Preoperative whole body disinfection--a controlled clinical study

No significant difference in skin contamination during anterior cruciate ligament reconstruction with and without preoperative skin cleaning

PURPOSE

This prospective study aimed to assess whether preoperative antiseptic skin cleansing reduces bacterial contamination and surgical site infections (SSI) following anterior cruciate ligament reconstruction (ACLR). We hypothesized that antiseptic cleaning would lower bacterial load, reducing contamination and early infections.

METHODS

One hundred and nineteen patients scheduled for ACLR were included in this prospective, nonrandomized study. Individuals were divided into two groups. Patients in the intervention group applied octenisan® wash lotion daily for three days before surgery and used the wash solution instead of their usual shower gel. Additionally, they swiped their leg with octenisan® soaked gloves on the morning of the operation. The control group followed their usual wash routine with no specific instructions. Fluid samples were taken before surgery from the irrigation bag and at 15-min intervals from the reservoir of the sterile surgical drape during the procedure. Suture material used for the ACL graft and meniscus repair were also collected for testing. The samples were subjected to a 14-day incubation period. Follow-up included outpatient visits at 6 weeks, 12 weeks and 6 months with a final evaluation at 12 months.

RESULTS

Contamination rates showed no significant difference between the control and intervention groups. The mean contamination rate in the control group was 6.4% (n = 22) and 6.6% (n = 24) in the intervention group (p = 0.28). At 12-month follow-up, 110 out of 119 participants were included (52 control, 58 intervention). T tests for age (p = 0.19), BMI (p = 0.66), and surgery duration (p = 0.38) showed no significant differences. No early SSI were observed in either group postoperatively.

CONCLUSION

Our results indicate that the use of antiseptic wash lotion and gloves does not influence the risk of bacterial contamination during surgery.

LEVEL OF EVIDENCE

Level III.

Evidence-based Prevention of Surgical Site Infection

Surgical site infection (SSI) remains an important complication of surgery. SSI is estimated to affect 2% to 5% of all surgical patients. Local and national efforts have resulted in significant improvements in the incidence of SSI. Familiarity with evidence surrounding high-quality SSI-reduction strategies is desirable. There exists strong evidence for mechanical and oral antibiotic bowel preparation in colorectal surgery, smoking cessation before elective surgery, prophylactic antibiotics, chlorhexidine-based skin antisepsis, and maintenance of normothermia throughout the perioperative period to reduce SSI. Use of other practices should be determined by the operating surgeon and/or local hospital policy.

New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective

Surgical site infections (SSIs) are among the most preventable health-care-associated infections and are a substantial burden to health-care systems and service payers worldwide in terms of patient morbidity, mortality, and additional costs. SSI prevention is complex and requires the integration of a range of measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations of national guidelines have been identified. Given the burden of SSIs worldwide, the numerous gaps in evidence-based guidance, and the need for standardisation and a global approach, WHO decided to prioritise the development of evidence-based recommendations for the prevention of SSIs. The guidelines take into account the balance between benefits and harms, the evidence quality, cost and resource use implications, and patient values and preferences. On the basis of systematic literature reviews and expert consensus, we present 13 recommendations on preoperative preventive measures.

Preoperative bathing or showering with skin antiseptics to prevent surgical site infection

BACKGROUND

Surgical site infections (SSIs) are wound infections that occur after invasive (surgical) procedures. Preoperative bathing or showering with an antiseptic skin wash product is a well-accepted procedure for reducing skin bacteria (microflora). It is less clear whether reducing skin microflora leads to a lower incidence of surgical site infection.

OBJECTIVES

To review the evidence for preoperative bathing or showering with antiseptics for preventing hospital-acquired (nosocomial) surgical site infections.

