Reducing the risk of surgical site infections: does chlorhexidine gluconate provide a risk reduction benefit?

Antibiotic dip and irrigation solutions confer increased antimicrobial efficacy of inflatable penile prosthesis hydrophilic surfaces compared with 0.05% chlorhexidine gluconate

BACKGROUND

Chlorhexidine gluconate (CHG) (0.05%) has recently been suggested as both a dip for the hydrophilic surface and an irrigation solution in the setting of penile prosthesis (PP) surgery.

AIM

The study sought to compare the antimicrobial efficacy of 0.05% CHG with vancomycin and gentamicin (VG) antibiotics as dip and/or irrigation solutions in the setting of a hydrophilic PP surface in vitro.

METHODS

Sterile PPs with a hydrophilic coating were obtained. A series of experiments were performed to evaluate the efficacy of normal saline (NS), 0.05% CHG, or VG as dip and/or irrigation solutions to reduce methicillin-sensitive Staphylococcus aureus adhesion to PP surfaces. The 8-mm discs from PPs were incubated in 105 colony-forming units/mL of methicillin-sensitive S aureus for 48 hours, plated, and counted. Disc-diffusion tests were conducted by suspending 6-mm discs for 2 minutes in NS, 0.05% CHG, or VG, then placing them coated side down onto plates streaked with the following organisms: methicillin-sensitive S aureus, S epidermidis, Enterococcus, and Escherichia coli. After 24 hours of growth, zones of inhibition were measured.

OUTCOMES

We found average bacterial counts (colony-forming units/mL) and zones of inhibition (mm) following a series of treatment protocols of PP discs.

RESULTS

PP discs dipped in VG reduced bacterial adhesion to the implant surface >0.05% CHG (~5.5 log vs ~1.5 log; P < .01). Discs irrigated with either 0.05% CHG or NS removed all dip solution adsorbed to the hydrophilic surface, allowing bacterial growth. VG irrigation adsorbed to the hydrophilic surface even after 0.05% CHG or NS dips, reducing bacterial adherence (~3 log). Dipping and irrigating discs with VG was most effective in reducing adherent bacteria (~5.5 log) and was the only irrigation that showed antimicrobial activity.

CLINICAL TRANSLATION

VG, when used both as a prophylactic dip and as an intraoperative irrigation solution for hydrophilic penile implant surfaces, has improved efficacy to 0.05% CHG and NS.

STRENGTHS AND LIMITATIONS

This is the first study to compare the use of VG, 0.05% CHG, and NS as prophylactic dips and intraoperative irrigations for hydrophilic penile implant surfaces. Limitations include the use of in vitro studies, which serve as a proxy for in vivo practices and may not be entirely accurate nor translatable clinically.

CONCLUSION

We demonstrated the superior efficacy of VG as a combined dip and irrigation solution for hydrophilic penile implant surfaces compared with 0.05% CHG.

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.

The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for the Mitigation of Complications of Neurostimulation

INTRODUCTION

The International Neuromodulation Society convened a multispecialty group of physicians based on expertise and international representation to establish evidence-based guidance on the mitigation of neuromodulation complications. This Neurostimulation Appropriateness Consensus Committee (NACC)® project intends to update evidence-based guidance and offer expert opinion that will improve efficacy and safety.

MATERIALS AND METHODS

Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to October 2023. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant.

RESULTS

The NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process.

CONCLUSIONS

The NACC recommends best practices regarding the mitigation of complications associated with neurostimulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.

The Effect of Preoperative Chlorhexidine Gluconate Cleanse on Lower Extremity Surgical Site Infections: A Retrospective Cohort Study

BACKGROUND

Lower extremity surgical sites are at an increased risk of wound infection following Mohs micrographic surgery.

OBJECTIVE

To evaluate the rate of lower extremity surgical site infections following a 14-day regimen of preoperative 4% chlorhexidine gluconate (CHG) rinses and postoperative wound occlusion for 14 days.

