In-use efficacy of a chlorhexidine in alcohol surgical rub: a comparative study

The Utility of Perioperative Products for the Prevention of Surgical Site Infections in Total Knee Arthroplasty and Lower Extremity Arthroplasty: A Systematic Review

Surgical site infections (SSIs) are among the most prevalent and devastating complications following lower extremity total joint arthroplasty (TJA). Strategies to reduce the rates can be divided into preoperative, perioperatives, and postoperative measures. A multicenter trial is underway to evaluate the efficacy of implementing a bundled care program for SSI prevention in lower extremity TJA including: (1) nasal decolonization; (2) surgical skin antisepsis; (3) antimicrobial incise draping; (4) temperature management; and (5) negative-pressure wound therapy for selected high-risk patients. The purposes of this systematic review were to provide a background and then to summarize the available evidence pertaining to each of these SSI-reduction strategies with special emphasis on total knee arthroplasty. A systematic review of the literature was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. Five individual literature searches were performed to identify studies evaluating nasal decolonization temperature management, surgical skin antisepsis, antimicrobial incise draping, and negative-pressure wound therapy. The highest level of evidence reports was used in each product review, and if there were insufficient arthroplasty papers on the particular topic, then papers were further culled from the surgical specialties to form the basis for the review. There was sufficient literature to assess all of the various prophylactic and preventative techniques. All five products used in the bundled program were supported for use as prophylactic agents or for the direct reduction of SSIs in both level I and II studies. This systematic review showed that various pre-, intra-, and postoperative strategies are efficacious in decreasing the risks of SSIs following lower extremity TJA procedures. Thus, including them in the armamentarium for SSI-reduction strategies for hip and knee arthroplasty surgeons should decrease the incidence of infections. We expect that the combined use of these products in an upcoming study will support these findings and may further enhance the reduction of total knee arthroplasty SSIs in a synergistic manner.

Does performing total joint arthroplasty in the afternoon or evening increase the risk of prosthetic joint infection?

PURPOSE

Does performing total joint arthroplasty in the afternoon or evening increase the rate of early prosthetic joint infection and the likelihood of early prosthetic joint infection?

METHODS

We evaluated patients retrospectively, who underwent primary total hip (THA) or knee arthroplasty (TKA) between January 2016 and December 2019, met the inclusion criteria and had at least 90 days of follow-up. Patients were divided into two groups. Group I consisted of patients whose surgeries had been started and finished before 14:00, and group II included patients whose surgeries started after 14:01. All patients were operated after non-septic cases in specific orthopedic operating rooms. Their demographic data and comorbidities were noted. Primary outcome was to compare the risk of PJI between the groups.

RESULTS

Group I and group II included 2309 and 1881 patients. Total number of patients with the diagnosis of PJI was 58 (1.4%). It was 31 (1.3%) and 27 (1.4%), respectively (p = 0.79). Performing total joint arthroplasty after 14:01 did not increase likelihood of infection (p = 0.83, OR 1.03). Among the parameters, PJI was significantly associated with age (p < 0.01, OR 0.99), smoking status (p < 0.01, OR 0.15) and operating time (p = 0.04, OR 0.99) in TKA and with direct anterior approach (p = 0.02, OR 4.72) in THA. Age (p = 0.06, OR 1.03) was the factor affecting the risk of subsequent PJI after total joint arthroplasty.

CONCLUSION

Performing total joint arthroplasty in the afternoon or in the evening, after aseptic cases does not increase the risk of subsequent of PJI.

Antiseptic efficacies of waterless hand rub, chlorhexidine scrub, and povidone-iodine scrub in surgical settings: a meta-analysis of randomized controlled trials

BACKGROUND

Presurgical hand washing is crucial for preventing surgical site infections (SSIs). Chlorhexidine gluconate (CHG) and povidone-iodine (PI) products have been conventionally used as hand scrubs for presurgical hand preparation. However, waterless hand rub (WHR) products have been developed for operating room staff.

AIM

The aim of this study was to conduct a systematic review and meta-analysis to compare the antiseptic efficacies of WHR, CHG, and PI in surgical settings.