SEARCH METHODS

For this fifth update we searched the Cochrane Wounds Group Specialised Register (searched 18 December 2014); the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014 Issue 11); Ovid MEDLINE (2012 to December Week 4 2014), Ovid MEDLINE (In-Process & Other Non-Indexed Citations December 18, 2014); Ovid EMBASE (2012 to 2014 Week 51), EBSCO CINAHL (2012 to December 18 2014) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials comparing any antiseptic preparation used for preoperative full-body bathing or showering with non-antiseptic preparations in people undergoing surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for selection, risk of bias and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

We did not identify any new trials for inclusion in this fifth update. Seven trials involving a total of 10,157 participants were included. Four of the included trials had three comparison groups. The antiseptic used in all trials was 4% chlorhexidine gluconate (Hibiscrub/Riohex). Three trials involving 7791 participants compared chlorhexidine with a placebo. Bathing with chlorhexidine compared with placebo did not result in a statistically significant reduction in SSIs; the relative risk of SSI (RR) was 0.91 (95% confidence interval (CI) 0.80 to 1.04). When only trials of high quality were included in this comparison, the RR of SSI was 0.95 (95%CI 0.82 to 1.10). Three trials of 1443 participants compared bar soap with chlorhexidine; when combined there was no difference in the risk of SSIs (RR 1.02, 95% CI 0.57 to 1.84). Three trials of 1192 patients compared bathing with chlorhexidine with no washing, one large study found a statistically significant difference in favour of bathing with chlorhexidine (RR 0.36, 95%CI 0.17 to 0.79). The smaller studies found no difference between patients who washed with chlorhexidine and those who did not wash preoperatively.

AUTHORS' CONCLUSIONS

This review provides no clear evidence of benefit for preoperative showering or bathing with chlorhexidine over other wash products, to reduce surgical site infection. Efforts to reduce the incidence of nosocomial surgical site infection should focus on interventions where effect has been demonstrated.

An update on modifiable factors to reduce the risk of surgical site infections

BACKGROUND CONTEXT

Despite an increase in physician and public awareness and advances in infection control practices, surgical site infection (SSI) remains to be one of the most common complications after an operation. Surgical site infections have been shown to decrease health-related quality of life, double the risk of readmission, prolong the length of hospital stay, and increase hospital costs.

PURPOSE

To critically evaluate the literature and identify modifiable factors to reduce the risk of SSI.

STUDY DESIGN/SETTING

Systematic review of the literature.

METHODS

A critical review of the literature was performed using OVID, Pubmed, and the Cochrane database and focused on eight identifiable factors: preoperative screening and decolonization of methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus protocols, antiseptic showers, antiseptic cloths, perioperative skin preparation, surgeon hand hygiene, antibiotic irrigation and/or use of vancomycin powder, closed suction drains, and antibiotic suture.

RESULTS

Screening protocols have shown that 18% to 25% of patients undergoing elective orthopedic surgery are nasal carriers of S. aureus and that carriers are more likely to have a nosocomial infection and SSI. The evidence suggests that an institutionalized prescreening program, followed by an appropriate eradication using mupirocin ointment and chlorhexidine soap/shower, will lower the rate of nosocomial S. aureus infections. Based on the current literature, definitive conclusions cannot be made on whether preoperative antiseptic showers effectively reduce the incidence of postoperative infection. The use of a chlorhexidine bathing cloth before surgery may decrease the risk of SSI. There is no definitive clinical evidence that one skin preparation solution effectively lowers the rate of postoperative infection compared with another. The use of dilute betadine irrigation or vancomycin powder in the wound before closure likely decreases the incidence of SSI.

CONCLUSIONS

There is strong evidence in the literature that optimizing specific preoperative, intraoperative, and postoperative variables can significantly lower the risk of developing an SSI.

Preoperative bathing or showering with skin antiseptics to prevent surgical site infection

BACKGROUND

Surgical site infections (SSIs) are wound infections that occur after invasive (surgical) procedures. Preoperative bathing or showering with an antiseptic skin wash product is a well-accepted procedure for reducing skin bacteria (microflora). It is less clear whether reducing skin microflora leads to a lower incidence of surgical site infection.