MATERIALS AND METHODS

Retrospective data were collected from procedures performed by the senior author from January 2022 through June 2023. To meet inclusion, patients must have completed waist-down CHG soak and rinse for 14 days before surgery, including the day before surgery. In addition, the patient must have kept the dressing clean, dry, and intact until the postoperative appointment at 14 days.

RESULTS

A total of 100 Mohs cases met inclusion criteria. Zero patients developed a surgical site infection.

CONCLUSION

Chlorhexidine gluconate preoperative rinsing and postoperative occlusion for 14 days may minimize the risk of wound infection. Although further research is indicated, an opportunity exists for the adoption of CHG into routine clinical practice in the outpatient dermatology setting.

Incisional Wound Irrigation for the Prevention of Surgical Site Infection: A Systematic Review and Network Meta-Analysis

Importance

Surgical site infections (SSIs) are common postoperative complications and associated with significant morbidity, mortality, and costs. Prophylactic intraoperative incisional wound irrigation is used to reduce the risk of SSIs, and there is great variation in the type of irrigation solutions and their use.

Objective

To compare the outcomes of different types of incisional prophylactic intraoperative incisional wound irrigation for the prevention of SSIs in all types of surgery.

Data Sources

PubMed, Embase, CENTRAL, and CINAHL databases were searched up to June 12, 2023.

Study Selection

Included in this study were randomized clinical trials (RCTs) comparing incisional prophylactic intraoperative incisional wound irrigation with no irrigation or comparing irrigation using different types of solutions, with SSI as a reported outcome. Studies investigating intracavity lavage were excluded.

Data Extraction and Synthesis

This systematic review and network meta-analysis is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Two reviewers independently extracted the data and assessed the risk of bias within individual RCTs using the Cochrane Risk of Bias 2 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation framework. A frequentist network meta-analysis was conducted, and relative risks (RRs) with corresponding 95% CIs were reported.

Main Outcome and Measure

The primary study outcome was SSI.

Results

A total of 1587 articles were identified, of which 41 RCTs were included in the systematic review, with 17 188 patients reporting 1328 SSIs, resulting in an overall incidence of 7.7%. Compared with no irrigation, antiseptic solutions (RR, 0.60; 95% CI, 0.44-0.81; high level of certainty) and antibiotic solutions (RR, 0.46; 95% CI, 0.29-0.73; low level of certainty) were associated with a beneficial reduction in SSIs. Saline irrigation showed no statistically significant difference compared with no irrigation (RR, 0.83; 95% CI, 0.63-1.09; moderate level of certainty).

Conclusions and Relevance

This systematic review and network meta-analysis found high-certainty evidence that prophylactic intraoperative incisional wound irrigation with antiseptic solutions was associated with a reduction in SSIs. It is suggested that the use of antibiotic wound irrigation be avoided due to the inferior certainty of evidence for its outcome and global antimicrobial resistance concerns.

Ventriculoperitoneal Shunt Surgery in Pediatrics: Does Preoperative Skin Antisepsis with Chlorhexidine/Alcohol Reduce Postoperative Shunt Infection Rate?

BACKGROUND

 In pediatrics, shunt infection is considered the most common complication of ventriculoperitoneal (VP) shunt insertion and the main cause of shunt failure. Careful surgical technique and hygienic skin preparations are highly important for prevention of shunt infections. Our objective was to assess the significance of using preoperative chlorhexidine/alcohol as a skin antiseptic in reducing the infection rate in pediatric VP shunts surgery.

METHODS

 We conducted a retrospective, case control study of 80 pediatric patients with active hydrocephalus. The control group (a single step of preoperative skin antisepsis using povidone-iodine and isopropyl alcohol) comprised 40 patients who underwent a shunt surgery between January 2019 and June 2020 and the study group (two steps of preoperative skin antisepsis using 2% chlorhexidine gluconate in 70% isopropyl alcohol as a first step followed by povidone-iodine as a second step) comprised 40 patients who underwent a shunt surgery between July 2020 and January 2022.

