Randomized clinical trial of preoperative skin antisepsis with chlorhexidine gluconate or povidone–iodine

Incisional surgical site infections by subcutaneous soaking of wound with aqueous 0.05% chlorhexidine gluconate in gastroenterological surgery: A randomized controlled trial

BACKGROUND

Chlorhexidine gluconate solution is superior to povidone-iodine for prevention of surgical site infection. However, the overall efficacy of chlorhexidine gluconate for surgical site infection prevention in various types of gastroenterological surgery, as well as the optimal concentration of chlorhexidine gluconate, remain unclear. The aim of the present study was to clarify whether subcutaneous wound soaking with chlorhexidine gluconate would reduce the incidence of surgical site infection associated with gastroenterological surgery in patients with wound classes Ⅱ to Ⅳ.

METHODS

Patients were randomly assigned (1:1) to either wound soaking with chlorhexidine gluconate (chlorhexidine gluconate group) or no chlorhexidine gluconate soaking (control group). After closure of the abdominal fascia, gentle subcutaneous soaking of the wound was performed using gauze fully soaked in aqueous 0.05% chlorhexidine gluconate before skin closure. Incisional surgical site infection was diagnosed using the Centers for Disease Control and Prevention criteria. The primary end point was the occurrence of incisional surgical site infection.

RESULTS

Among 363 patients, 245 (67%) underwent laparoscopic surgery. All 363 patients were included-181 in the chlorhexidine gluconate group (49.9%) and 182 (50.1%) in the control group. There were no significant inter-group differences in patient background, the type of procedure, or wound classification. The incidence proportion of incisional surgical site infection was significantly lower in the chlorhexidine gluconate group than in the control group (9.4% vs 19.2%; P = .008).

CONCLUSION

Subcutaneous wound soaking with chlorhexidine gluconate reduces the incidence of incisional surgical site infection in patients undergoing gastroenterological surgery.

Surgical site antiseptic preparations for otolaryngology - Head and neck surgery: A current review

OBJECTIVE

To review current literature and guidelines on antiseptic surgical site preparations for preventing surgical site infections with consideration of contraindications specific to head and neck surgery.

DATA SOURCES

PubMed/MEDLINE, clinicaltrials.gov, accessdata.fda.gov, Manufacturer websites.

REVIEW METHODS

A scoping review on the literature and clinical studies comparing the efficacy of different surgical site preparations. Studies were included if they were a randomized controlled trial (RCT) comparing at least two commonly used and available antiseptic preparations. Additionally, a compilation of warnings and contraindications from manufacturer labels and articles are included. Due to the lack of randomized controlled trials concerning antiseptic preparation use in head and neck surgery specifically, an additional search was executed for articles not limited to randomized controlled trials that compared different antiseptic preparation used in surgeries concerning the head and neck.

RESULTS

Of 56,983 resulting abstracts and 3798 of them being screened, 25 RCTs were included. These RCTs included a variety of surgeries including gastrointestinal, obstetric, gynecologic, orthopedic, and vascular procedures. When searching for abstracts concerning head and neck surgeries, 9 studies were found and included.

CONCLUSIONS

To reduce surgical site infections and avoid application in situations with contraindications, practicing surgeons need to be familiar with the existing literature regarding different surgical preparations and what warnings manufacturers have listed on the products. Optimal surgical site preparation for head and neck surgery is challenging as proximity to oxygen contraindicates newer alcohol-based options that are potentially flammable. We summarize evidence-based surgical site preparation for head and neck surgery.

Randomized controlled trial of olanexidine gluconate and povidone iodine for surgical site infection after gastrointestinal surgery

Aim

Antiseptics used at surgical sites are vital to preventing surgical site infections (SSI). In this study, a comparative investigation of the novel antiseptics olanexidine gluconate (OG) and povidone-iodine (PI) was conducted to determine whether OG is more effective than PI against SSI after gastrointestinal surgery.

Methods

This prospective, randomized, single-blind, interventional, single-center study was conducted between August 2018 and February 2021. Patients scheduled for large-scale gastrointestinal surgeries were randomized into two groups and administered OG (OG group) or PI (PI group) as preoperative antiseptics. The primary endpoint was the SSI occurrence rate within 30 days after surgery.

Results

In total, 525 patients were enrolled in this study, of whom 256 and 254 were in the OG and PI groups, respectively. The total SSI occurrence rate in the OG group (10.8%; n = 26) and the PI group (13.0%; n = 33) was not significantly different (p = 0.335). The occurrence rate of superficial incisional SSI and organ/space SSI did not significantly differ between the groups; however, that of deep incisional SSI showed a significant difference, with 0.4% (n = 1) in the OG group and 4.3% (n = 11) in the PI group (p = 0.003).

