashing practices of operating room staff.

DESIGN

Single-blind study.

METHODS

The study was conducted with 66 staff (surgeons and operating room nurses) employed in the surgery department of a university hospital in Turkey. Data were collected using a Staff Information Form prepared in light of the literature to collect the participants' sociodemographic data and the Surgical Hand Washing Procedure Checklist developed according to the guidelines of the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO) and Association of Surgical Technologists (AST). The staff assigned to operating rooms were identified, and then, their surgical handwashing practices were observed by one of the researchers.

FINDINGS

Of the participants, 77.3% were dressed suitable to the operating room field, 56.1% appropriately wet both of their hands and forearms, and 72.7% used a sufficient amount of antiseptic solution (3-5 ml) in their palms. More than half of them (51.5%) inappropriately performed the procedure of surgical handwashing (applying an antiseptic solution to hands and arms with circular motions, starting from the fingertips up to 3-5 cm above their elbows for a minute), and 47% incorrectly performed the procedure of rinsing hands and arms while keeping the hands above the elbows under running water and passing arms through the water in one direction during this process.

CONCLUSION

In the study, it was determined that none of the team members completed the preparation, application and drying steps of the surgical handwashing procedure. Therefore, it is necessary to make arrangements that will facilitate the handwashing procedures of the personnel. Personnel-related problems, such as the duration of washing and drying methods, are possible to be avoided with periodic in-service training and with posters demonstrating the washing stages, which might lead to behavioural changes.

Current concepts in the prevention, diagnosis and treatment of fracture-related infection (FRI)

Fracture-related infection (FRI) is one of the most challenging complications following operative management of fractures. It can have profound implications for the patient, can be associated with considerable morbidity and often lead to impaired outcomes. There are significant healthcare-related costs. In recent years, there has been significant progress towards developing preventative strategies. Furthermore, diagnostic algorithms and management protocols have recently been reported. Lack of a strong evidence base has previously hindered efforts to implement these and develop established standards of care. There are multiple aspects of care that need to be considered and a multi-disciplinary approach is recommended. In this narrative review, we present the most up-to-date recommendations in the prevention, diagnosis and management of FRI.

Is sterile exposure in perianal procedures necessary? A single-institution experience and results from a national survey

BACKGROUND

Surgical site infections (SSI) are the most common postoperative complications. To minimize the risk of SSI, there is a strict asepsis policy in the operating theatre. The aim of this study was to evaluate the risk and cost-saving benefit of performing perianal surgery in a non-sterile setting.

METHODS

All patients who had perianal surgery at our institution between January 2014 and December 2017 in a sterile (S) or non-sterile (NS) setting for an infectious or non-infectious cause were included. The primary outcome was the 30-day SSI rate. The secondary outcome was the reintervention rate. A questionnaire was sent to surgeons in the Netherlands to assess current policy with regard to asepsis in perianal procedures. Finally, a cost analysis was performed.

RESULTS

In total, 376 patients were included. The rate of SSI in infectious procedures was 13% (S) versus 14% (NS, p = 0.853) and 5.1% (S) versus 0.9% (NS) in non-infectious procedures (p = 0.071). Reintervention rates in infectious procedures were 3.4% (S) versus 8.6% (NS, p = 0.187) and 1.3% (S) versus 0.0% (NS) in non-infectious procedures (p = 0.227). The questionnaire revealed that most surgeons perform perianal surgery in a sterile setting although they did not consider this useful. The potential national cost-saving benefit of a non-sterile setting is €124.61 per patient.

CONCLUSIONS

This study suggests that it is safe to perform perianal surgery in a non-sterile setting with regard to the SSI and reintervention rate. Adjustment of the current practice will contribute to a reduction in healthcare expenses.

The Prevention of Periprosthetic Joint Infection in Primary Total Hip Arthroplasty Using Pre-Operative Chlorhexidine Bathing

Periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is a devastating complication. The aim of this study was to investigate whether preoperative bathing using chlorhexidine gluconate (CHG) before THA can effectively reduce the postoperative PJI rate. A total of 933 primary THA patients, with the majority being female (54.4%) were included in the study. Primary THA patients who performed preoperative chlorhexidine bathing were assigned to the CHG group (190 subjects), and those who did not have preoperative chlorhexidine bathing were in the control group (743 subjects). The effects of chlorhexidine bathing on the prevention of PJI incidence rates were investigated. Differences in age, sex, and the operated side between the two groups were not statistically significant. Postoperative PJI occurred in four subjects, indicating an infection rate of 0.43% (4/933). All four infected subjects belonged to the control group. Although the PJI cases were significantly more in the control group than in the CHG group, statistical analysis revealed no statistical significance in the risk of PJI occurrence between the two groups (p = 0.588). Preoperative skin preparation by bathing with a 2% chlorhexidine gluconate cleanser did not produce significant effects on the prevention of postoperative PJI in primary THA.