RESULTS

 Shunt infection was encountered in 11 (13.7%) patients. It was significantly higher in preterm babies (p = 0.010), patients with a previous shunt revision (p < 0.001), and those with a previous shunt infection (p < 0.001). The incidence of infection was 22.5% in the control group and 5% in study group, with a statistically significant difference (p = 0.023).

CONCLUSIONS

 Two steps of preoperative skin antisepsis, first using chlorhexidine/alcohol and then povidone-iodine scrub solution, may significantly reduce the infection rate in pediatric VP shunt surgeries.

Preoperative Application of Chlorhexidine to Reduce Infection with Cesarean Delivery after Labor (PRACTICAL): A Randomized Clinical Trial

OBJECTIVE

To evaluate whether use of both preoperative 2% chlorhexidine gluconate abdominal cloth and 4% chlorhexidine gluconate vaginal scrub is effective in reducing surgical site infections (SSIs) in patients undergoing cesarean delivery after labor.

STUDY DESIGN

This is a single-center, randomized clinical trial in which patients were randomized 1:1 to receive 2% chlorhexidine gluconate cloth applied to the abdomen in addition to the application of 4% chlorhexidine gluconate vaginal scrub versus standard of care. The primary outcome was rate of SSIs, including endometritis, by 6 weeks postdelivery. The secondary outcomes were other wound complications (erythema at the operative site, skin separation, drainage, fever, hematoma, seroma) by 6 weeks postdelivery, hospital readmission for wound complications, and day of discharge after cesarean delivery.

RESULTS

A total of 319 patients between September 2018 and February 2021 met eligibility criteria: 160 were randomized to the chlorhexidine gluconate abdominal cloth and vaginal scrub group and 159 were randomized to the standard of care group. The groups did not have significant differences in maternal demographic characteristics. Of the 302 (95%) individuals included in primary analysis, there was no statistically significant difference in SSI and endometritis rate by 6 weeks postdelivery (6.6% in chlorhexidine vs. 5.3% standard of care, p = 0.65). Secondary outcomes were also similar among the two groups.

CONCLUSION

The combination of preoperative 2% chlorhexidine gluconate abdominal cloth and 4% chlorhexidine gluconate vaginal scrub does not appear to reduce the risk of SSI with cesarean delivery after trial of labor when compared with standard of care.

KEY POINTS

· Preoperative chlorhexidine abdominal cloth/vaginal scrub does not decrease SSI in cesarean after labor.. · Preoperative chlorhexidine abdominal cloth/vaginal scrub does not decrease other wound complications in cesarean after labor.. · There was no difference in discharge day, 2-week or 6-week SSI rates..

Effect of Commercially Available Wound Irrigation Solutions on Uninfected Host Tissue in a Murine Model

Background

Commercially available irrigation solutions are used to reduce bacterial contamination and prevent surgical site infections. However, the effect of these solutions on the healing capacity of tissue has not been well-established. The purpose of this study was to investigate the effects of 5 commercially available irrigation solutions on host tissue in a murine model.

Methods

There were 5 treatment groups: bacitracin, Clorpactin, Irrisept, Prontosan, Bactisure, and normal saline control. The irrigation solutions were applied to the wound for 30 seconds or 1 minute, as per the manufacturer's instructions, and then washed with normal saline. Mice were sacrificed at 3 days and 10 days. The tissue was examined histologically for inflammation, edema, granulation tissue formation, and re-epithelialization. Granulation tissue formation and re-epithelialization were surrogates for effective wound healing.

Results

All of the irrigation solutions had negative effects on host tissue in the acute phase. The inflammation and edema were improved in the later phase (10 days). Recovery and healing of the open wounds were observed for all groups at 10 days. The antiseptic irrigation solutions had similar cytotoxic effects on host tissue at 3 days and did not have delayed or compromised wound healing at 10 days when compared to normal saline control.

Conclusions

Single short-duration use of these commercially available antiseptic irrigation solutions appears to be safe in an uninfected wound. Data from this study will provide surgeons with useful information regarding the safety of using antiseptic wound irrigation solutions intraoperatively for prevention of surgical site infections.