METHODS

PubMed, Embase, and Cochrane Library databases as well as the ClinicalTrials.gov registry were searched for studies published before October 2018. Randomized controlled trials (RCTs) comparing the clinical outcomes of the use of WHRs, CHG, or PI for presurgical hand washing were included. A random effects model was used for meta-analysis. Colony-forming unit (cfu) counts, SSI rates, and preference and compliance were determined to measure efficacies.

FINDINGS

Eleven RCTs involving 5135 participants were included. Residual cfu counts were significantly lower in the WHR and CHG groups than in the PI group. The differences in cfu counts between the WHR and CHG groups were non-significant. No significant differences were observed in the SSI rates between the WHR and traditional hand scrub groups. Moreover, WHRs were considered most favourable and were associated with higher compliance rates than the other products.

CONCLUSION

WHRs and CHG exhibited higher antiseptic efficacies than PI. However, additional studies with consistent outcome measurements and accurate grouping are required to obtain comprehensive results. Moreover, preference, compliance, and the cost determine the selection of hand wash products.

Preoperative Hand Decontamination in Ophthalmic Surgery: A Comparison of the Removal of Bacteria from Surgeons' Hands by Routine Antimicrobial Scrub versus an Alcoholic Hand Rub

PURPOSE

The goal of this experiment was to evaluate and compare the antimicrobial efficacy of routine preoperative hand washing using commercial medicated sponge brushes versus an alcoholic hand rub, by comparing bacterial growth on ophthalmic surgeons' hands after application of each of these methods.

METHODS

Twenty ophthalmic surgeons were recruited at the Hadassah-Hebrew University Medical Center in Jerusalem, Israel. Samples were collected twice from the hands of each surgeon after hand decontamination using two different protocols during routine surgical practice. The routine preparation consisted of a 3-minute surgical scrub using commercial brush-sponges incorporating either 4% chlorhexidine gluconate (CHG) or 1% povidone-iodine (PVP-I) formulations with detergent, followed by drying the hands with a sterile towel, while the 70% ethanol solution was applied for 60-seconds and allowed to air dry. Half of the group was randomly assigned to provide samples first after the routine method and the alcoholic solution a week later, and the other half of the group was sampled in the reverse order. Viable counts of bacteria were evaluated using a modified glove juice method. Bacterial colonies were enumerated after incubation for 24 hours and expressed as colony forming units (CFU)/mL for each pair of hands.

RESULTS

Geometric mean counts were 1310 and 39 CFU/mL, in the routine and alcohol rub groups, respectively, representing a mean log₁₀ reduction in 1.53. The difference between the paired bacterial counts for the routine versus the alcohol rub was statistically significant (p < 0.0001). There was no statistically significant difference between log₁₀ reductions for CHG and PVP-I (p = 0.97).

CONCLUSIONS

This study provides evidence that an alcohol rub protocol is more effective in reducing bacterial counts on hands than routine surgical hand preparation with PVP-I and CHG in a population of practicing ophthalmic surgeons in the operative clinical setting. Thus, it provides a safe alternative as a preoperative hand disinfection method.

Surgical hand antisepsis to reduce surgical site infection

BACKGROUND

Medical professionals routinely carry out surgical hand antisepsis before undertaking invasive procedures to destroy transient micro-organisms and inhibit the growth of resident micro-organisms. Antisepsis may reduce the risk of surgical site infections (SSIs) in patients.

OBJECTIVES

To assess the effects of surgical hand antisepsis on preventing surgical site infections (SSIs) in patients treated in any setting. The secondary objective is to determine the effects of surgical hand antisepsis on the numbers of colony-forming units (CFUs) of bacteria on the hands of the surgical team.

SEARCH METHODS

In June 2015 for this update, we searched: The Cochrane Wounds Group Specialized Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations) and EBSCO CINAHL. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials comparing surgical hand antisepsis of varying duration, methods and antiseptic solutions.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed studies for inclusion and trial quality and extracted data.