Conclusion

OG, as a preoperative skin antiseptic, did not reduce the occurrence rate of total SSI. However, deep incisional SSI may be reduced using OG.

A Comparison of Chlorhexidine-Alcohol and Povidone-Iodine-Alcohol on the Incidence of Surgical Site Infection

BACKGROUND

Surgical site infection (SSI) persists as a global challenge, accounting for 20%-25% of all healthcare-associated infections. The SSI rate has been reported to range from 2.5% to 41.9%. Skin preparation with acceptable antiseptic preparations has a high recommendation from the Centers for Disease Control as an SSI preventive measure.

AIM

The aim was to compare the efficacy of 10% povidone-iodine in 70% isopropyl alcohol with 2% chlorhexidine in 70% isopropyl alcohol in preventing SSI.

METHOD

This prospective randomized study included patients who were followed up for 30 days looking for SSI. Swabs were taken from wounds that developed SSI. A culture of all swabs was done.

RESULT

One hundred and fifty-three patients were recruited into the study. Overall, eight (5.23%) of the 153 patients developed SSI. The SSI rate in clean wounds was 2.6%, while the SSI rate in clean-contaminated wounds was 7.9%. No statistically significant difference was found (p=0.141) between the two groups.

Comparing the efficacy of chlorhexidine and povidone-iodine in preventing surgical site infections: A systematic review and meta-analysis

Surgical site infections (SSIs) post-surgery impact patient health and raise healthcare costs. This meta-analysis examines the efficacy of antiseptics, chlorhexidine and povidone-iodine, in reducing SSIs, including various types, to settle ongoing debates on their comparative effectiveness. A systematic literature search conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was executed on four established databases without temporal restrictions. Only randomized controlled trials (RCTs) including patients aged 18 years or older undergoing clean or potentially contaminated surgeries were included. Two independent evaluators carried out study selection, data extraction and quality assessment, adhering to Cochrane Collaboration's risk of bias tool. Statistical analyses were performed using chi-square tests and the I2 index to evaluate heterogeneity, and meta-analyses were conducted employing either fixed-effects or random-effects models as warranted by the heterogeneity assessments. A total of 16 RCTs were included after rigorous selection from an initial pool of 1742 articles. The studies demonstrated low levels of heterogeneity, supporting the use of a fixed-effects model. Chlorhexidine exhibited statistically lower rates of overall SSIs (RR 0.75; 95% CI 0.64-0.88; p < 0.001), superficial SSIs (RR 0.62; 95% CI 0.47-0.82; p < 0.001) and deep SSIs compared to povidone-iodine. The study furnishes compelling evidence in favour of chlorhexidine as a more efficacious antiseptic agent over povidone-iodine in minimizing the risk of various types of SSIs.

Effectiveness of chlorhexidine versus povidone-iodine for preventing surgical site wound infection: A meta-analysis

A systematic evaluation was conducted to assess the efficacy of two disinfectants, chlorhexidine and povidone-iodine, as primary components in preventing surgical site infection (SSI). A comprehensive computerised search was performed in the PubMed, EMBASE, Web of Science, Cochrane Library, CNKI and Wanfang databases for randomised controlled trials (RCTs) on chlorhexidine and povidone-iodine disinfection for the prevention of SSI from inception until July 2023. Two independent researchers completed literature screening, data extraction and quality assessment of the included studies. The meta-analysis was conducted using RevMan 5.4 software. Ultimately, 20 RCTs were included, which included 13 133 patients, with 6460 patients in the chlorhexidine group and 6673 patients in the povidone-iodine group. The meta-analysis results revealed that the incidence rate of surgical site wound infections [odds ratio (OR): 0.67, 95% confidence interval (CI): 0.58-0.78, p < 0.001)], superficial SSI rate (OR: 0.59, 95% CI: 0.46-0.75, p < 0.001) and deep SSI rate (OR: 0.49, 95% CI: 0.31-0.79, p = 0.003) were all lower in patients subjected to chlorhexidine disinfection compared to those patients receiving povidone-iodine disinfection. Existing evidence suggests that chlorhexidine is more effective than povidone-iodine at preventing SSI. However, owing to the potential quality limitations of the included studies, further validation through high-quality large-scale RCTs is warranted.

Effect of aqueous olanexidine versus alcohol-based chlorhexidine for surgical skin antisepsis on incidence of surgical site infections in gastrointestinal surgery: multicentre randomised controlled clinical trial (OEDO trial) protocol

INTRODUCTION

Surgical site infections (SSIs) are among the most common nosocomial infections in surgery patients. Two types of preparations, povidone-iodine and chlorhexidine-alcohol, are commonly used in preoperative antiseptic procedures worldwide. However, there are inconsistencies among international guideline recommendations concerning skin antiseptics. This trial aimed to evaluate the superiority of olanexidine, which reduced SSI rates more than povidone-iodine in our previous randomised trial, over chlorhexidine-alcohol in clean-contaminated surgery.