Intraoperative Wound Lavage System for Deep Neck Infection: A Retrospective Cohort Study

Introduction  Multiple solutions are currently used to cleanse a deep neck infection (DNI), and a variety of devices are available to deliver wound irrigation solutions. An essential difference between these devices is the pressure that the irrigation solution exerts over the wound tissue. Objective  To compare low-pressure and high-pressure irrigation delivery systems for wound cleansing in DNI. Methods  we designed a retrospective cohort study and reviewed the medical records of patients operated on due to DNI from June 2016 to December 2017 at our institution. One cohort included patients treated with an intraoperative irrigation method that exerts low pressure over the irrigated tissue, and the other cohort, to a system capable of generating higher pressure. The Pearson Chi-squared test was used to analyze the data. Results  A total of 42 patients whose ages ranged from 16 months to 72 years were included. The low-pressure irrigation system was used in 18 patients, and the high-pressure system was used in 24 patients. No statistical differences were observed regarding the irrigation methods, the complexity of the DNI, and the overall outcomes. Conclusions  The present is the first study in which low- and high-pressure systems for wound lavage were evaluated in the treatment of DNI. When comparing these methods, we did not find one to be superior to the other; however, the additional cost associated with the high-pressure devices may not justify their in head and neck procedures.

Efficacy of biofilm disrupters against Candida auris and other Candida species in monomicrobial and polymicrobial biofilms

Candida species are now considered global threats by the CDC and WHO. Candida auris specifically is on the critical pathogen threat list along with Candida albicans. In addition, it is not uncommon to find Candida spp. in a mixed culture with bacterial organisms, especially Staphylococcus aureus producing polymicrobial infections. To eradicate these organisms from the environment and from patient surfaces, surface agents such as chlorhexidine (CHD) and Puracyn are used. Biofilm disrupters (BDs) are novel agents with a broad spectrum of antimicrobial activity and have been used in the management of chronic wounds and to sterilise environmental surfaces for the past several years. The goal of this study was to evaluate BDs (BlastX, Torrent, NSSD) and CHD against Candida spp. and S. aureus using zone of inhibition assays, biofilm and time-kill assays. All BDs and CHD inhibited C. auris growth effectively in a concentration-dependent manner. Additionally, CHD and the BDs showed excellent antimicrobial activity within polymicrobial biofilms. A comparative analysis of the BDs and CHD against C. auris and C. albicans using biofilm kill-curves showed at least 99.999% killing. All three BDs and CHD have excellent activity against different Candida species, including C. auris. However, one isolate of C. auris in a polymicrobial biofilm assay showed resistance/tolerance to CHD, but not to the BDs. The fungicidal activity of these novel agents will be valuable in eradicating surface colonisation of Candida spp, especially C. auris from colonised environmental surfaces and from wounds in colonised patients.

An evidence-based review of optimal perioperative practices in minor hand surgery

BACKGROUND

Like many surgical subspecialties, there have been frequent advancements and discoveries in the field of hand and upper extremity surgery. With a rapidly growing literature base, it can be difficult to remain updated on the latest recommendations.

METHODS

A comprehensive literature search was completed on PubMed using MeSH terms. Topics included nutrition management, anticoagulation, immunosuppressive medication management, antibiotic use, skin preparation, splinting, tourniquet use, and suture choice. Data from articles with a level of evidence 1A-3 C were included.

RESULTS

A total of 42 articles were identified and reviewed to provide evidence for recommendations regarding various aspects of pre-, intra-, and post-operative care.

CONCLUSIONS

The objective of this manuscript is to serve as a resource for evidence-based recommendations by the findings of recent evidence related to perioperative care in elective hand surgery. Additional studies are required in certain areas of the literature in order to provide stronger recommendations.