Hand hygiene for the prevention of infections in neonates

BACKGROUND

Annually, infections contribute to approximately 25% of the 2.8 million neonatal deaths worldwide. Over 95% of sepsis-related neonatal deaths occur in low- and middle-income countries. Hand hygiene is an inexpensive and cost-effective method of preventing infection in neonates, making it an affordable and practicable intervention in low- and middle-income settings. Therefore, hand hygiene practices may hold strong prospects for reducing the occurrence of infection and infection-related neonatal death.

OBJECTIVES

To determine the effectiveness of different hand hygiene agents for preventing neonatal infection in community and health facility settings.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 5), in the Cochrane Library; MEDLINE via PubMed (1966 to 10 May 2019); Embase (1980 to 10 May 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 10 May 2019). We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials. Searches were updated 1 June 2020.

SELECTION CRITERIA

We included RCTs, cross-over trials, and quasi-RCTs that included pregnant women, mothers, other caregivers, and healthcare workers who received interventions within the community or in health facility settings DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane and the GRADE approach to assess the certainty of evidence. Primary outcomes were incidence of (study author-defined) suspected infection within the first 28 days of life, bacteriologically confirmed infection within the first 28 days of life, all-cause mortality within the first seven days of life (early neonatal death), and all-cause mortality from the 8th to the 28th day of life (late neonatal death).

MAIN RESULTS

Our review included five studies: one RCT, one quasi-RCT, and three cross-over trials with a total of more than 5450 neonates (two studies included all neonates but did not report the actual number of neonates involved). Four studies involved 279 nurses working in neonatal intensive care units and all neonates on admission. The fifth study did not clearly state how many nurses were included in the study. Studies examined the effectiveness of different hand hygiene practices for the incidence of (study author-defined) suspected infection within the first 28 days of life. Two studies were rated as low risk for selection bias, another two were rated as high risk, and one study was rated as unclear risk. One study was rated as low risk for allocation bias, and four were rated as high risk. Only one of the five studies was rated as low risk for performance bias. 4% chlorhexidine gluconate (CHG) compared to plain liquid soap We are uncertain whether plain soap is better than 4% chlorhexidine gluconate (CHG) for nurses' skin based on very low-certainty evidence (mean difference (MD) -1.75, 95% confidence interval (CI) -3.31 to -0.19; 16 participants, 1 study; very low-certainty evidence). We identified no studies that reported on other outcomes for this comparison. 4% chlorhexidine gluconate compared to triclosan 1% One study compared 1% w/v triclosan with 4% chlorhexidine gluconate and suggests that 1% w/v triclosan may reduce the incidence of suspected infection (risk ratio (RR) 1.04, 95% CI 0.19 to 5.60; 1916 participants, 1 study; very low-certainty evidence). There may be fewer cases of infection in the 1% w/v triclosan group compared to the 4% chlorhexidine gluconate group (RR 6.01, 95% CI 3.56 to 10.14; 1916 participants, 1 study; very low-certainty evidence); however, we are uncertain of the available evidence. We identified no study that reported on all-cause mortality, duration of hospital stay, and adverse events for this comparison. 2% CHG compared to alcohol hand sanitiser (61% alcohol and emollients) We are uncertain whether 2% chlorhexidine gluconate reduces the risk of all infection in neonates compared to 61% alcohol hand sanitiser with regards to the incidence of all bacteriologically confirmed infection within the first 28 days of life (RR 2.19, 95% CI 1.79 to 2.69; 2932 participants, 1 study; very low-certainty evidence) in the 2% chlorhexidine gluconate group, but the evidence is very uncertain.   The adverse outcome was reported as mean visual scoring on the skin. There may be little to no difference between the effects of 2% CHG on nurses' skin compared to alcohol hand sanitiser based on very low-certainty evidence (MD 0.80, 95% CI 0.01 to 1.59; 118 participants, 1 study; very low-certainty evidence). We identified no study that reported on all-cause mortality and other outcomes for this comparison. None of the included studies assessed all-cause mortality within the first seven days of life nor duration of hospital stay.  AUTHORS' CONCLUSIONS: We are uncertain as to the superiority of one hand hygiene agent over another because this review included very few studies with very serious study limitations.

Surgical hand hygiene and febrile urinary tract infections in endourological surgery: a single-centre prospective cohort study

Surgical hand hygiene reduces the risk of surgical site infections (SSIs). SSIs are not considered an issue in endourological surgery, whereas febrile urinary tract infections (f-UTIs) and urological sepsis are becoming problematic. We wondered whether surgical hand hygiene is necessary for endourological surgery. Therefore, we aimed to evaluate the influence of surgical hand hygiene on f-UTI onset in endourological surgery by comparing procedures in which surgical hand hygiene with double gloving was used with those in which regular hand hygiene with double gloving was used between April 2016 and July 2020. In this prospective cohort study of 477 patients who underwent endourological surgeries, surgeons in the surgical hand hygiene and regular hygiene groups performed surgery on 259 and 218 patients, respectively. There was no significant difference in patient background, and multivariate analyses revealed no significant differences in f-UTI onset (odds ratio, 0.87; p = 0.74) between the two groups. In conclusion, regular hand hygiene with double gloving may be considered an alternative to surgical hand hygiene to prevent endourological f-UTIs, which could alter operational protocols for endourological surgery. Further studies are needed to validate our findings.

Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining

A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.

SBA 2020: Regional anesthesia safety recommendations update

The purpose of the Brazilian Society of Anesthesiology (SBA)’s Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

Surgical hand rubbing versus surgical hand scrubbing: Systematic review and meta-analysis of efficacy

BACKGROUND

Surgical hand rubbing (SHR) and surgical hand scrubbing (SHS) are two common methods used by surgeons to reduce surgical site infections. To date, the optimal method that can effectively reduce these infections remains unknown. In this study, we performed a comprehensive statistical analysis to compare the efficacy of these two methods in effectively controlling surgical site infections.

METHODS

A systemic review and meta-analysis was performed by mining literature from major databases, including Pubmed, Embase, Cochrane library, Ovid and Google Scholar, and recruiting studies published between 1980 and 1st April 2019. Analysis was performed using Revman, version 5.3, software, and focused on primary outcomes that included colony-forming unit (CFU) counts and logarithmic reduction of CFU after hand antisepsis and after surgery.

RESULTS

Seven clinical trials met our inclusion criteria, with a total of 764 healthcare workers analyzed. We found no statistically significant differences between the two methods with regards to CFU counts and logarithmic reduction of CFU after hand antisepsis and surgery, as well as antisepsis and surgery times.

CONCLUSION

From the literature, it was evident that SHR had similar efficacy to SHS, without necessarily increasing costs. Owing to advantages such as ease of application, exposure to less dermal irritation, and less time consumption, SHR is recommended as a cost-effective alternative for management of surgical site infections.

Association Between Eliminating Water From Surgical Hand Antisepsis at a Large Ophthalmic Surgical Hospital and Cost

Importance

Alcohol-based surgical scrub is recommended for presurgical antisepsis by leading health organizations. Despite this recommendation, water-based scrub techniques remain common practice at many institutions.

Objective

To calculate the potential financial savings that a large, subspecialty ophthalmic surgical center can achieve with a conversion to waterless surgical hand preparation.

Design, Setting, and Participants

A review of accounting records associated with the purchase of scrubbing materials and water company invoices was conducted to assess direct costs attributable to water consumption and scrub materials for brushless, alcohol-based surgical scrub and water-based presurgical scrub. The flow rate of scrub sinks to estimate water consumption per year was tested. Savings associated with operating room (OR) and personnel time were calculated based on the prescribed scrub times for waterless techniques vs traditional running-water techniques. The study was conducted from January 5 to March 1, 2019.

Main Outcomes and Measures

The primary outcomes for this study were the quantity of water consumed by aqueous scrubbing procedures as well as the cost differences between alcohol-based surgical scrub and water-based scrub procedures per OR per year.

Results

Scrub sinks consumed 15.9 L of water in a 2-minute period, projecting a savings of 61 631 L and $277 in water and sewer cost per operating room per year. Alcohol-based surgical scrub cost $1083 less than aqueous soap applied from wall-mounted soap dispensers and $271 less than preimpregnated scrub brushes per OR per year in supply costs. The decrease in scrub time from adopting waterless scrub technique could save between approximately $280 000 and $348 000 per OR per year.

Conclusions and Relevance

Adopting waterless scrub techniques has the potential for economic savings attributable to water. Savings may be larger for surgical facilities performing more personnel-intensive procedures.

Understanding the factors involved in determining the bioburdens of surgical masks

Background

Surgical site infection (SSI) continues to be one of the most common postoperative complications. In our previous study, surgical mask (SM) bioburden was identified to be a potential source of SSI. In the present study, we investigated the factors involved in SM bioburden.

Methods

Bioburdens of the disposable SM (A: medical mask; B: medical surgical mask) and newly laundered cloth SM (C) were tested by immediately making an impression of the external surface of the mask on sterile culture media. SM microstructure was observed using a scanning electron microscope (SEM). Filtering efficiency and airflow resistance were evaluated with TSI Automated Filter Tester 8130 (TSI Incorporated) according to GB/19083-2010. Whether speaking during operation and washing the face pre-operatively affect SM bioburdens was also evaluated. Surgical procedures were performed in a dynamic operation room. Fifty cases of mask use were enrolled in this study.

Results

The bioburden of mask A was the highest. The bioburden of mask B was the lowest. Mask C possessed the lowest filtering efficiency and the highest airflow resistance. SM bioburden was higher in the speaking group. SM bioburden showed no significant difference after washing the face, despite the finding that washing could significantly reduce facial bioburden.

Conclusions

Multiple factors influence SM bioburdens. Mask B showed the lowest bioburden and best protection effects. Mask C is not recommended to be used, especially considering that surgeons do not wash the cloth masks daily. Unnecessary talking during operation is not recommended, and washing the face before surgery is not strictly necessary.