METHODS AND ANALYSIS

This multicentre randomised controlled clinical trial will compare two antiseptics (1.5% olanexidine and 1.0% chlorhexidine-alcohol) to prevent SSI in clean-contaminated gastrointestinal surgeries with surgical wounds. On providing consent, patients aged <18 years will be included. The primary outcome will be the postoperative 30-day overall SSI rate, while the secondary outcomes will be the postoperative 30-day superficial incisional SSI rate, deep incisional SSI rate, organ/space SSI rate, positive bacterial wound culture rate, cultured bacterial strains, rates of intervention-related toxicity and allergic events (eg, erythema, pruritus, dermatitis and other symptoms of allergy around the region disinfected by the antiseptic during surgery), rate of reoperations due to SSI, medical economic effect indicators (based on health insurance claims) and hospital duration. The Mantel-Haenszel method will be used to estimate the adjusted risk ratio and its 95% CI for the primary analysis, which will compare the treatment effects.

ETHICS AND DISSEMINATION

The protocol was approved by the Institutional Review Board of Keio University School of Medicine and subsequently by the board of each participating site. Participant recruitment began in January 2023. The final results will be published in medical journals after international peer review.

TRIAL REGISTRATION NUMBER

UMIN000049712.

Evidence-based guideline for the prevention and management of perioperative infection

BACKGROUND

We have updated the guideline for preventing and managing perioperative infection in China, given the global issues with antimicrobial resistance and the need to optimize antimicrobial usage and improve hospital infection control levels.

METHODS

We conducted a comprehensive evaluation of the evidence for prevention and management of perioperative infection, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Revisions were made to the guidelines in response to feedback from the experts.

RESULTS

There were 17 questions prepared, for which 37 recommendations were made. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the meta-analysis results, recommendations were graded using the Delphi method to generate useful information.

CONCLUSIONS

This guideline provides evidence to perioperative antimicrobial prophylaxis that increased the rational use of prophylactic antimicrobial use, with substantial improvement in the risk-benefit trade-off.

PA, Phelps K, Bosse M, Karunakar M, Kempton L, Sims S, Hsu J, Seymour R, Churchill C, Mayfield A, Sweeney J, Jaeblon T, Beer R, Bauer B, Meredith S, Talwar S, Domes CM, Gage MJ, Reilly RM, Paniagua A, Dupree J, Weaver MJ, von Keudell AG, Sagona AE, Mehta S, Donegan D, Horan A, Dooley M, Heng M, Harris MB, Lhowe DW, Esposito JG, Alnasser A, Shannon SF, Scott AN, Clinch B, Weber B, Beltran MJ, Archdeacon MT, Sagi HC, Wyrick JD, Le TT, Laughlin RT, Thomson CG, Hasselfeld K, Lin CA, Vrahas MS, Moon CN, Little MT, Marecek GS, Dubuclet DM, Scolaro JA, Learned JR, Lim PK, Demas S, Amirhekmat A, Dela Cruz YM. Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial

BACKGROUND

Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture.

METHODS

We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304.

FINDINGS

Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4).

INTERPRETATION

For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds.

FUNDING

US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.

Efficacy of different preoperative skin antiseptics on the incidence of surgical site infections: a systematic review, GRADE assessment, and network meta-analysis

BACKGROUND

Surgical site infection (SSI) is the most common postoperative complication and substantially increases health-care costs. Published meta-analyses and international guidelines differ with regard to which preoperative skin antiseptic solution and concentration has the highest efficacy. We aimed to compare the efficacy of different skin preparation solutions and concentrations for the prevention of SSIs, and to provide an overview of current guidelines.

METHODS

This systematic review and network meta-analysis compared different preoperative skin antiseptics in the prevention of SSIs in adult patients undergoing surgery of any wound classification. We searched for randomised controlled trials (RCTs) in MEDLINE, Embase, and Cochrane CENTRAL, published up to Nov 23, 2021, that directly compared two or more antiseptic agents (ie, chlorhexidine, iodine, or olanexidine) or concentrations in aqueous and alcohol-based solutions. We excluded paediatric, animal, and non-randomised studies, and studies not providing standard preoperative intravenous antibiotic prophylaxis. Studies with no SSIs in both groups were excluded from the quantitative analysis. Two reviewers screened and reviewed eligible full texts and extracted data. The primary outcome was the occurrence of SSI (ie, superficial, deep, and organ space). We conducted a frequentist random effects network meta-analysis to estimate the network effects of the skin preparation solutions on the prevention of SSIs. A risk-of-bias and Grading of Recommendations, Assessment, Development, and Evaluation assessment were done to determine the certainty of the evidence. This study is registered with PROSPERO, CRD42021293554.