Prevention of Surgical Site Infection Following Open Spine Surgery: The Efficacy of Intraoperative Wound Irrigation with Normal Saline Containing Gentamicin Versus Dilute Povidone-Iodine

BACKGROUND

Intraoperative wound irrigation (IOWI) is an important step in preventing surgical site infection (SSI). This study compared the effectiveness of saline with gentamicin versus povidine-iodine (PI) as IOWI solutions in preventing SSI in open spine surgery.

METHODS

It is a prospective comparative study. Patients who had noninstrumented open spine surgery were randomized into 2 groups. Group A and B patients had their surgical wounds irrigated with saline containing gentamicin solution and dilute PI solution, respectively. Both groups were assessed for the occurrence of SSI.

RESULTS

A total of 80 patients, divided into 2 groups of 40 each completed the study. Overall, the SSI rate was 17.5% for patients in the normal saline containing gentamicin group (A) and 2.5% for those in the dilute PI group (B), this difference was statistically significant (P = 0.025). The cervical and thoracic spine regions have the same SSI rate (7.1% and 0%, respectively) in both groups. However, in the lumbosacral region, the SSI rate was 31.6% in A and 0% in B, this was statistically significant (P = 0.006). The isolated organisms in patients with SSI were staphylococcus species (42.86% of SSI in A and 0% in B) and pseudomonas species (42.86% of SSI in group A and 100% in group B), and this difference was profound in the lumbosacral spine region (P = 0.008).

CONCLUSIONS

IOWI with 3.5% dilute PI solution is more efficacious in preventing SSI and has wider microbial coverage compared to normal saline containing gentamicin solution as IOWI fluid in noninstrumented open spine surgery.

Prophylactic intraoperative wound irrigation with antibiotic solution for the prevention of surgical incisional wound infections: Systematic literature review and meta-analysis

BACKGROUND

There is no consensus on the use of prophylactic intraoperative wound irrigation (pIOWI) for reducing surgical-site infections (SSIs), particularly surgical incisional wounds, and opinions are divided on whether an antibiotic should be mixed with the solution used for incisional wound irrigation. No large, reliable cohort studies or meta-analyses of pIOWI for surgical incisional wounds were found in PubMed or Embase.

METHODS

We searched the PubMed, Embase, Cochrane Library, Insight, Scopus, and Web of Science databases for primary research articles investigating the relevance of pIOWI with antibiotics for SSIs. The initial search was limited to human studies published before January 2022, which were indexed as randomized controlled trials (RCTs); clinical trials; or observational, cross-sectional, or cohort studies. We used R statistical software version 4.1.2 for this meta-analysis.

RESULTS

The odds ratio of the random-effects model was 0.519 [95% confidence interval (CI); 0.311, 0.864, P-value < 0.0117], indicating that the intervention had a statistically significant effect on surgical complications. To examine the heterogeneity of the entire study, we performed statistical analysis (τ² (tau square) = 0.4175 [0.0732; 2.8178]; τ (tau) = 0.6461 [0.2706; 1.6786]; Higgins' I² = 64.0% [34.8%; 80.1%]; and H = 1.67 [1.24; 2.24]).

CONCLUSIONS

Many studies have shown that inclusion of antibiotics in the irrigation solution significantly lowers the rate of soft-tissue-related SSIs, but those studies contain both heterogeneity and many biases. Further large, prospective RCTs only limited to incisional SSIs and excluding other variables and biases in the field of plastic surgery are needed.

Pre-Admission Use of Chlorhexidine-Impregnated Gauze for Skin Preparation Reduces the Incidence of Peri-Prosthetic Joint Infection after Primary Total Knee Arthroplasty: A Prospective Cohort with Retrospective Controls