MAIN RESULTS

Fourteen trials were included in the updated review. Four trials reported the primary outcome, rates of SSIs, while 10 trials reported number of CFUs but not SSI rates. In general studies were small, and some did not present data or analyses that could be easily interpreted or related to clinical outcomes. These factors reduced the quality of the evidence. SSIsOne study randomised 3317 participants to basic hand hygiene (soap and water) versus an alcohol rub plus additional hydrogen peroxide. There was no clear evidence of a difference in the risk of SSI (risk ratio (RR) 0.97, 95% CI 0.77 to 1.23, moderate quality evidence downgraded for imprecision).One study (500 participants) compared alcohol-only rub versus an aqueous scrub and found no clear evidence of a difference in the risk of SSI (RR 0.56, 95% CI 0.23 to 1.34, very low quality evidence downgraded for imprecision and risk of bias).One study (4387 participants) compared alcohol rubs with additional active ingredients versus aqueous scrubs and found no clear evidence of a difference in SSI (RR 1.02, 95% CI 0.70 to 1.48, low quality evidence downgraded for imprecision and risk of bias).One study (100 participants) compared an alcohol rub with an additional ingredient versus an aqueous scrub with a brush and found no evidence of a difference in SSI (RR 0.50, 95% CI 0.05 to 5.34, low quality evidence downgraded for imprecision). CFUsThe review presents results for a number of comparisons; key findings include the following.Four studies compared different aqueous scrubs in reducing CFUs on hands.Three studies found chlorhexidine gluconate scrubs resulted in fewer CFUs than povidone iodine scrubs immediately after scrubbing, 2 hours after the initial scrub and 2 hours after subsequent scrubbing. All evidence was low or very low quality, with downgrading typically for imprecision and indirectness of outcome. One trial comparing a chlorhexidine gluconate scrub versus a povidone iodine plus triclosan scrub found no clear evidence of a difference-this was very low quality evidence (downgraded for risk of bias, imprecision and indirectness of outcome).Four studies compared aqueous scrubs versus alcohol rubs containing additional active ingredients and reported CFUs. In three comparisons there was evidence of fewer CFUs after using alcohol rubs with additional active ingredients (moderate or very low quality evidence downgraded for imprecision and indirectness of outcome). Evidence from one study suggested that an aqueous scrub was more effective in reducing CFUs than an alcohol rub containing additional ingredients, but this was very low quality evidence downgraded for imprecision and indirectness of outcome.Evidence for the effectiveness of different scrub durations varied. Four studies compared the effect of different durations of scrubs and rubs on the number of CFUs on hands. There was evidence that a 3 minute scrub reduced the number of CFUs compared with a 2 minute scrub (very low quality evidence downgraded for imprecision and indirectness of outcome). Data on other comparisons were not consistent, and interpretation was difficult. All further evidence was low or very low quality (typically downgraded for imprecision and indirectness).One study compared the effectiveness of using nail brushes and nail picks under running water prior to a chlorhexidine scrub on the number of CFUs on hands. It was unclear whether there was a difference in the effectiveness of these different techniques in terms of the number of CFUs remaining on hands (very low quality evidence downgraded due to imprecision and indirectness).

AUTHORS' CONCLUSIONS

There is no firm evidence that one type of hand antisepsis is better than another in reducing SSIs. Chlorhexidine gluconate scrubs may reduce the number of CFUs on hands compared with povidone iodine scrubs; however, the clinical relevance of this surrogate outcome is unclear. Alcohol rubs with additional antiseptic ingredients may reduce CFUs compared with aqueous scrubs. With regard to duration of hand antisepsis, a 3 minute initial scrub reduced CFUs on the hand compared with a 2 minute scrub, but this was very low quality evidence, and findings about a longer initial scrub and subsequent scrub durations are not consistent. It is unclear whether nail picks and brushes have a differential impact on the number of CFUs remaining on the hand. Generally, almost all evidence available to inform decisions about hand antisepsis approaches that were explored here were informed by low or very low quality evidence.

Diversities in perceived knowledge and practice of preoperative skin preparation in Swedish orthopaedic surgery

Preoperative skin preparations may reduce the risk of hospital-acquired infections. This cross sectional questionnaire study aimed to identify the practice and knowledge of preoperative skin preparation in Swedish orthopaedic surgery departments. One hundred and six respondents (response rate 68%) from 13 Swedish orthopaedic departments reported a diversity of current recommendations and evidence, and good knowledge of skin preparations. This study found variations in practice and deviations from recommendations, despite high levels of knowledge.

The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee

INTRODUCTION

The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) evaluated evidence regarding the safety and efficacy of neurostimulation to treat chronic pain, chronic critical limb ischemia, and refractory angina and recommended appropriate clinical applications.