FINDINGS

Overall, 2326 articles were identified, 33 studies were eligible for the systematic review, and 27 studies with 17 735 patients reporting 2144 SSIs (overall incidence of 12·1%) were included in the quantitative analysis. Only 2·0-2·5% chlorhexidine in alcohol (relative risk 0·75, 95% CI 0·61-0·92) and 1·5% olanexidine (0·49, 0·26-0·92) significantly reduced the rate of SSIs compared with aqueous iodine. For clean surgery, we found no difference in efficacy between different concentrations of chlorhexidine in alcohol. Seven RCTs were at high risk of bias, 24 had some concerns, and two had low risk of bias. Heterogeneity across the studies was moderate (I²=27·5%), and netsplitting did not show inconsistencies between direct and indirect comparisons. Five of ten studies that mentioned adverse events related to the skin preparation solutions reported no adverse events, and five reported a total of 56 mild events (mainly erythema, pruritus, dermatitis, skin irritation, or mild allergic symptoms); none reported a substantial difference in adverse events between groups.

INTERPRETATION

For adult patients undergoing a surgical procedure of any wound classification, skin preparation using either 2·0-2·5% chlorhexidine in alcohol or 1·5% olanexidine is most effective in the prevention of SSIs. For clean surgery, no specific concentration of chlorhexidine in alcohol can be recommended. The efficacy of olanexidine was established by a single randomised trial and further investigation is needed.

FUNDING

Dutch Association for Quality Funds Medical Specialists.

The effect of preoperative skin preparation on clinical outcomes with incisional surgery: a network meta-analysis

BACKGROUND

Preoperative skin antiseptics are used prior to surgery to reduce the risk of surgical site infection (SSI). There is debate as to which is the most effective. The aim of this network meta-analysis (NMA) is to compare the effectiveness of different skin preparations at reducing SSIs in patients undergoing incisional surgery.

METHODS

The study protocol was published in PROSPERO (CRD4202181599) a priori with predefined search terms and inclusion/exclusion criteria. The skin preparations for comparison were: chlorhexidine/alcohol (CHA), chlorhexidine/water (CHW), poviodine/alcohol (PVIA), poviodine/water (PVIW). The records identified were screened by two authors independently by title, abstract and in full text. The revised tool for risk-of bias (ROB2) assessment was used.

RESULTS

Twenty-nine RCTs involving 15 796 patients were included in the NMA. A significant but small increase in the odds of infection was seen in the PVIW group compared to the CHA group (OR 1.34, 95%CrI 1.09-1.64), but other comparisons were not statistically significantly different. Ranking the treatment arms showed there was a 64% probability that CHA is the most effective and a 62.7% probability that PVIW is the least effective treatment.

CONCLUSION

Chlorhexidine/alcohol (CHA) was found to be the most effective for prevention of superficial and deep SSI while PVIW was the least. There was no differences seen between CHA and PVIA, or CHW and PVIW. The superiority of CHA is likely due to the effect of the alcohol in the base. Hence the choice between CHA and PVIA should be based on health and cost considerations.

Clinical study of a new skin antiseptic olanexidine gluconate in gastrointestinal cancer surgery

Background

Surgical site infection (SSI) is a common complication of gastrointestinal surgery. Olanexidine gluconate (OLG) is a novel skin antiseptic that is effective against a wide range of bacteria. The purpose of this study was to evaluate the bactericidal efficacy of OLG in gastrointestinal cancer surgery.

Methods

This retrospective study included a total of 281 patients who underwent gastrointestinal cancer surgery (stomach or colon). The patients were divided into two groups: 223 patients were treated with OLG (OLG group), and 58 patients were treated with povidone-iodine (PVP-I) (control group). The efficacy and safety outcomes were measured as the rate of SSI within 30 days after surgery. In addition, we conducted subgroup analyses according to the surgical approach (open or laparoscopic) or primary lesion (stomach or colon).

Results

There was a significant difference in the rate of SSI between the control group and OLG group (10.3% vs. 2.7%; p = 0.02). There was a significant difference in the SSI rate in terms of superficial infection (8.6% vs. 2.2%; p = 0.0345) but not in deep infection (1.7% vs. 0.5%; p = 0.371). There was no significant difference between the control group and OLG group in the overall rate of adverse skin reactions (5.2% vs. 1.8%; p = 0.157).