APSIC guidelines for the prevention of surgical site infections

Background

The Asia Pacific Society of Infection Control (APSIC) launched the APSIC Guidelines for the Prevention of Surgical Site Infections in 2018. This document describes the guidelines and recommendations for the setting prevention of surgical site infections (SSIs). It aims to highlight practical recommendations in a concise format designed to assist healthcare facilities at Asia Pacific region in achieving high standards in preoperative, perioperative and postoperative practices.

Method

The guidelines were developed by an appointed workgroup comprising experts in the Asia Pacific region, following reviews of previously published guidelines and recommendations relevant to each section.

Results

It recommends that healthcare facilities review specific risk factors and develop effective prevention strategies, which would be cost effective at local levels. Gaps identified are best closed using a quality improvement process. Surveillance of SSIs is recommended using accepted international methodology. The timely feedback of the data analysed would help in the monitoring of effective implementation of interventions.

Conclusions

Healthcare facilities should aim for excellence in safe surgery practices. The implementation of evidence-based practices using a quality improvement process helps towards achieving effective and sustainable results.

Best products for skin antisepsis

Application of antiseptic products to the skin plays an important role in prevention of a variety of health care-associated infections. Preoperative bathing or showering is widely recommended to reduce the risk of surgical site infections. Evidence of the impact of this measure on surgical site infection rates is mixed, and further prospective trials comparing standardized protocols for showering with plain soap or chlorhexidine gluconate (CHG)-containing soap, or bathing with 2% CHG-impregnated cloths are needed to establish the most effective approach. Current evidence favors the use of alcohol-containing solutions, often containing CHG or povidone-iodine, for surgical site preparation of the skin. Preparation of vaginal mucosa prior to gynecologic surgery may be performed using either povidone-iodine or CHG. Surgical hand antisepsis can be performed by scrubbing with an antimicrobial soap or by handrubbing using an alcohol-based handrub. Addition of CHG to alcohol-based handrubs intended for surgical hand antisepsis is not necessary if they meet recommended efficacy criteria. Daily CHG bathing of intensive care unit patients has been shown to reduce a variety of health care-associated infections, most commonly bloodstream infections (BSIs). Achieving and maintaining optimum application protocols may be challenging, suggesting the need for ongoing staff education, monitoring, and feedback. Additional studies are needed to determine the impact of daily CHG bathing of non-intensive care unit patients. Alcoholic CHG is currently the preferred antiseptic for skin preparation prior to insertion of central and arterial intravascular catheters. CHG-impregnated dressings have been shown to reduce catheter-associated BSI. Because of the widespread use of antiseptics, especially CHG, surveillance for emergence of increased tolerance or resistance is warranted. Antiseptics are applied to the skin for a variety of purposes in health care. Common scenarios in which topical antiseptics are used include preoperative bathing, surgical site preparation, surgical hand hygiene, daily bathing of intensive care unit patients, and prevention of intravascular catheter-associated BSI. The purpose of this article is to review recent evidence regarding the best products for skin antisepsis.

Penile Prosthesis Infection: Myths and Realities

Penile prosthesis infection is the most significant complication following prosthesis implant surgery leading to postoperative morbidity, increased health care costs, and psychological stress for the patient. We aimed to identify risk factors associated with increased postoperative penile prosthesis infection. A review of the literature was performed via PubMed using search terms including inflatable penile prosthesis, penile implant, and infection. Articles were given a level of evidence score using the 2011 Oxford Centre for Evidence-Based Medicine Guidelines. Multiple factors were associated with increased risk of post-prosthesis placement infection (Level of Evidence Rating) including smoking tobacco (Level 1), CD4 T-cell count <300 (Level 4), Staphylococcus aureus nasal carriage (Level 2), revision surgery (Level 2), prior spinal cord injury (Level 3), and hemoglobin A1c level >8.5 (Level 2). Factors with no effect on infection rate include: preoperative cleansing with antiseptic (Level 4), history of prior radiation (Level 3), history of urinary diversion (Level 4), obesity (Level 3), concomitant circumcision (Level 3), immunosuppression (Level 4), age >75 (Level 4), type of hand cleansing (Level 1), post-surgical drain placement (Level 3), and surgical approach (Level 4). Factors associated with decreased rates of infection included: surgeon experience (Level 2), "No Touch" technique (Level 3), preoperative parenteral antibiotics (Level 2), antibiotic coated devices (Level 2), and operative field hair removal with clippers (Level 1). Optimization of pre-surgical and intraoperative risk factors is imperative to reduce the rate of postoperative penile prosthesis infection. Additional research is needed to elucidate risk factors and maximize benefit.

Adherence to preoperative hand hygiene and sterile gowning technique among consultant surgeons, surgical residents, and nurses: a pilot study at an academic medical center in Indonesia

Background

Healthcare-associated infections (HAI) is a major problem for patient safety and surgical site infection (SSI) is a type of HAI and the most common form of infection related to surgical health care. Transmission of microorganisms can be minimized by aseptic procedures. The main objective of this study is to compare adherence to preoperative sterile gowning and hand hygiene technique among consultant surgeons, surgical residents, and nurses.

