From Infection Control and Hospital Epidemiology
| Abstract and Introduction |
Abstract
Objective. To evaluate the clinical effectiveness of preoperative skin antiseptic preparations and application techniques for the prevention of surgical site infections (SSIs).
Design. Systematic review of the literature using Medline, EMBASE, and other databases, for the period January 2001 to June 2011.
Methods. Comparative studies (including randomized and nonrandomized trials) of preoperative skin antisepsis preparations and application techniques were included. Two researchers reviewed each study and extracted data using standardized tables developed before the study. Studies were reviewed for their methodological quality and clinical findings.
Results. Twenty studies (n = 9,520 patients) were included in the review. The results indicated that presurgical antiseptic showering is effective for reducing skin flora and may reduce SSI rates. Given the heterogeneity of the studies and the results, conclusions about which antiseptic is more effective at reducing SSIs cannot be drawn.
Conclusions. The evidence suggests that preoperative antiseptic showers reduce bacterial colonization and may be effective at preventing SSIs. The antiseptic application method is inconsequential, and data are lacking to suggest which antiseptic solution is the most effective. Disinfectant products are often mixed with alcohol or water, which makes it difficult to form overall conclusions regarding an active ingredient. Large, well-conducted randomized controlled trials with consistent protocols comparing agents in the same bases are needed to provide unequivocal evidence on the effectiveness of one antiseptic preparation over another for the prevention of SSIs.
Design. Systematic review of the literature using Medline, EMBASE, and other databases, for the period January 2001 to June 2011.
Methods. Comparative studies (including randomized and nonrandomized trials) of preoperative skin antisepsis preparations and application techniques were included. Two researchers reviewed each study and extracted data using standardized tables developed before the study. Studies were reviewed for their methodological quality and clinical findings.
Results. Twenty studies (n = 9,520 patients) were included in the review. The results indicated that presurgical antiseptic showering is effective for reducing skin flora and may reduce SSI rates. Given the heterogeneity of the studies and the results, conclusions about which antiseptic is more effective at reducing SSIs cannot be drawn.
Conclusions. The evidence suggests that preoperative antiseptic showers reduce bacterial colonization and may be effective at preventing SSIs. The antiseptic application method is inconsequential, and data are lacking to suggest which antiseptic solution is the most effective. Disinfectant products are often mixed with alcohol or water, which makes it difficult to form overall conclusions regarding an active ingredient. Large, well-conducted randomized controlled trials with consistent protocols comparing agents in the same bases are needed to provide unequivocal evidence on the effectiveness of one antiseptic preparation over another for the prevention of SSIs.
Introduction
Surgical site infections (SSIs) occur in approximately 2%–5% of patients who undergo clean extra-abdominal surgeries, such as thoracic and orthopedic surgery, and in up to 20% of patients who undergo intra-abdominal surgery interventions. SSIs can lead to increased morbidity and mortality and are associated with prolonged hospital stay and greater hospital costs. The Institute for Healthcare Improvement reports that SSIs in the United States increase the length of hospital stay by an average of 7.5 days, at an estimated cost of $130 million to $845 million per year. In 2006, SSIs accounted for 14% of healthcare-associated infections in the United Kingdom, resulting in additional costs of between £814 and £6,626, depending on severity.
Because microbial contamination of the surgical site is a requirement for the development of an SSI, prevention techniques aim to minimize the presence and spread of microorganisms. Prevention strategies include antibiotic prophylaxis, antiseptic prophylaxis, hair removal, perioperative glucose control, and maintenance of normothermia.Topical antiseptics may be applied to the skin preoperatively to reduce SSI risk. The main types of antiseptics are iodine or iodophor (such as povidone-iodine [PI]), alcohol, and chlorhexidine gluconate (CHG). CHG and PI can be mixed with either alcohol or water, which may have implications for effectiveness.
The Centers for Disease Control and Prevention (CDC) guidelines recommend that patients shower or bathe with an antiseptic solution the night before surgery and that the skin be prepared with "an appropriate antiseptic agent.” Clinical practice guidelines from the National Institute for Health and Clinical Excellence recommend that patients shower or bathe with soap the day before or the day of surgery and that iodophor-impregnated surgical drapes be used when incise drapes are required. They also recommend preparing the skin at the surgical site with antiseptic immediately before incision, but they do not indicate a preference for CHG or PI.
We conducted a systematic review of the available published data on the comparative clinical effectiveness and safety of preoperative skin antiseptic preparations for preventing SSIs. This review is an update of a comprehensive report by the Canadian Agency for Drugs and Technologies in Health.[7]
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