Conclusion

This retrospective study demonstrates that OLG is more effective than PVP-I in preventing SSI during gastrointestinal cancer surgery.

Preoperative Optimization and Tips to Avoiding Surgical Complications Before the Incision

In preparation for surgery, it is important for surgeons to have a detailed discussion with patients about the risks, benefits, and alternatives to surgery. Patient optimization, ensuring the patient is in the best medical condition before surgery, is also an important aspect of patient care that the surgeon must consider. Although complications cannot be eliminated, there are often opportunities to optimize patients, so these risks can be minimized based on current evidence-based medicine. To minimize the risk of complications, the surgeon should take an active role in each step of the patient's care beginning with the history and physical examination, obtaining the correct preoperative labs, and continuing through positioning, draping, and prepping before making an incision.

Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES)

This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.

Comparative efficacy of 0.2% chlorhexidine and 10% Betadine for perioral skin disinfection prior to oral surgical procedures: a clinical trial

BACKGROUND

Surgical site infection (SSI) is a possible postoperative complication. Preoperative application of antiseptics on the surgical site can decrease the rate of SSIs.

AIM

This study aimed to compare the efficacy of 0.2% chlorhexidine (CHX) and 10% Betadine (povidone-iodine) for perioral skin disinfection prior to oral surgical procedures.

METHODS

This clinical trial (IRCT20181017041365N1) (registration date: 2019/05/04) evaluated 57 male patients who were randomly selected among those presenting to the Periodontology Department of Ahvaz Jundishapur University. Baseline microbial samples were collected from the perioral skin at the right and left sides of the face in each patient by sterile swabs. Next, the perioral area was disinfected with 10% Betadine in the right side and 0.2% CHX in the left side. Secondary microbial samples were then collected. Wilcoxon matched-pairs signed-ranks and Mann-Whitney test were used to compare the colony counts. The significance level was set at p ≤ 0.05. Data were analyzed with the Stata program, version15.1.

RESULTS

The bacterial colony count was 3147 (314,700) in the Betadine and 3139 (313,900) in the CHX group at baseline (P = 0.86). These values changed to 1196 (119,600) in the Betadine (P < 0.001) and 857 (85,700) in the CHX (P < 0.001) group after disinfection. A significant difference was found in colony count between the CHX and Betadine groups after intervention (P = 0.0001).

CONCLUSION

According to the results, 0.2% CHX has higher antimicrobial efficacy than 10% Betadine for perioral disinfection prior to oral surgical procedures.

TRIAL REGISTRATION

IRCT20181017041365N1. Registered on 2019/05/04.

Surgical site infection prevention bundle for children submitted to cardiac surgery

OBJECTIVE

To build and validate the content and appearance of a surgical site infection prevention bundle for children submitted to cardiac surgery.

METHOD

Methodological study in two phases: 1) Bundle construction from an integrative literature review from which interventions have been extracted to compose the instrument; 2) Bundle content and appearance validation by 24 judges.

RESULTS

The 24 found articles presented 17 interventions for surgical site infection prevention in this population. Out of them, seven intervention proposals have been chosen to compose the bundle and sent for assessment by judges. The final proposal includes all the seven items chosen in the construction phase and has achieved a content validity index over 0.8 in all items referring to content and appearance.

CONCLUSION

The content and appearance of the developed bundle proposes care for the prevention of surgical site infection throughout the perioperative period.

Efficacy comparison of chlorhexidine and iodine preparation in reduction of surgical site infection: A systemic review and meta-analysis

BACKGROUND

Chlorhexidine and povidone-iodine are the most common disinfectants used in preoperative skin preparation. However, there is no consistent conclusion regarding the prevention of surgical site infection (SSI) and bacterial culture data.

OBJECTIVE

To assess the efficacy of chlorhexidine and povidone-iodine in the prevention of postoperative SSI and relevant bacterial data.

DESIGN

Systematic Review and Meta-Analysis SETTINGS: N/A PARTICIPANTS: N/A METHOD: Literature relevant to "skin antisepsis" and "surgical site infections" was retrieved from PUBMED, Web of Science, EMBASE, CINHAL and CNKI. The incidence of SSI was the primary outcome, while the secondary outcome was bacterial data from the infected incision. All data were analyzed with Revman 5.3 and Stata Statistical Software.

RESULTS

A total of 36 studies were identified in this study, which included 16,872 participants. This study revealed that chlorhexidine is superior to povidone-iodine in the prevention of postoperative SSI (risk ratio [RR], 0.73; 95% confidence interval [CI], 0.61-0.87; p = 0.019, I² = 39%). Further meta-regression analysis revealed that the effect of chlorhexidine was directly associated with the type of incision, but failed to differentiate between the subgroups divided according to the type of incision. With respect to bacteria colonization, the most common bacteria for chlorhexidine arm were propionibacterium's, while the most common bacteria for the iodine arm were staphylococci species.