Methods

This research was conducted by observing the implementation of the pre-operative sterile gowning and hand hygiene technique of abdominal surgery by consultant surgeons, surgical residents, and nurses using aseptic instrument tests of the Objective Structured Clinical Examination (OSCE) Faculty of Medicine Universitas Gadjah Mada from August 10, 2018 to September 10, 2018. Observations were made when participants performed hand scrubbing, gowning, and donning the gloves procedures. The observer completed mobile online forms, so that the medical personnel under observation did not know that they were being observed.

Results

Twelve consultant surgeons, 16 surgical residents, and 12 nurses were observed. All of the medical personnel showed a good score with total percentage mean 83.58%. The highest total mean score was achieved by consultant surgeons (86.39%), but mean score did not vary significantly between medical personnel (p = .091). In the hand scrubbing procedure, scrub the nail and palm using brush side and the skin of hand and arm using sponge side, in both hands had the lowest mean score (1.82 ± 1.152 of the maximum score of 4). While in the gowning procedure, taking and unfolding the sterile gown had the lowest mean score (1.97 ± .158 of the maximum score of 2). In the donning the glove procedure, grasping left glove with right hand and putting the glove over the left hand in opposite direction procedure had the lowest mean score (1.97 ± .158 of the maximum score of 2).

Conclusions

The mean score of each group of health personnel in each section showed good results. Comparison of hand hygiene and gowning procedure performance between groups of health personnel did not show significant differences. However, larger scale research is needed after this pilot study.

Effectiveness of architectural separation of septic and aseptic operating theatres for improving process quality and patient outcomes: a systematic review

BACKGROUND

Architectural division of aseptic and septic operating theatres is a distinct structural feature of surgical departments in Germany. Internationally, hygienists and microbiologists mainly recommend functional separation (i.e. aseptic procedures first) without calling for separate operating floors and rooms. However, patients with severe musculoskeletal infections (e.g. joint empyema, spondylodiscitis, deep implant-associated infections) may benefit from the permanent availability of septic operating capacities without delay caused by an ongoing aseptic surgical program. A systematic literature review on the influence of a structural separation of septic and aseptic operating theatres on process and/or outcome quality has not yet been conducted.

METHODS

Systematic literature search in PubMed MEDLINE, Ovid Embase, CINAHL and the Cochrane Library, screening of referenced citations, and assessment of grey literature.

RESULTS

A total of 572 articles were found through the systematic literature search. No head-to-head studies (neither randomised, quasi-randomised nor observational) were identified which examined the impact of structural separation of septic and aseptic operating theatres on process and/or outcome quality.

CONCLUSIONS

This review did not identify evidence in favour nor against architectural separation of septic or aseptic operating theatre. Specifically, there is no evidence of a harmful effect of architectural separation. Unless prospective studies, ideally randomised trials, will be available, it is unjustified to call for abolishing established hospital structures. Future investigations must address patient-centered endpoints, surgical site infections, process quality and hospital economy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (International prospective register of systematic reviews): CRD42018086568.

Surgical Site Infections in Spine Surgery: Preoperative Prevention Strategies to Minimize Risk

STUDY DESIGN

Literature review.

OBJECTIVES

A review of the literature identifying preoperative risk factors for developing surgical site infections after spine surgery and discussion of the preventive strategies to minimize risks.

METHODS

A review of the literature and synthesis of the data to provide an updated review on the preoperative management of surgical site infection.

RESULTS

Preoperative prevention strategies of reducing surgical site infections in spine surgery remains a challenging problem. Careful mitigation of modifiable patient comorbidities, blood glucose control, smoking, obesity, and screening for pathologic microorganisms is paramount to reduce this risk. Individualized antibiotic regimens, skin preparation, and hand hygiene also play a critical role in surgical site infection prevention.

CONCLUSIONS

This review of the literature discusses the preoperative preventive strategies and risk management techniques of surgical site infections in spine surgery. Significant decreases in surgical site infections after spine surgery have been noted over the past decade due to increased awareness and implementation of the prevention strategies described in this article. However, it is important to recognize that prevention of surgical site infection requires a system-wide approach that includes the hospital system, the surgeon, and the patient. Continued efforts should focus on system-wide implementation programs including careful patient selection, individualized antibiotic treatment algorithms, identification of pathologic organisms, and preoperative decolonization programs to further prevent surgical site infections and optimize patient outcomes.

Current Evidence for the Prevention of Endophthalmitis in Anti-VEGF Intravitreal Injections

Intravitreal injection of a therapeutic substance is the most common procedure performed in ophthalmology. It has a low incidence of serious complications but is associated with a small chance of endophthalmitis. Although the rate of endophthalmitis is between 0.019% and 0.09%, the associated visual morbidity is often devastating. Procedural changes have evolved over the years to improve patient comfort and reduce injection-related injury and infection. Despite the availability of published evidence, there remains considerable variations and lack of consensus in practical clinical settings. In addition, emerging literature concerning the use of speculums, the use of prophylactic topical antibiotics, and the setting of injections continues to impact the ophthalmologist's injection practice. This article provides an up to date assessment of various aspects of the procedure such as the setting, ventilation, type of anaesthetic, and control of sterility during the procedure; including discussions on performing bilateral eye same-day injections and the use of antibiotics.