METHODS

The NACC used literature reviews, expert opinion, clinical experience, and individual research. Authors consulted the Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Neuropathic Pain (2006), systematic reviews (1984 to 2013), and prospective and randomized controlled trials (2005 to 2013) identified through PubMed, EMBASE, and Google Scholar.

RESULTS

Neurostimulation is relatively safe because of its minimally invasive and reversible characteristics. Comparison with medical management is difficult, as patients considered for neurostimulation have failed conservative management. Unlike alternative therapies, neurostimulation is not associated with medication-related side effects and has enduring effect. Device-related complications are not uncommon; however, the incidence is becoming less frequent as technology progresses and surgical skills improve. Randomized controlled studies support the efficacy of spinal cord stimulation in treating failed back surgery syndrome and complex regional pain syndrome. Similar studies of neurostimulation for peripheral neuropathic pain, postamputation pain, postherpetic neuralgia, and other causes of nerve injury are needed. International guidelines recommend spinal cord stimulation to treat refractory angina; other indications, such as congestive heart failure, are being investigated.

CONCLUSIONS

Appropriate neurostimulation is safe and effective in some chronic pain conditions. Technological refinements and clinical evidence will continue to expand its use. The NACC seeks to facilitate the efficacy and safety of neurostimulation.

Recognizing and managing infections in total joint arthroplasty

Periprosthetic joint infections are a devastating complication of joint arthroplasty procedures, affecting 1% to 4% of patients. With the increasing demand for joint replacement, the clinical and financial burden of periprosthetic joint infections is challenging. This article reviews the diagnosis and treatment of periprosthetic joint infections.

Current preventive measures for health-care associated surgical site infections: a review

Healthcare-associated infections (HAIs) continue to be a tremendous issue today. It is estimated 1.7 million HAIs occur per year, and cost the healthcare system up to $45 billion annually. Surgical site infections (SSIs) alone account for 290,000 of total HAIs and approximately 8,000 deaths. In today's rapidly changing world of medicine, it is ever important to remain cognizant of this matter and its impact both globally and on the individual lives of our patients. This review aims to impress upon the reader the unremitting significance of HAIs in the daily practice of medicine. Further, we discuss the etiology of HAIs and review successful preventive measures that have been demonstrated in the literature. In particular, we highlight preoperative, intraoperative, and postoperative interventions to combat SSIs. Finally, we contend that current systems in place are often insufficient, and emphasize the benefits of institution-wide adoption of multiple preventive interventions. We hope this concise update and review can inspire additional dialogue for the continuing progress towards improving patient care and patient lives.

New method for assessing hand disinfection shows that pre-operative alcohol/chlorhexidine rub is as effective as a traditional surgical scrub

BACKGROUND

Several studies have shown that rubbing hands with an alcohol/chlorhexidine solution provides equivalent microbial decontamination to a conventional surgical scrub using aqueous chlorhexidine. However, the authors believe that these studies have methodological flaws that limit their applicability to the operating theatre environment. As such, a method was developed to compare products in an everyday operating theatre environment using working operating theatre personnel.

AIM

To determine whether or not an alcohol/chlorhexidine rub is as efficacious as a traditional surgical scrub using a novel method.

METHODS

Bacterial counts at baseline were collected from 20 anaesthetists using the glove juice method. Subsequently, with sequential exchange of sterile gloves, one hand underwent a 3-min scrub using 4% aqueous chlorhexidine, and the other hand underwent a 60-s rub with a 70% isopropyl alcohol/0.5% chlorhexidine solution. The residual bacterial count was collected for each hand after 30 min using the glove juice method. These counts were converted to log10 values to compare the baseline counts of right and left hands, and efficacy between the treatment groups.

FINDINGS

Mean [± standard deviation (SD)] bacterial counts at baseline were (log10) 4.42 ± 0.81 for left hands and 4.64 ± 0.60 for right hands (P > 0.05). The mean (± SD) reduction from baseline was (log10) 1.45 ± 0.50 for 4% chlorhexidine and 2.01 ± 0.98 for alcohol/chlorhexidine (P > 0.05).

CONCLUSION

An alcohol/chlorhexidine hand rub was found to be as efficacious as a traditional scrub after 30 min; this study differs from previous work as it was undertaken in a population of practising anaesthetists in their working environment. The McKenzie method allows baseline and study evaluations to be performed contemporaneously on the same individual. Each subject was his/her own control. This method offers a more clinically relevant way to compare disinfectant solutions than standard methods.