OBJECTIVES

To review the evidence for preoperative bathing or showering with antiseptics for preventing hospital-acquired (nosocomial) surgical site infections.

SEARCH METHODS

For this fourth update we searched the Cochrane Wounds Group Specialised Register (searched 29 June 2012); the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012 Issue 6); Ovid MEDLINE (2010 to June Week 3 2012), Ovid MEDLINE (In-Process & Other Non-Indexed Citations June 27, 2012); Ovid EMBASE (2010 to 2012 Week 25), EBSCO CINAHL (1882 to 21 June 2012) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials comparing any antiseptic preparation used for preoperative full-body bathing or showering with non-antiseptic preparations in people undergoing surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for selection, risk of bias and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

We did not identify any new trials for inclusion in this fourth update. Seven trials involving a total of 10,157 participants were included. Four of the included trials had three comparison groups. The antiseptic used in all trials was 4% chlorhexidine gluconate (Hibiscrub/Riohex). Three trials involving 7791 participants compared chlorhexidine with a placebo. Bathing with chlorhexidine compared with placebo did not result in a statistically significant reduction in SSIs; the relative risk of SSI (RR) was 0.91 (95% confidence interval (CI) 0.80 to 1.04). When only trials of high quality were included in this comparison, the RR of SSI was 0.95 (95%CI 0.82 to 1.10). Three trials of 1443 participants compared bar soap with chlorhexidine; when combined there was no difference in the risk of SSIs (RR 1.02, 95% CI 0.57 to 1.84). Three trials of 1192 patients compared bathing with chlorhexidine with no washing, one large study found a statistically significant difference in favour of bathing with chlorhexidine (RR 0.36, 95%CI 0.17 to 0.79). The smaller studies found no difference between patients who washed with chlorhexidine and those who did not wash preoperatively.

AUTHORS' CONCLUSIONS

This review provides no clear evidence of benefit for preoperative showering or bathing with chlorhexidine over other wash products, to reduce surgical site infection. Efforts to reduce the incidence of nosocomial surgical site infection should focus on interventions where effect has been demonstrated.

A quick and effective method of limb preparation with health, safety and efficiency benefits

INTRODUCTION

Pre-operative limb preparation (PLP) usually involves lifting the limb and holding it in a fixed 'static' posture for several minutes. This is hazardous to theatre staff. Furthermore, 'painting' the limb can be time consuming and difficult areas such as between toes and fingers may remain unsterile. We demonstrate the time efficiency and asepsis achieved using the 'sterile bag' preparation technique. An additional advantage is the ability to prepare and anaesthetise a limb prior to theatre, increasing efficiency substantially for units with a large throughput of cases, such as day-case hand surgery lists.

METHODS

We monitored the duration of PLP in 20 patients using the 'sterile bag' technique compared to 20 patients using a conventional 'painting' method. Additionally, microbiology samples acquired from prepared upper limbs of 27 sequential patients operated on by a single surgeon over a two-month period were sent for culture immediately prior to commencement of surgery.

RESULTS

The mean duration of the 'sterile bag' PLP was significantly lower than that of the conventional method (24 seconds vs 85 seconds, p=0.045). The technique can take as little as ten seconds (n=1). Final microbiology reports showed no growth for any of the 27 patients from whom a culture sample was taken.

CONCLUSIONS

The sterile bag technique is effective in achieving asepsis, has the potential to increase theatre efficiency and reduces manual handling hazards compared to the conventional method. It is now taught to all theatre staff in our hospital during manual handling training. It can be undertaken in approximately ten seconds with practice for the upper limb.