Alcohol-based surgical hand preparation: translating scientific evidence into clinical practice

Background

Although alcohol-based surgical hand preparation offers potential advantages over the traditional surgical scrubbing technique, implementing it may be challenging due to resistance of surgeons in changing their practice. We aimed to implement alcohol-based surgical hand preparation in the hospital setting evaluating the impact of that on the quality and duration of the procedure, as well as on the prevention of surgical site infections.

Methods

A quasi-experimental study conducted at a tertiary-care university hospital from April 01 to November 01, 2017. Participants were cardiac and orthopedic surgical teams (n = 56) and patients operated by them (n = 231). Intervention consisted of making alcohol-based handrub available in the operating room, convincing and training surgical teams for using it, promoting direct observation of surgical hand preparation, and providing aggregated feedback on the quality of the preparation. The primary study outcome was the quality of the surgical hand preparation, inferred by the compliance with each one of the steps predicted in the World Health Organization (WHO) technique, evaluated through direct observation. Secondary study outcome was the patient’s individual probability of developing surgical site infection in both study periods. We used the Wilcoxon for paired samples and McNemar’s test to assess the primary study outcome and we build a logistic regression model to assess the secondary outcome.

Results

We observed 534 surgical hand preparation events. Among 33 participants with full data available for both study periods, we observed full compliance with all the steps predicted in the WHO technique in 0.03% (1/33) of them in the pre-intervention period and in 36.36% (12/33) of them in the intervention period (OR:12.0, 95% CI: 2. 4-59.2, p = 0.002). Compared to the pre-intervention period, the intervention reduced the duration of the preparation (4.8 min vs 2.7 min, respectively; p < 0.001). The individual risk of developing a surgical site infection did not significantly change between the pre-intervention and the intervention phase (Adjusted RR = 0.66; 95% CI 0. 16-2.70, p = 0.563).

Conclusion

Our results demonstrate that, when compared to the traditional surgical scrub, alcohol-based surgical hand preparation improves the quality and reduces the duration of the preparation, being at least equally effective for the prevention of surgical site infections.

Surgical hand antisepsis: experimental study

Purpose

Nosocomial infections account for one of the most serious complications in hospitalized patients around the world. Surgical site infections have significant economic implications, and surgical antisepsis plays an important role in such processes.

Methods

With prior approval by the Institutional Review Board and informed consent, 10 volunteers were randomly assigned to 3 protocols on hand antisepsis: protocol A (chloroxylenol 3%), protocol B (benzalkonium chloride at 1%), and protocol C (ethyl alcohol 61%, 1% chlorhexidine gluconate). Smears from both hands were cultured after each hand pro tocol (t0) and at the end of suturing (t1). Colony forming units were counted (CFUs on blood agar dishes) with digital counting software (Open CFU). Friedman test was used to compare the mean values among the groups, and a Bonferroni correction was made to determine the dissimilar group, with a P = 0.015.

Results

At t0 for protocol A the CFU count was 82.8 ± 1.3; protocol B was 9.7 ± 30; protocol C was 0.1 ± 0.3 (P < 0.001). At t1 for protocol A the CFU was 80.7 ± 89.4; protocol B was 7.5 ± 32; protocol C was 0.0 ± 0.0 (P < 0.001). No adverse events were present among the subjects.

Conclusion

Ethyl alcohol at 61% with 1% chlorhexidine gluconate showed higher efficacy than the traditional washing antiseptics.

Association of hand and arm disinfection with asthma control in US nurses

OBJECTIVES

To investigate the association between occupational exposure to disinfectants/antiseptics used for hand hygiene and asthma control in nurses.

METHODS

In 2014, we invited female nurses with asthma drawn from the Nurses' Health Study II to complete two supplemental questionnaires on their occupation and asthma (cross-sectional study, response rate: 80%). Among 4055 nurses (mean age: 59 years) with physician-diagnosed asthma and asthma medication use in the past year, we examined asthma control, as defined by the Asthma Control Test (ACT). Nurses were asked about the daily frequency of hand hygiene tasks: 'wash/scrub hands with disinfectants/hand sanitizers' (hand hygiene) and 'wash/scrub arms with disinfecting products' (surrogate of surgical hand/arm antisepsis). Analyses were adjusted for age, race, ethnicity, smoking status and body mass index.

RESULTS

Nurses with partly controlled asthma (ACT: 20-24, 50%) and poorly controlled asthma (ACT ≤19, 18%) were compared with nurses with controlled asthma (ACT=25, 32%). In separate models, both hand and arm hygiene were associated with poorly controlled asthma. After mutual adjustment, only arm hygiene was associated with poorly controlled asthma: OR (95% CI) for <1 time/day, 1.38 (1.06 to 1.80); ≥1 time/day, 1.96 (1.52 to 2.51), versus never. We observed a consistent dose-response relationship between frequency of arm hygiene tasks (never to >10 times/day) and poor asthma control. Associations persisted after further adjustment for surfaces/instruments disinfection tasks.