Background: Peri-prosthetic joint infection (PJI) has long been a devastating complication after total knee arthroplasty (TKA), with native skin flora always identified as the causative agents. The aim of this study was to investigate the efficacy of pre-admission use of chlorhexidine-impregnated gauze for pre-operative skin preparation on infection rates after primary TKA surgeries. Patients and Methods: Patients undergoing TKAs performed from January 2017 until January 2021 were prospectively recruited. The experimental group included patients who used chlorhexidine-impregnated gauze the evening before surgery for skin preparation. These patients were compared with a retrospective cohort of TKAs performed during the previous four years without this step as control group. During a one-year follow-up, complications including PJI and superficial infections were collected as the primary outcomes for analysis. Results: A total of 1,218 TKAs in the experimental group and 1,033 TKAs in the control group were included in the study. A total of seven (0.6%) cases of PJI were identified in the experimental group, whereas 16 (1.5%) cases were diagnosed in the control group; a significant difference was detected (χ² = 5.245; p = 0.022). Eighteen (1.5%) cases of superficial infection were identified in the experimental group, and 28 (2.7%) cases were observed in the control group; a significant difference was found between groups (χ² = 4.243; p = 0.039). No significant differences were found on other wound-related complications. Conclusions: Pre-admission use of chlorhexidine-impregnated gauze for skin preparation was found to be an effective practice in reducing the incidence of PJI after TKA procedures, which has the potential of being utilized for patients undergoing TKA surgeries.

Irrigation techniques used in spine surgery for surgical site infection prophylaxis: a systematic review and meta-analysis

Background

The greater likelihood of morbidity, mortality, length of hospital stays and poorer long-term outcomes as a result of surgical site infections secondary to spinal surgery makes prophylactic measures an imperative focus. Therefore, the aim of this review was to evaluate the available research related to the efficacy of different intraoperative irrigation techniques used in spinal surgery for surgical site infection (SSI) prophylaxis.

Methods

We performed a comprehensive search using Ovid Medline, EMBASE, Web of Science and the Cochrane library pertaining to this topic. Our meta-analysis was conducted according to PRISMA guidelines. The inclusion criteria consist of spine surgeries with intraoperative use of any wound irrigation technique, comparison groups with a different intraoperative irrigation technique or no irrigation, SSI identified with bacterial cultures or clinically in the postoperative period, reported SSI rates. Data extracted from eligible studies included, but was not limited to, SSI rates, irrigation technique and control technique. Exclusion criteria consist of articles with no human subjects, reviews, meta-analyses and case control studies and no details about SSI identification or rates. Pooled risk ratios were calculated. A meta-analysis was performed with a forest plot to determine risk estimates’ heterogeneity with I² index, Q-statistic, and p value under a random-effects model. Funnel plot was used to assess publication bias. All databases were last checked on January, 2022. PROBAST tool was used to assess both risk of bias and applicability concerns.

Results

After reviewing 1494 titles and abstracts, 18 articles met inclusion criteria. They included three prospective randomized-controlled trials, 13 retrospective cohort studies, two prospective cohort studies. There were 54 (1.8%) cases of SSIs in the povidone-iodine irrigation group (N = 2944) compared to 159 (4.6%) in the control group (N = 3408). Using intraoperative povidone-iodine wound irrigation produced an absolute risk reduction of 2.8%. Overall risk ratio was 0.32 (95% CI 0.20–0.53, p < 0.00001). In a global analysis, study heterogeneity and synthesizing mostly retrospective data were primary limitations.

Conclusion

The most evidence exists for povidone-iodine and has Level 2 evidence supporting SSI reduction during spinal surgery. Other antiseptic solutions such as dilute chlorhexidine lack published evidence in this patient population which limits the ability to draw conclusions related to its use in spinal surgery.

Level of Evidence

II – Systematic Review with Meta-Analysis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05763-2.

Prevention of Orthopedic Prosthetic Infections Using Evidence-Based Surgical Site Infection Care Bundles: A Narrative Review

