Conversion to Chlorhexidine Gluconate for Perioperative Vaginal Preparation: An Evidence‐Based Process Improvement Project

Decreasing post hysterectomy surgical site infections with the implementation of a hysterectomy-specific bundle

BACKGROUND

Surgical site infections (SSI) are a common complication of hysterectomy. Surgical bundles have been shown to reduce SSIs. Here we describe a bundle that was used to combat an abnormal rise in SSI events that resulted in a greater than 75% reduction at our institution.

METHODS

A hysterectomy-specific bundle was developed based on the prior success of SSI prevention bundles. Development involved longitudinal education and training to ensure accuracy and compliance. All inpatient abdominal, laparoscopic, and vaginal hysterectomies performed at a tertiary referral center were included. The preintervention, intervention, and postintervention periods were each one year in length. SSI rates were peer-reviewed monthly and overall trends were tracked, including compliance with bundle guidelines.

RESULTS

Preintervention, an abnormal rise in SSI was identified at 3.76%. During the intervention, 309 inpatient hysterectomies were completed. In this period, 6 posthysterectomy SSI events occurred (3.76% vs 1.94%, P = .21). Four SSIs followed laparotomy and 2 followed laparoscopy. Compliance during the intervention period ranged from 79% to 89% with a mean of 85%. In the postintervention period, there were 6 SSI following 689 hysterectomies (3.76% vs 0.87%, P = .004). The majority of SSI occurred after abdominal hysterectomy.

CONCLUSIONS

Implementation of a hysterectomy-specific surgical bundle allowed for a significant reduction in post hysterectomy SSI during a yearlong intervention period and a sustained, further reduction in the postintervention period.

Impact of converting from povidone iodine to chlorhexidine gluconate for vaginal preparation prior to hysterectomy

BACKGROUND

While vaginal preparation prior to hysterectomies to reduce the risk of contamination by vaginal flora is standard, there is no consensus on the appropriate choice of antisepsis agent. The aim of this study was to evaluate whether the conversion from povidone-iodine (PI) to chlorhexidine gluconate (CHG) would reduce surgical site infection (SSI) rates and improve standardized infection ratios (SIR).

METHODS

A quality improvement process was implemented to educate all providers, trainees, and staff followed by wide-spread conversion to CHG vaginal preparation prior to all hysterectomies starting on June 1, 2021. The SSI rates and SIRs were compared between the preintervention and postintervention periods.

RESULTS

There was no significant change in SSI rate or SIR from the preintervention to the postintervention period, indicating that CHG is noninferior to PI. The SSI rate was 1.53% preintervention compared to 1.57% post, and the SIR was 1.976 and 2.049, respectively.

CONCLUSIONS

While our data suggests that the conversion from PI to CHG for vaginal prep alone is insufficient to reduce SSI rates and SIRs, it is noninferior and should be considered as part of a larger preventative bundle.

Clinical and Personal Lubricants Impact the Growth of Vaginal Lactobacillus Species and Colonization of Vaginal Epithelial Cells: An in Vitro Study

BACKGROUND

Vaginal lubricants are commonly used during gynecological examinations, during sexual activities, or to alleviate vaginal dryness. Many lubricants contain potentially bacteriostatic or bactericidal agents (parabens, chlorhexidine gluconate, nonoxynol-9). Our objective was to evaluate the impact of lubricants that vary in formulation on the growth and viability of vaginal Lactobacillus species and vaginal epithelial cell (VEC) colonization in an in vitro model.

METHODS

Growth curve, disk diffusion, and minimal inhibitory assays were used to determine the impact of lubricants or excipients on the growth of Lactobacillus crispatus, Lactobacillus gasseri, Lactobacillus jensenii, and Lactobacillus iners. L. crispatus strain was used in VEC colonization assays. Statistical differences were determined by analysis of variance.

RESULTS

Lubricants containing chlorhexidine gluconate or nonoxynol-9 (N-9; Conceptrol, K-Y Jelly, and Surgilube) significantly inhibited Lactobacillus species growth (P < 0.05). In contrast, other clinical lubricants (E-Z Lubricating Jelly, McKesson Lubricating) and personal lubricants (Astroglide Liquid, Good Clean Love Almost Naked, K-Y Warming Jelly) did not exhibit this effect. Chlorhexidine gluconate had a detrimental effect on Lactobacillus growth and exhibited stronger antimicrobial activity compared with methylparaben and propylparaben (P < 0.0001). There were lubricants that did not induce cytotoxicity in VEC (Good Clean Love Almost Naked, E-Z Lubricating Jelly, McKesson Lubricating Jelly), but these products did substantially decrease the attachment of L. crispatus to VEC, particularly when VEC were preexposed to lubricants before inoculation with bacteria (P < 0.0001).

CONCLUSIONS

This in vitro model indicates that select vaginal lubricants, particularly those with chlorhexidine gluconate, have potentially adverse effects on women's health by reducing growth and recolonization of vaginal Lactobacillus species.