CONCLUSIONS

Frequency of hand/arm hygiene tasks in nurses was associated with poor asthma control. The results suggest an adverse effect of products used for surgical hand/arm antisepsis. This potential new occupational risk factor for asthma warrants further study.

Optimum Operating Room Environment for the Prevention of Surgical Site Infections

BACKGROUND

Surgical site infections (SSI), whether they be incisional or deep, can entail major morbidity and death to patients and additional cost to the healthcare system. A significant amount of effort has gone into optimizing the surgical patient and the operating room environment to reduce SSI.

METHODS

Relevant guidelines and literature were reviewed.

RESULTS

The modern practice of surgical antisepsis involves the employment of strict sterile techniques inside the operating room. Extensive guidelines are available regarding the proper operating room antisepsis as well as pre-operative preparation. The use of pre-operative antimicrobial prophylaxis has become increasingly prevalent, which also presents the challenge of opportunistic and nosocomial infections. Ongoing investigative efforts have brought about a greater appreciation of the surgical patient's endogenous microflora, use of non-bactericidal small molecules, and pre-operative microbial screening.

CONCLUSIONS

Systematic protocols exist for optimizing the surgical sterility of the operating room to prevent SSIs. Ongoing research efforts aim to improve the precision of peri-operative antisepsis measures and personalize these measures to tailor the patient's unique microbial environment.

Alternatives to antibiotics for prevention of surgical infection

BACKGROUND

Surgical-site infection (SSI) is still the second most common healthcare-associated infection, after respiratory tract infection. SSIs are associated with higher morbidity and mortality rates, and result in enormous healthcare costs. In the past decade, several guidelines have been developed that aim to reduce the incidence of SSI. Unfortunately, there is no consensus amongst the guidelines, and some are already outdated. This review discusses the recent literature regarding alternatives to antibiotics for prevention of SSI.

METHODS

A literature search of PubMed/MEDLINE was performed to retrieve data on the prevention of SSI. The focus was on literature published in the past decade.

RESULTS

Prevention of SSI can be divided into preoperative, perioperative and postoperative measures. Preoperative measures consist of showering, surgical scrubbing and cleansing of the operation area with antiseptics. Perioperative factors can be subdivided as: environmental factors, such as surgical attire; patient-related factors, such as plasma glucose control; and surgical factors, such as the duration and invasiveness of surgery. Postoperative measures consist mainly of wound care.

CONCLUSION

There is a general lack of evidence on the preventive effectiveness of perioperative measures to reduce the incidence of SSI. Most measures are based on common practice and perceived effectiveness. The lack of clinical evidence, together with the stability of the high incidence of SSI (10 per cent for colorectal procedures) in recent decades, highlights the need for future research.

Surgical wound infection in urology. Analysis of risk factors and associated microorganisms

OBJECTIVES

Open surgery continues to have a fundamental role in urology, and one of its main complications is surgical wound infection. Our objective was to analyse surgical wound infection in patients who underwent surgery in our Department of Urology and to assess the risk factors, microorganisms and resistances by type of surgery.

MATERIAL AND METHODS

This was a prospective observational study that included 940 patients: 370 abdominal/open lumbar surgeries and 570 genitoperineal surgeries. We analysed age, sex, comorbidities, stay and type of surgery, as well as the causal microorganisms and antibiotic resistances.

RESULTS

For genitoperineal surgery, we found 15 cases (2.6%) of surgical wound infection associated with previous urinary catheterisation. Most of the isolated microorganisms corresponded to enterobacteriaceae, highlighting the resistance to beta-lactam. In abdominal/lumbar surgery, we found 41 cases (11.1%) of surgical wound infection. The incidence rate was 3.3% in prostate surgery; 9.8% in renal surgery; and 45.0% in cystectomy. Heart disease was associated with a higher incidence rate of surgical wound infection. The most common microorganisms were Enterococcus spp. (27.1%), E.coli (22.9%) and Staphylococcus aureus (14.6%). Enterococcus and beta-lactamase-producing E.coli are resistant to ampicillin in 37.5% and 41.7% of cases, respectively.

CONCLUSIONS

We found a low incidence rate of surgical wound infection in genitoperineal surgery, compared with renal surgery and cystectomy. The presence of heart disease and carrying a previous urinary catheter are factors associated with surgical wound infection. Enterococcus and E.coli are the most common pathogens, with high rates of resistance.

[Prevention of postoperative infections : Evidence-based principles]

BACKGROUND

Surgical site infections (SSI) are one of the most frequent postoperative complications worldwide and preventive measures are still an important research topic. High infection rates are not uncommon, especially in visceral surgery. At the same time, frequently not all evidence-based measures are carried out in a standardized manner. The aim of this article is to summarize the relevant literature on evidence-based measures for prevention of SSI. Although evidence-based medicine has already become well-established in surgery, the opinion of experts often still prevails.