Background: The number of primary/revision total joint replacements (TJR) are expected to increase substantially with an aging population and increasing prevalence of comorbid conditions. The 30-day re-admission rate, in all orthopedic specialties, is 5.4% (range, 4.8%-6.0%). A recent publication has documented that the surgical site infection (SSI) infection rate associated with revision total knee (rTKR, 15.6%) and revision total hip (rTHR, 8.6%) arthroplasties are four to seven times the rate of the primary procedures (2.1%-2.2%). These orthopedic infections prolong hospital stays, double re-admissions, and increase healthcare costs by a factor of 300%. Methods: A search of PubMed/MEDLINE, EMBASE and the Cochrane Library publications, which reported the infection risk after TKR and THR, was undertaken (January 1, 1995 to December 31, 2021). The search also included documentation of evidence-based practices that lead to improved post-operative outcomes. Results: The evidence-based approach to reducing the risk of SSI was grouped into pre-operative, peri-operative, and post-operative periods. Surgical care bundles have existed within other surgical disciplines for more than 20 years, although their use is relatively new in peri-operative orthopedic surgical care. Pre-admission chlorhexidine gluconate (CHG) showers/cleansing, staphylococcal decolonization, maintenance of normothermia, wound irrigation, antimicrobial suture wound closure, and post-operative wound care has been shown to improve clinical outcome in randomized controlled studies and meta-analyses. Conclusions: Evidence-based infection prevention care bundles have improved clinical outcomes in all surgical disciplines. The significant post-operative morbidity, mortality, and healthcare cost, associated with SSIs after TJR can be reduced by introduction of evidence-based pre-operative, intra-operative, and post-operative interventions.

The European Hernia Society Prehabilitation Project: A Systematic Review of Intra-Operative Prevention Strategies for Surgical Site Occurrences in Ventral Hernia Surgery

Background

Ventral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, pre- and intra-operative strategies have received increasing focus in recent years. To assess possible preventive surgical strategies, this European Hernia Society endorsed project was launched. The aim of this review was to evaluate the current literature focusing on pre- and intra-operative strategies for surgical site occurrences (SSO) and specifically surgical site infection (SSI) in ventral hernia repair.

Methods

A systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases used were Pubmed and Web of Science. Original retrospective or prospective human adult studies describing at least one intra-operative intervention to reduce SSO after ventral hernia repair were considered eligible.

Results

From a total of 4775 results, a total of 18 papers were considered suitable after full text reading. Prehospital chlorhexidine gluconate (CHG) scrub appears to increase the risk of SSO in patients undergoing ventral hernia repair, while there is no association between any type of surgical hat worn and the incidence of postoperative wound events. Intraoperative measures as prophylactic negative pressure therapy, surgical drain placement and the use of quilt sutures seem beneficial for decreasing the incidence of SSO and/or SSI. No positive effect has been shown for antibiotic soaking of a synthetic mesh, nor for the use of fibrin sealants.

Conclusion

This review identified a limited amount of literature describing specific preventive measures and techniques during ventral hernia repair. An advantage of prophylactic negative pressure therapy in prevention of SSI was observed, but different tools to decrease SSIs and SSOs continuously further need our full attention to improve patient outcomes and to lower overall costs.

A Novel Irrigant to Eliminate Planktonic Bacteria and Eradicate Biofilm Superstructure With Persistent Effect During Total Hip Arthroplasty

BACKGROUND

Numerous studies have examined the use of topical and irrigation-related adjuvants to decrease the risk of periprosthetic joint infection (PJI) after total hip arthroplasty. Many issues related to their use remain to be investigated. These include cost, antibiotic stewardship, bactericidal effect on planktonic bacteria, host cytotoxicity, necessity to irrigate/dilute potentially cytotoxic agents after their application, and impact on biofilm.

METHODS

Bacterial strains of microorganisms were grown in optimal medium. After the growth phase, the organisms were exposed to the novel irrigation solution (XPerience) or phosphate buffer solution (PBS) for 5 minutes before a neutralizing broth was added. The colony-forming units per milliliter and the log reduction in colony-forming units in the treated sample vs the control were then determined. Subsequently, biofilms of microorganisms were grown on hydroxyapatite-coated glass slides. Each slide was then exposed to irrigation solutions for various contact times. Biofilm quantification was performed and the log10 density of each organism was obtained.