Antibacterial effects on dry-fast and traditional water-based surgical scrubbing methods: a two-time points experimental study

This study determined the in-use effects of dry-fast and traditional hand-washing surgical scrubs among operating room staff members. This is a static group comparison study with purposive sampling. A total of 156 staff members were recruited in an operating room in a medical center located in southern Taiwan. The participants were divided into traditional and dry-fast hand-washing groups. Microbial counts were measured right after the two groups finished surgical scrubbing and at the completion of surgery. The results showed that the use of dry-fast antisepsis has a better persistent effect (P = 0.001), more nurses chose dry-fast antisepsis than surgeons (P = 0.012), and the post-operation number of colonies for nurses was significantly higher than that for surgeons (P = 0.003). Operating room nurses are long-term and frequent users of antibacterial agents, and their requirement of skin protection is higher. The dry-fast technique has the advantage of being less irritating to the skin and less time consuming; therefore, brush-free and dry-fast antisepsis is recommended.

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.

Effect of surgical site infections with waterless and traditional hand scrubbing protocols on bacterial growth

BACKGROUND

Alcohol-based antiseptic scrub formulation has long been used for hand cleansing in the operating room. Recently, a waterless surgical scrub formulation containing 1% chlorhexidine gluconate was developed to provide a comparable antiseptic effect. The present study explored the scrub time required when using waterless hand scrub and traditional hand scrub formulations for operating room staff and compared bacterial growth on the hands after surgical hand scrubbing in the 2 groups.

METHODS

Operating room staff members (n = 100) were recruited randomly from medical centers in Taiwan. Two days in July 2010 were chosen for testing in advance, and the participants were assigned equally to use either a waterless scrub or traditional scrub formulation on 2 separate days. Scrub times were recorded and microorganisms on hands after scrubbing were sampled on 2 separate days. Two days after sampling, the colonies grown on bacterial culture plates were counted and expressed as colony-forming units (CFU) per plate.

RESULTS

At 48 hours after sampling, microorganisms were found on 7 of the 50 plates in the waterless scrub group (1-9 CFU) and on 7 of the 50 plates in the traditional scrub group (1-5 CFU). The difference between the groups was no statistically significant (95% CI, 0.85-1.71). Nine surgical patients were found to have contact with the 14 participants with microorganisms found after scrubbing in the operating room. Among these 9 patients, 1 patient with diabetes who underwent amputation developed local reddish swelling suggestive of surgical site infection necessitating a 7-day course of cefalexin. The incidence of surgical site infection was not signifcantly different in the 2 groups.

CONCLUSIONS

Our findings suggest that waterless hand scrub is as effective as traditional hand scrub in cleansing the hands of microorganisms and more efficient in terms of scrub time.

Eficácia de três métodos de degermação das mãos utilizando gluconato de clorexidina degermante (GCH 2%)

A degermação cirúrgica das mãos e dos antebraços é um procedimento que integra as atividades de paramentação cirúrgica como uma medida de prevenção de infecção do sítio cirúrgico. Com o advento dos princípios antissépticos degermantes, a necessidade do uso de escovas para a degermação cirúrgica tem sido questionada e recomendado o abandono deste uso devido às lesões provocadas na pele. Com a finalidade de fundamentar a eficácia da técnica da degermação cirúrgica sem o uso de escovas ou esponjas, o objetivo deste estudo foi avaliar três métodos para degermação cirúrgica utilizando a formulação degermante de gluconato de clorexidina - GCH 2%: com escova, com esponja e sem artefato. Foram avaliados 29 profissionais da saúde, utilizando o método de caldo de luva para coleta de micro-organismos antes e depois de cada método testado. As análises estatísticas comprovaram não haver diferenças estatísticas significantes na redução microbiana entre os três métodos analisados (p=0,148), o que teoricamente descarta a necessidade da continuidade do uso de escovas e esponjas para a realização da degermação das mãos.