MATERIAL AND METHODS

The current literature on preventive measures and recommendations was reviewed and the results are appraised.

RESULTS

Many different preventive measures could be identified in the literature, which can be classified into preoperative, intraoperative and postoperative measures. Recommendations for implementation of individual measures are made depending on the underlying evidence.

CONCLUSION

The occurrence of SSI can effectively be reduced by adhering to evidence-based principles.

Evaluation of antimicrobial persistent activity of alcohol-based hand antiseptics against bacterial contamination

The purpose of this study was to evaluate persistent activity of three alcohol-based antiseptics widely used in the clinical routine containing chlorhexidine, triclosan or mecetronium after hand disinfection. Four tests were used to evaluate the antimicrobial activity of antiseptics on: (i) resident microbiota; (ii) nutrient agar plates (NAP) subsequently inoculated with a test organism; and transient microbiota acquired by contact with dry hands (iii), or (iv) a wet inert surface that had been artificially contaminated. Four reference strains (Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis) and an Acinetobacter baumannii strain responsible for a hospital outbreak were used as transient microbiota. Antimicrobial activity was calculated according to the CFUs reduction by reference to non-disinfected control hands. The antiseptics were applied according to European Standard EN1500. Solutions containing chlorhexidine or triclosan showed some persistent effects on transient microbiota on inert humid surfaces and NAP, but not on contaminated dry hands. Solutions containing mecetronium showed no persistent effect on transient flora in any of the trials. All alcohol-based antiseptics tested were more effective against resident flora than soap. No persistent activity was observed for A. baumannii in any of the trials. Chlorhexidine and triclosan are preferred when an antiseptic with persistent activity is desired, but a moist environment appears to be necessary for that antibacterial activity. Accordingly, relevant conclusions regarding the persistent activity of antiseptics for clinical practice and protection against bacterial contamination cannot be derived from this study for the alcoholic solutions tested.

Prospective study analyzing risk factors and characteristics of healthcare-associated infections in a Urology ward

PURPOSE

Healthcare-associated infections (HAIs) in urological patients have special features due to specific risk factors. Our objective was to evaluate the characteristics and risk factors for HAIs in patients hospitalized in a Urology ward.

MATERIALS AND METHODS

We evaluated prospectively, from 2012 to 2015, the incidence, types and risk factor for HAIs, microbiological and resistance patterns.

RESULTS

The incidence of HAIs was 6.3%. The most common types were urinary infections (70.5%) and surgical site infections (22.1%). Univariate analysis showed an increased risk of HAIs among patients with American Society of Anesthesiologists physical status classification system III-IV (odds ratio [OR], 1.39; p<0.001), immunosuppression (OR, 1.80; p=0.013), previous urinary infection (OR, 4.46; p<0,001), and urinary catheter before admission (OR, 1.74; p<0.001). The surgical procedures with the highest incidence of HAIs were radical cystectomy (54.2%) and renal surgery (8.7%). The most frequently isolated microorganisms were Escherichia coli (25.1%), Enterococcus spp. (17.5%), Klebsiella spp. (13.5%) and Pseudomonas aeruginosa (12.3%). Enterococcus sp was the most common microorganism after radical cystectomy and in surgical site infections, E. coli showed resistance rates of 53.5% for fluoroquinolones, 9.3% for amikacin. The percentage of extended-spectrum betalactamase producing E. coli was 24.7%. Klebsiella spp. showed resistance rates of 47.8% for fluoroquinolones, 7.1% for amikacin and 4.3% for carbapenems. Enterococcus spp showed resistance rates of 1.7% for vancomycin and; P. aeruginosa of 33.3% for carbapenems and 26.2% for amikacin.

CONCLUSIONS

Comorbidities, previous urinary infections, and urinary catheter are risk factors for HAIs. The microorganisms most commonly isolated were E. coli, Enterococcus and P. aeruginosa. Prospective monitoring may decrease the incidence of infections.

Use of Chlorhexidine Preparations in Total Joint Arthroplasty

Prosthetic joint infection (PJI) is a serious complication after total joint arthroplasty (TJA). Chlorhexidine is a widely used antiseptic because of its rapid and persistent action. It is well tolerated and available in different formulations at various concentrations. Chlorhexidine can be used for pre-operative skin cleansing, surgical site preparation, hand antisepsis of the surgical team and intra-articular irrigation of infected joints. The optimal intra-articular concentration of chlorhexidine gluconate in irrigation solution is 2%, to provide a persistent decrease in biofilm formation, though cytotoxicity might be an issue. Although chlorhexidine is relatively cheap, routine use of chlorhexidine without evidence of clear benefits can lead to unnecessary costs, adverse effects and even emergence of resistance. This review focuses on the current applications of various chlorhexidine formulations in TJA. As the treatment of PJI is challenging and expensive, effective preparations of chlorhexidine could help in the prevention and control of PJI.