Preoperative Skin Cleanser

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Looks like it’s time for me to rethink my preference for preoperative skin cleanser. This past week there were two new prospective studies published in the Jan. 7 issue of the New England Journal of Medicine, along with an accompanying editorial.

The Centers for Disease Control and Prevention estimates that in American hospitals alone, there are 1.7 million healthcare-associated infections each year. Of these infections, 22% are surgical site infections (SSIs). So if simply changing the preop skin cleanser will reduce my patient’s SSI risk, then I will do so.

Rabih Darouiche, MD and colleagues found using chlorhexidine as the preoperative skin cleanser reduced infections by 41% compared with povidone-iodine. Their study involve randomly assigning 897 adults undergoing clean-contaminated surgery to preoperative skin preparation with chlorhexidine gluconate (CHG) and alcohol or with povidone-iodine (P-I). Patients were assessed for occurrence of SSIs within 30 days postoperatively.

CHG-alcohol use was associated with a lower overall rate of SSIs (9.5% vs. 16.1% for P-I), lower rates of superficial (4.2% vs. 8.6%) and deep (1.0% vs. 3.0%) incisional SSIs. There was no significant difference between the two groups where organ-space infections (4.4% and 4.6%, respectively) or sepsis from SSIs (2.7% and 4.3%) was involved.

Lonneke G.M. Bode, M.D and colleagues found that screening and decolonizing patients who are nasal carriers of S. aureus, combined with washing with chlorhexidine soap reduced the risk of SSIs by 58%.

"The weight of evidence suggests that chlorhexidine–alcohol should replace povidone–iodine as the standard for preoperative surgical scrubs," Dr. Wenzel writes. "The use of intranasal mupirocin and chlorhexidine baths for carriers of S. aureus who have been identified preoperatively by means of a real-time [PCR] assay could be reserved primarily for patients who are undergoing cardiac surgery, all patients receiving an implant, and all immunosuppressed surgical candidates. Currently, the incremental value of preoperative baths with chlorhexidine alone for all surgical patients is unclear, but this relatively straightforward procedure could be examined critically in future studies."

REFERENCES
Minimizing Surgical-Site Infections; N Engl J Med. 2010;362:9-17, 75-77; Richard P. Wenzel, M.D.
Chlorhexidine–alcohol versus povidone–iodine for surgical-site antisepsis; N Engl J Med 2010 Jan 7; 362:18; Darouiche RO et al.
Preventing surgical-site infections in nasal carriers of Staphylococcus aureus; N Engl J Med 2010 Jan 7; 362:9; Bode LGM et al.
Advances in Preventing Surgical-Site Infections. JWatch Infect. Diseases 2010: 1-1