Primary total joint arthroplasty performed in operating rooms following cases of known infection

No study has examined infection rates in "clean" cases following "dirty" cases. This study evaluated patients undergoing elective primary total joint arthroplasties performed in operating rooms following cases of known infection for development of postoperative infection. A retrospective review of all elective primary total joint arthroplasties performed over a 5-year period at our institution was conducted. Patients who underwent primary total joint arthroplasties that followed cases of known infection in the same operating room were examined (minimum follow-up of 1 year) to determine the occurrence of infection based on culture data and subsequent procedures. Thirty-nine total joint arthroplasties (27 total knee arthroplasties and 12 total hip arthroplasties) in 35 patients were performed following cases of known infection in the same operating room. Of these patients, 1 (2.6%) developed a periprosthetic joint infection. The infecting organism (Propionibacterium acnes) was the same as that isolated from the preceding "dirty" case. Further investigation is necessary to determine whether performing primary total joint arthroplasties immediately following "dirty" cases increases risk of infection.

Cultivating quality: reducing surgical site infections in children undergoing cardiac surgery

At Children's Hospital Boston, the cardiovascular operating room nurses led an initiative aimed at reducing surgical site infections (SSIs) in pediatric patients undergoing cardiac surgery. After first standardizing how skin preparation was performed, the nurses sought to determine which agents might be most effective. A literature review yielded relevant research; a survey of other pediatric surgery centers was also conducted. Based on what they learned, the nurses were able to recommend, implement, and evaluate a practice change. This has resulted in reduced SSI rates and improved patient outcomes.

Results of a Survey regarding Perioperative Antiseptic Practices

Background:

Currently, there are many options available for perioperative antiseptic techniques for cutaneous surgery. However, there is a paucity of scientific evidence available to suggest which techniques are worthwhile and which are not.

Objectives:

To determine if there is any consensus among dermatologic surgeons as to which perioperative techniques are being used and which are not.

Methods:

A questionnaire regarding perioperative techniques was mailed to the 641 members of the American College of Mohs Surgery (ACMS).

Results:

Forty-one percent of those queried returned the questionnaire within the allotted time. Surgical caps and booties were the least used antiseptic techniques. Respondents tended to use antiseptic techniques less often for less invasive procedures and more often for more invasive procedures. Few people used surgical caps, surgical gowns, or booties for any procedure.

Conclusions:

Many traditional perioperative antiseptic techniques are not being performed by respondents. Calculated infection rates are very low for all queried procedures.

Use of chlorhexidine-impregnated patch at pin site to reduce local morbidity: the ChIPPS Pilot Trial

Pin tract infection is one of the most common complications associated with the use of external fixation. While some studies have identified the potential benefit of chlorhexidine gluconate-impregnated polyurethane dressings to reduce the incidence of catheter-related bloodstream infections, we are unaware of any published studies that evaluate the effectiveness of similar technologies in reducing the risk for external-fixation-related pin tract infections. Therefore, the purpose of this study was to evaluate the effectiveness of chlorhexidine gluconate-impregnated polyurethane dressing in reducing percutaneous-device-related skin colonisation and local infections. In this initial retrospective cohort, data were abstracted for two groups of consecutive patients undergoing surgery involving external fixation at an interdisciplinary foot and ankle surgical unit. All patients received surgical treatment of their foot/ankle pathology along with application of a hybrid external fixator. Twenty patients (45% male, age 54.5 +/- 3.69 years) received chlorhexidine gluconate-impregnated polyurethane dressing and twenty (55% male, age 55.8 +/- 3.22 years) received standard pin care. There was a significantly higher rate of pin tract infection in patients who received standard pin care compared with those who received chlorhexidine gluconate-impregnated polyurethane dressings (25% versus 0%, P = 0.047). There was no significant difference in any of the descriptive study characteristics (age, gender, diabetes and presence of neuropathy). The results of this initial study suggest that chlorhexidine gluconate-impregnated polyurethane dressing may be effective to reduce the incidence of pin tract infections and help decrease morbidity associated with external fixation.

Surgical hand antisepsis to reduce surgical site infection

BACKGROUND

Surgical hand antisepsis, to destroy transient micro-organisms and inhibit the growth of resident micro-organisms, is routinely carried out before undertaking invasive procedures. Antisepsis may reduce the risk of surgical site infections in patients.

OBJECTIVES

To determine the effects of surgical hand antisepsis on the number of surgical site infections (SSIs) in patients. The secondary objective is to determine the effects of surgical hand antisepsis on the numbers of colony forming units (CFUs) of bacteria on the hands of the surgical team.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials (Issue 2, 2007), MEDLINE (Week 5, 2007), CINAHL (June 2007), EMBASE (Week 23, 2007) and ZETOC (2005).