Use of a surgical preparation and sterile dressing change during office visit treatment of chronic foot and ankle wounds decreases the incidence of infection and treatment costs

Foot and ankle surgeons work with a patient population burdened by multiple factors that adversely affect wound healing and the ability to combat infection. As a result, many of these patients are seen for treatment of chronic ulcerations on their lower extremities that are highly susceptible to colonization and possible progression to a limb- and/or life-threatening infection. The Limb Preservation Service at the Madigan Army Medical Center hypothesized that implementation of a standardized protocol involving a formal physician-directed surgical preparation of the affected lower extremity and a physician-applied sterile dressing at each outpatient clinic appointment would reduce the incidence of infection, use of systemic antibiosis, and thus the requirement for frequent follow-up office appointments. Initiation of this protocol resulted in the reduction of infection to the extent that antibiotic need was eliminated. The frequency of office visits required for follow-up was also significantly reduced. This is key in treating a patient population in which the financial burden to treat chronic wounds and associated infections represents a large portion of the health care money spent for their medical care.

Bandages, dressings, and cranial neurosurgery

OBJECT

Bandages and dressings are commonly applied to incisional scalp wounds to prevent complications, particularly infection, during the early stages of wound healing. Bandaging cranial incisional wounds requires resources, consumes healthcare workers' time, and incurs expense; it is therefore important to examine its efficacy.

METHODS

All cranial operations (excluding shunt placements, procedures on the scalp alone, and bur hole procedures) performed between June 30, 2001 and January 1, 2006, by two neurosurgeons at either of two hospitals, one adult and one pediatric institution, were reviewed. Surgical site infections (SSIs) and other postoperative complications were investigated with respect to the use of bandaging for incisional wounds and other aspects of postoperative wound management. The operations were classified into four categories based on wound type: "clean," "clean-contaminated," "contaminated," and "dirty," according to the criteria of the Centers for Disease Control and Prevention.

CONCLUSIONS

A total of 702 operations were performed in 577 patients; only five patients received any type of surgical bandaging. There were four SSIs (0.57%; 95% confidence interval [CI] 0.16-1.45). The postoperative infection rate in the 626 clean cases was 0.48% (95% CI 0.10-1.39) and was 2.63% (95% CI 0.07-13.81) in the 38 clean-contaminated cases. The data obtained in this investigation is consistent with the position that bandaging incisional scalp wounds after cranial surgery adds little if any benefit beyond the easier, simpler, and cheaper practice of using antibiotic ointment as a dressing without bandaging.

Preoperative bathing or showering with skin antiseptics to prevent surgical site infection

BACKGROUND

Surgical site infections (SSIs) are wound infections that occur after invasive (surgical) procedures. Preoperative bathing or showering with an antiseptic skin wash product is a well-accepted procedure for reducing skin bacteria (microflora). It is less clear whether reducing skin microflora leads to a lower incidence of surgical site infection.

OBJECTIVES

To review the evidence for preoperative bathing or showering with antiseptics for the prevention of hospital-acquired (nosocomial) surgical site infection.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE (January 1966 to December 2005) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials comparing any antiseptic preparation used for preoperative full-body bathing or showering with non-antiseptic preparations in patients undergoing surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for selection, trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Six trials involving a total of 10,007 participants were included. Three of the included trials had three comparison groups. The antiseptic used in all trials was 4% chlorhexidine gluconate (Hibiscrub). Three trials involving 7691 participants compared chlorhexidine with a placebo. Bathing with chlorhexidine compared with a placebo did not result in a statistically significant reduction in SSIs; the relative risk of SSI (RR) was 0.91 (95% confidence interval (CI) 0.80 to 1.04). When only trials of high quality were included in this comparison, the RR of SSI was 0.95 (95%CI 0.82 to 1.10). Three trials of 1443 participants compared bar soap with chlorhexidine; when combined there was no difference in the risk of SSIs (RR 1.02, 95% CI 0.57 to 1.84). Two trials of 1092 patients compared bathing with chlorhexidine with no washing, one large study found a statistically significant difference in favour of bathing with chlorhexidine (RR 0.36, 95%CI 0.17 to 0.79). The second smaller study found no difference between patients who washed with chlorhexidine and those who did not wash preoperatively.