CONCLUSION

In comparison to povidone-iodine, chlorhexidine showed better results in preventing postoperative SSI.

Aqueous olanexidine versus aqueous povidone-iodine for surgical skin antisepsis on the incidence of surgical site infections after clean-contaminated surgery: a multicentre, prospective, blinded-endpoint, randomised controlled trial

BACKGROUND

Surgical site infection (SSI) is the most common problem after surgery. Although several guidelines have indicated the efficacy of antiseptics, such as chlorhexidine-alcohol and povidone-iodine, in reducing SSI rate, the optimal recommendation is still not established. Olanexidine might have higher bactericidal activity than other antiseptic agents. However, no randomised study has evaluated the efficacy and safety of olanexidine over conventional antiseptics. We compared the effect of aqueous olanexidine and aqueous povidone-iodine on the incidence of SSI following clean-contaminated surgery.

METHODS

This was a multicentre, prospective, randomised, blinded-endpoint superiority trial for surgical skin antisepsis in clean-contaminated gastrointestinal and hepatobiliary pancreatic surgeries in four Japanese hospitals. Patients aged 20 years or older who underwent elective clean-contaminated wound surgery were randomly assigned in a 1:1 replacement ratio using a computer-generated block randomisation. Patients were randomly assigned to surgical skin antisepsis with an aqueous formulation of 1·5% olanexidine or surgical skin antisepsis with an aqueous formulation of 10% povidone-iodine before surgery. We used olanexidine in a ready-to-use applicator, and povidone-iodine was administered by a brush or by compression using pliers. Both antiseptics were applied from the papilla with a cranial limit and to the upper thigh with a caudal limit. The antiseptics were allowed to dry for 3 min, and then surgery started. Participants, some investigators, and data analysts were masked to treatment allocation. Participant enrolment was done by non-masked investigators. The primary outcome was 30-day SSI assessed in the intention-to-treat population. The surgical wound site of each participant was observed daily. After discharge, participants underwent at least one outpatient visit within 30 days after surgery. This trial is registered with University hospital Medical Information Network, 000031560.

FINDINGS

Between June 10, 2018, and April 18, 2019, 883 patients were assessed for eligibility. 587 patients were eligible and 294 received olanexidine and 293 received aqueous povidone-iodine before surgery. 30-day SSI occurred in 19 (7%) patients in the olanexidine group and 39 patients (13%) patients in the povidone-iodine group (adjusted risk difference -0·069; 90% CI -0·109 to -0·029; adjusted risk ratio [RR] 0·48, 90% CI 0·30 to 0·74; p=0·002). Five patients (2%) in the olanexidine group and five (2%) in the povidone-iodine group developed adverse skin reactions (adjusted RR 0·99, 95% CI 0·29 to 3·40; p=1·00).

INTERPRETATION

Olanexidine significantly reduced the occurrence of overall SSI and superficial incisional SSI compared with aqueous povidone-iodine in clean-contaminated surgery. Our results indicate that olanexidine might have a role to prevent SSI in patients who undergo clean-contaminated surgeries.

FUNDING

Keio University and Ohyama Health Foundation.

New insight into the association between bile infection and clinically relevant pancreatic fistula in patients undergoing pancreatoduodenectomy

BACKGROUND

The association between bacterial infection and clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD) has not been fully elucidated.

METHODS

Microbiological data for intraoperative bile culture (BC) and drain culture on postoperative day 4 (DC) were collected. The study population was classified into the following three groups: P1 (positive BC and DC), P2 (positive BC and negative DC), and N (negative BC). A total of 209 patients (P1: 38, P2: 72, and N: 99) who underwent PD between May 2013 and May 2018 met the inclusion criteria of the study.

RESULTS

The rate of CR-POPF was significantly higher in the P1 group (34.2%) than in the P2 (12.5%; P = .007) and N groups (14.1%; P = .008). Between P1 and P2 groups, a significant difference was observed in the proportion of Enterococcus faecalis grown in BC (42.1% vs 4.2%; P < .001). Multivariable logistic regression analysis showed that the presence of E faecalis in bile was independently associated with CR-POPF.

CONCLUSIONS

The detection of both bile and postoperative abdominal fluid infections can be more accurate in predicting CR-POPF. Furthermore, the presence of E faecalis in bile may serve as a novel surrogate marker for CR-POPF.