SELECTION CRITERIA

Randomised controlled trials comparing surgical hand antisepsis of varying duration, methods and antiseptic solutions.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed studies for selection, trial quality and extracted data.

MAIN RESULTS

Ten trials were included in this review. Only one trial reported the primary outcome, rates of SSIs, and nine trials measured numbers of CFUs. One trial involving 4387 patients found alcohol rubs with additional active ingredients were as effective as aqueous scrubs in reducing SSIs. Four trials compared different alcohol rubs containing additional active ingredients with aqueous scrubs for numbers of CFUs on hands. One trial found N-duopropenide more effective than chlorhexidine and povidone iodine aqueous scrubs. One trial found 45% propanol-2, 30% propanol-1 with 0.2% ethylhexadecyldimethyl ammonium ethylsulfate more effective than chlorhexidine scrubs. One trial found no difference between 1% chlorhexidine gluconate in 61% ethyl alcohol or zinc pyrithione in 70% ethyl alcohol against aqueous povidone iodine. A fourth trial found 4% chlorhexidine gluconate scrubs more effective than chlorhexidine in 70% alcohol rubs. Four trials compared the relative effects of different aqueous scrubs in reducing CFUs on hands. Three trials found chlorhexidine gluconate scrubs were significantly more effective than povidone iodine scrubs. One trial found no difference between chlorhexidine gluconate scrubs and povidone iodine plus triclosan scrubs. Two trials found no evidence of a difference between alternative alcohol rubs in terms of the number of CFUs. Four trials compared the effect of different durations of scrubs and rubs on the numbers of CFUs on hands. One trial found no difference after the initial scrub but found subsequent three minute scrubs using chlorhexidine significantly more effective than subsequent scrubs lasting 30 seconds. One trial found that following a one minute hand wash, a three minute rub appears to be more effective than the five minute rub using alcohol disinfectant. The other comparisons demonstrated no difference.

AUTHORS' CONCLUSIONS

Alcohol rubs used in preparation for surgery by the scrub team are as effective as aqueous scrubbing in preventing SSIs however this evidence comes from only one, equivalence, cluster trial which did not appear to adjust for clustering. Four comparisons suggest that alcohol rubs are at least as, if not more, effective than aqueous scrubs though the quality of these is mixed and each study presents a different comparison, precluding meta analysis. There is no evidence to suggest that any particular alcohol rub is better than another. Evidence from 4 studies suggests that chlorhexidine gluconate based aqueous scrubs are more effective than povidone iodine based aqueous scrubs in terms of the numbers of CFUs on the hands. There is limited evidence regarding the effects on CFUs numbers of different scrub durations. There is no evidence regarding the effect of equipment such as brushes and sponges.

Comparative of a new and innovative 2% chlorhexidine gluconate-impregnated cloth with 4% chlorhexidine gluconate as topical antiseptic for preparation of the skin prior to surgery

BACKGROUND

Decreasing the microbial skin burden reduces the risk of surgical site infection (SSI). The present study compares the activity of an innovative 2% chlorhexidine gluconate (CHG)-impregnated preoperative skin preparation cloth (PC) with a standard application procedure with a 4% CHG surgical skin preparation (SP).

METHODS

A paired, randomized, parallel phase III study was conducted adhering to the Food and Drug Administration (FDA) design criteria for evaluating preoperative skin preparations. Subjects' left and right sides of the inguinal and abdominal skin sites (n = 30) were randomized to either PC or SP treatment. Following baseline cultures, PC sites were prepped for 3 minutes, and SP sites were prepped for 4 minutes. Skin site cultures were obtained at 10 minutes, 30 minutes, and 6 hours postpreparation. Bacterial recovery was expressed as log(10) colony-forming units (cfu)/cm(2) for baseline and postapplication microbial recovery.

RESULTS

Mean microbial baseline for the abdominal and inguinal skin sites were as follows: PC = 3.36 cfu/cm(2) and 6.15 cfu/cm(2); SP = 3.51 cfu/cm(2) and 6.16 cfu/cm(2), respectively. Log(10) reduction for PC abdominal and inguinal prepped sites at 10 minutes, 30 minutes, and 6 hours postpreparation were 2.50, 2.33, and 2.54; 3.45, 3.50, and 3.64, respectively. Log(10) reductions for SP abdominal and inguinal prepped sites at 10 minutes, 30 minutes, and 6 hours were 2.18, 2.19, and 2.77; 2.78, 2.63, and 3.15, respectively.