AUTHORS' CONCLUSIONS

This review provides no clear evidence of benefit for preoperative showering or bathing with chlorhexidine over other wash products, to reduce surgical site infection. Efforts to reduce the incidence of nosocomial surgical site infection should focus on interventions where effect has been demonstrated.

Preoperative bathing or showering with skin antiseptics to prevent surgical site infection

BACKGROUND

Surgical site infections (SSIs) are wound infections that occur after invasive (surgical) procedures. Preoperative bathing or showering with an antiseptic skin wash product is a well-accepted procedure for reducing skin bacteria (microflora). It is less clear whether reducing skin microflora leads to a lower incidence of surgical site infection.

OBJECTIVES

To review the evidence for preoperative bathing or showering with antiseptics for the prevention of hospital-acquired (nosocomial) surgical site infection.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE (January 1966 to December 2005) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials comparing any antiseptic preparation used for preoperative full-body bathing or showering with non-antiseptic preparations in patients undergoing surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for selection, trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Six trials involving a total of 10,007 participants were included. Three of the included trials had three comparison groups. The antiseptic used in all trials was 4% chlorhexidine gluconate (Hibiscrub). Three trials involving 7691 participants compared chlorhexidine with a placebo. Bathing with chlorhexidine compared with a placebo did not result in a statistically significant reduction in SSIs; the relative risk of SSI (RR) was 0.91 (95% confidence interval (CI) 0.80 to 1.04). When only trials of high quality were included in this comparison, the RR of SSI was 0.95 (95%CI 0.82 to 0.10). Three trials of 1443 participants compared bar soap with chlorhexidine; when combined there was no difference in the risk of SSIs (RR 1.02, 95% CI 0.57 to 1.84). Two trials of 1092 patients compared bathing with chlorhexidine with no washing. No difference was found in the postoperative SSI rate between patients who washed with chlorhexidine and those who did not wash preoperatively (RR 0.70, 95% CI 0.19 to 2.58).

AUTHORS' CONCLUSIONS

This review provides evidence of no benefit for preoperative showering or bathing with chlorhexidine over other wash products, to reduce surgical site infection. Efforts to reduce the incidence of nosocomial surgical site infection should focus on interventions where effect has been demonstrated.

Efficacy evaluation of a 4% chlorhexidine gluconate as a full-body shower wash

A 4% chlorhexidine gluconate (Xttrium Laboratories, Chicago, Ill.) was used in a shower bath application to evaluate its merits in reducing resident skin microorganisms. Five volunteers completed a 14-day microbial stabilization period, a 7-day baseline period, and a 5-day test period. Subjects followed a standard protocol, performed five shower washes and were sampled at both the abdominal and inguinal regions immediately after the shower wash as well as at 3 and 6 hours later on days 1, 2, and 5. Chlorhexidine gluconate provided significant microbial reductions from baseline, with greater reductions noted as the study progressed. Use of chlorhexidine gluconate in a shower wash application in conjunction with a preoperative skin-preparation procedure may reduce the probability of surgically associated infections.

Hair and neurosurgery

The value of removing hair in preparation for neurosurgery is addressed in detail. One neurosurgeon's series, accrued over 40 consecutive months, of 638 prospectively examined, consecutive cases is the basis of this report. The overall surgical wound infection rate was 1.1%. The infection rate for the 313 cranial cases was 0.3% and 2.8% for the 218 procedures involving cerebrospinal fluid diversion (shunts). These data are discussed in the context of extensive nonneurosurgical and microbiological literature. It is concluded that the removal of hair by shaving does not lower the risk of surgical wound infection and may increase the risk. A technique for preparing skin and hair for neurosurgery and for the management of hair during neurosurgical procedures is discussed.

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 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.