Multicentre, open-label, randomised, controlled clinical trial comparing 2% chlorhexidine-70% isopropanol and 5% povidone iodine-69% ethanol for skin antisepsis in reducing surgical-site infection after cardiac surgery: the CLEAN 2 study protocol

INTRODUCTION

Surgical-site infection (SSI) is the second most frequent cause of healthcare-associated infection worldwide and is associated with increased morbidity, mortality and healthcare costs. Cardiac surgery is clean surgery with low incidence of SSI, ranging from 2% to 5%, but with potentially severe consequences.Perioperative skin antisepsis with an alcohol-based antiseptic solution is recommended to prevent SSI, but the superiority of chlorhexidine (CHG)-alcohol over povidone iodine (PVI)-alcohol, the two most common alcohol-based antiseptic solutions used worldwide, is controversial. We aim to evaluate whether 2% CHG-70% isopropanol is more effective than 5% PVI-69% ethanol in reducing the incidence of reoperation after cardiac surgery.

METHODS AND ANALYSIS

The CLEAN 2 study is a multicentre, open-label, randomised, controlled clinical trial of 4100 patients undergoing cardiac surgery. Patients will be randomised in 1:1 ratio to receive either 2% CHG-70% isopropanol or 5% PVI-69% ethanol for perioperative skin preparation. The primary endpoint is the proportion of patients undergoing any re-sternotomy between day 0 and day 90 after initial surgery and/or any reoperation on saphenous vein/radial artery surgical site between day 0 and day 30 after initial surgery. Data will be analysed on the intention-to-treat principle.

ETHICS AND DISSEMINATION

This protocol has been approved by an independent ethics committee and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

EudraCT 2017-005169-33 and NCT03560193.

Comparison of olanexidine versus povidone-iodine for preventing surgical site infection in gastrointestinal surgery: study protocol for a multicentre, single-blind, randomised controlled clinical trial

INTRODUCTION

The prevalence of surgical site infection (SSI) remains higher in gastrointestinal surgery than in other surgeries. Although several guidelines have indicated the efficacy of chlorhexidine and povidone-iodine in reducing the SSI rate, the optimal recommendation has still not been established. Therefore, it is necessary to determine the more effective antiseptic for surgical site preparation. Olanexidine (1.5% olanedine, Otsuka Pharmaceutical Factory, Tokushima, Japan), which is a new antiseptic in Japan, has antimicrobial activity against a wide range of bacteria, including Gram-positive and Gram-negative bacteria. Our study will contribute to determining a new antiseptic for use in gastrointestinal and other surgeries.

METHODS AND ANALYSIS

We propose a multicentre, randomised controlled clinical trial for comparing two treatments, that is, 1.5% olanexidine or 10% povidone-iodine, for surgical skin preparation to prevent SSI in clean-contaminated gastrointestinal surgeries with surgical wounds. Patients aged ≥20 years at the time of consent will be included. The primary outcome measure is the 30-day postoperative SSI rate. For the primary analysis, which is aimed at comparing the treatment effects, the adjusted risk ratio and its 95% CI will be estimated using the Mantel-Haenszel method.

ETHICS AND DISSEMINATION

The protocol was first approved by the Institutional Review Board of Keio University School of Medicine, followed by the institutional review board of each participating site. Participant recruitment began in June 2018. The final results will be published in international peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

UMIN 000031560; Pre-results.

Bartsch D. Superficial Surgical Site Infection Following the Use of Intracutaneous Sutures Versus Staples

BACKGROUND

Superficial wound infections after gastrointestinal surgery markedly impair the affected patients' quality of life. As it is still unknown which method of skin closure is best for the reduction of wound infections in elective gastrointestinal sur- gery, we compared the frequency of wound infections after intracutaneous suturing versus skin stapling.

METHODS

In a prospective, randomized, single-center study, patients undergoing elective gastrointestinal surgery were intraoperatively randomized to skin closure either with an intracutaneous suture or with staples. The primary endpoint-the occurrence of a grade A1 wound infection within 30 days of surgery-was evaluated according to the intention-to-treat principle.

RESULTS

Out of a total of 280 patients, 141 were randomized to intracutaneous suturing and 139 to stapling. The groups did not differ significantly with respect to age, sex, or ASA classification. 19 of the 141 patients in the intracutaneous suturing group (13.5%) had a grade A1 wound infection, compared with 23 of 139 in the stapling group (16.6%) (odds ratio [OR]: 0.79; 95% confidence interval: [0.41; 1.52]; p = 0.47). A multiple regression analysis revealed that the type of surgery (colorectal vs. other), the approach, and the incision length were independent risk factors for a grade A1 wound infection. When wound dehiscences were additionally considered, wound complications were found to have arisen significantly more often in the stapling group than in the intracutaneous suturing group (16.3% [23/141] versus 30.2% [42/139], OR: 0.45 [0.25; 0.80]; p = 0.006).