CONCLUSION

Microbial reductions from abdominal-inguinal PC prepped sites were significantly reduced (P < .05) compared with baseline, exceeding the FDA log-reduction criteria for a preoperative topical skin preparation. Compared with baseline, microbial reductions at the SP-prepped abdominal-inguinal sites were significant (P < .05). SP abdominal-prepped sites met the FDA log-reduction criteria; inguinal sites, however, failed to meet expected FDA log-reduction criteria at 10 minutes postpreparation. The PC-treated inguinal sites at 10 minutes, 30 minutes, and 6 hours post-skin preparation demonstrated significantly greater microbial reductions than did the SP-treated inguinal sites (P < .01).

Surgical hand scrubs in relation to microbial counts: systematic literature review

AIM

This paper reports a systematic review whose objective was to determine the effectiveness of surgical hand scrubs in relation to bacterial growth on the hands of operating room staff members.

BACKGROUND

Despite the need for surgical hand scrubs, evidence shows that frequent and prolonged use of antiseptics and brushes may damage the skin. Consequently, lesions may appear, become more heavily colonized by microorganisms and increase the risk of transmitting infection to patients. Recommendations about surgical hand scrubs vary widely and their effectiveness in relation to microbial counts is unknown.

METHOD

A variety of healthcare databases were searched covering the period between January 1990 and December 2004. Based on selection criteria, the abstracts of studies identified were checked to determine whether they fulfilled the inclusion criteria. All studies were assessed as having adequate methodological quality. Using Cochrane Review Manager 4.2 software, weighted mean difference and 95% confidence intervals were calculated.

FINDINGS

Three studies were included in this review. Two studies compared the effectiveness of surgical hand scrubs using an alcohol-based product and a 6-minute scrub using 4% chlorhexidine gluconate; meta-analysis showed a statistically significant difference (weighted mean difference = -0.63, 95% confidence intervals = -0.99 to -0.27, P = 0.0006). One study compared the effectiveness of 2- and 3-minute surgical hand scrubs using 4% chlorhexidine gluconate; meta-analysis showed no difference (weighted mean difference = 0.29, 95% confidence intervals = -0.13 to 0.71, P = 0.18).

CONCLUSION

Surgical hand scrubs using an alcohol-based product were more effective than a 6-minute scrub using 4% chlorhexidine gluconate. There is no evidence to support a 2-minute surgical hand scrub as being more effective than a 3-minute one using 4% chlorhexidine gluconate.

Influence of Skin Flora and Preventive Measures on Surgical Site Infection during Cardiac Surgery

BACKGROUND

The skin flora responsible for most surgical site infections (SSIs) include Staphylococcus aureus, coagulase-negative staphylococci, Propionibacterium acnes, gram-negative bacilli, micrococci, and diphtheroids. The two major methods of reducing local concentrations of bacteria are administration of an antibiotic and cleansing of the skin. Resistance to antibiotics is a major concern. Mortality rates in patients infected by methicillin-resistant Staphylococcus aureus or comparably virulent bacteria may be as high as 74%.

METHODS

Review of current practice and guidelines.

RESULTS

There is no standard regimen for antimicrobial prophylaxis. No added benefit is conferred by prophylaxis exceeding 48 h. A number of preoperative skin care techniques have been used to limit concentrations of bacteria at the surgical site, including antiseptic preparations, adhesive barrier drapes, topical antibiotics, hair removal, and hand hygiene.

CONCLUSIONS

Antibiotic prophylaxis minimizes the risk of SSI in patients having cardiac surgery. The emergence of antibiotic-resistant bacteria makes it necessary to avoid the use of antimicrobials when they are not necessary. Preoperative skin care does reduce contamination at the incisional site and may reduce the risk of SSI.

General principles of surgery applied to cattle

Basic principles of surgery are important to review, even for experienced surgeons. Although aseptic surgical principles are not always applicable in the field, we have to respect some guidelines. Recent research will influence the way that we do things, based on what we have been taught and our experience. Respecting those simple principles can make a big difference in the final outcome.