CONCLUSION

In elective gastrointestinal surgery, intracutaneous suturing was not found to be associated with a lower rate of superficial wound infections than skin stapling, but fewer wound dehiscences occurred in the intracutaneous suturing group.

Evaluation of 4 Presurgical Skin Preparation Methods in Mice

Mice routinely undergo surgical procedures for use in research; however, studies of skin preparation methods to achieve antisepsis are rare. The present study evaluated 4 skin preparation treatments: depilatory agent followed by povidone-iodine and alcohol scrub; depilatory agent followed by povidone-iodine and saline scrub; electric clippers followed by povidone-iodine and alcohol scrub; and electric clippers followed by povidone-iodine and saline scrub. Swabs for bacterial culture were obtained immediately after hair removal and after scrubbing to measure the reduction in bacterial load. Full-thickness incisions were assigned ASEPSIS wound scores and examined histologically on days 0, 1, and 7 after surgery. Neither bacterial load growth nor ASEPSIS wound scores differed among any of the treatments. Histopathology revealed statistically significant but biologically irrelevant differences. Overall all treatment methods achieved acceptable bacterial load reduction and surgical site healing.

Comparative clinical effectiveness of preoperative skin antiseptic preparations of chlorhexidine gluconate and povidone iodine for preventing surgical site infections in dogs

Contamination of surgical sites often resulting from inadequate surgical site preparation and poor asepsis is a common cause of surgical site infection (SSI) and postoperative complications. Standard practice ensuring preoperative skin disinfection helps to prevent the incidence of SSI. The choice of antiseptic therefore poses a serious counterbalance for the surgeon. This study was carried out to determine whether skin asepsis immediately prior to surgical site incision will reduce skin microbial burden that may potentiate the incidence of SSI and to compare the clinical effectiveness of chlorhexidine gluconate B.P 0.3%W/V, Cetrimide B.P 3.05 W/V (CG + Cetrimide) against povidone iodine 10% (PI) in pre-surgical skin preparation and asepsis in dogs. A total of 15 dogs were used for the study. Both side of each dog was used for the study, right side for CG + Certrimide and left side for PI; (n = 30). Aseptic agents’ chlorhexidine gluconate 0.3% and Cetrimide 3.0% and povidine iodine 10% were used as pre surgical scrub solutions prior to surgery. Swab samples were evaluated before scrubbing, 0, 30, 60 and 90 min after scrubbing. Percent reductions of bacterial colony forming units were determined for all site scrub techniques. Mixed-design ANOVA results revealed significant difference (P < 0.05) within groups and no significant difference (P > 0.05) in the disinfectant effects between groups treated with CG + Cetrimide and povidone iodine respectively across the various time periods. Changes in the mean bacteria count were observed to be equivalent using CG + Cetrimide and povidone iodine. It was concluded that there was no significant difference between CG + Cetrimide and PI in preoperative surgical skin preparations.

Skin preparation for abdominal surgery

INTRODUCTION

Surgical site infections (SSI) are a public health issue. The purpose of this review is to review the literature on methods of pre-operative skin preparation for the prevention of SSI in abdominal surgery.

METHODS

In order to obtain the best level of evidence, only meta-analyses and randomized controlled clinical trials were selected from the Cochrane Library and PubMed databases. High-powered non-randomized studies were included when results were not available for the questions asked. The primary endpoint was the rate of SSI within 30 days.

RESULTS

Analysis of the 20 selected studies suggested that hair removal in the operative field is not recommended except when it interferes with surgery; in this case, hair clipping or chemical depilation is recommended and shaving should be banned. For the pre-operative shower, the choice of a detergent product with or without antiseptic does not seem to matter, and there were no published data on the required number of showers or the interval before surgery. Application of an alcohol-based solution to the operative field for cutaneous disinfection is recommended; the products used seem to be equivalent, and there is no need for pre-operative detergent scrubbing. There is no strong evidence to recommend adhesive plastic drapes for clean or contaminated surgery.

CONCLUSION

Some recommendations on skin preparation before abdominal surgery to reduce the rate of SSI are based on a high level of evidence. Other recommendations such as the number and duration of pre-operative showers or use of adhesive plastic skin drapes are less well supported.

RETRACTED: Preoperative chlorhexidine versus povidone-iodine antisepsis for preventing surgical site infection: A meta-analysis and trial sequential analysis of randomized controlled trials

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editor of the Journal. The retraction has been made because the Editor has been informed that a similar article containing the same research was submitted to another journal by other authors. The authors have admitted errors in drafting and submitting the paper and apologise for the mistakes.

Surgical infection

Real and present danger