RESULTS

In vitro testing of the irrigant demonstrated 6-log reductions in planktonic bacteria in 5 minutes, and 4-log to 8-log reductions in biofilms. Laboratory tissue testing has demonstrated minimal cytotoxic effects to host tissue allowing for solution to remain in contact with the host without need for subsequent irrigation, creating a barrier to biofilm for up to 5 hours after its application.

CONCLUSION

This novel irrigant demonstrates high efficacy against both planktonic bacteria and bacterial biofilms in laboratory testing. Large series in vivo data are necessary to further establish its efficacy in reducing primary and recurrent surgical site infections.

Disinfection Strategies for Carbapenem-Resistant Klebsiella pneumoniae in a Healthcare Facility

Disinfectant resistance is evolving into a serious problem due to the long-term and extensive use of disinfectants, which brings great challenges to hospital infection control. As a notorious multidrug-resistant bacterium, carbapenem-resistant Klebsiella pneumoniae (CRKP) is one of the most common and difficult pathogens of nosocomial infection. The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) tests of seven kinds of disinfectants (0.1% benzalkonium bromide, 4% aqueous chlorhexidine, 75% alcohol, entoiodine II, 2% glutaraldehyde, 2000 mg/L chlorine-containing disinfectants, and 3% hydrogen peroxide) were detected by the broth dilution method. Three efflux pump genes (oqxA, oqxB, and qacE∆1-sul1) were detected by PCR. The mean MIC value of aqueous chlorhexidine from the intensive care unit (ICU) (0.0034%) was significantly higher than that from non-ICUs (0.0019%) (p < 0.05). The positive rates of three efflux pump genes oqxA, oqxB and qacE∆1-sul1 were 60.9% (39/64), 17.2% (11/64) and 71.9% (46/64) in the detected CRKP isolates, respectively. This study discovered that CRKP strains demonstrated extensive resistance to clinical disinfectants and suggest that it is necessary to perform corresponding increases in the concentration of aqueous chlorhexidine and chlorine-containing disinfectants on the basis of current standards in the healthcare industry.

Effect of wound irrigation on the prevention of surgical site infections: A meta-analysis

We performed a meta‐analysis to evaluate the effect of wound irrigation on the prevention of surgical site infections. A systematic literature search up to January 2022 was done and 24 studies included 4967 subjects under surgery at the start of the study; antibiotic irrigation was used with 1372 of them, 1261 were aqueous povidone‐iodine irrigation, and 2334 were saline irrigation or no irrigation for surgical site infections prevention in all surgical populations. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to evaluate the effect of different wound irrigation on the prevention of surgical site infections by the dichotomous method with a random or fixed‐influence model. Antibiotic irrigation had significantly lower surgical site infections in all surgical populations (OR, 0.48; 95% CI, 0.36‐0.62, P < .001) compared with saline irrigation or no irrigation for the subject under surgery. Aqueous povidone‐iodine irrigation had significantly lower surgical site infections in all surgical populations (OR, 0.40; 95% CI, 0.20‐0.81, P = .01) compared with saline irrigation or no irrigation for the subject under surgery. Antibiotic irrigation and aqueous povidone‐iodine irrigation significantly lowered surgical site infections in all surgical populations compared with saline irrigation or no irrigation for the subject under surgery. Further studies are required.

Postoperative Infection: Prevention, Diagnosis, and Treatment Guidelines for the Sports Surgeon

Postoperative infection remains a potentially devastating complication facing the sports medicine surgeon. Infection prevention begins with a thorough history and physical examination to identify patient specific risk factors and aid in risk stratification. Perioperative steroid injections should be used cautiously, with increased time prior to or following surgery being associated with lower infection risk. Sterile preparation with an alcohol containing solution is typically preferred, though there is limited evidence to identify which product is superior. Diagnosis can be challenging with a high index of suspicion needed to identify and appropriately manage patients. Treatment involves prompt irrigation and debridement with deep cultures. Antibiotic coverage should begin with empiric broad treatment and be tailored based on culture results. Early consultation with an infectious disease specialist is recommended to ensure appropriate antibiotic coverage and duration of treatment.

The Effectiveness of Pre-operative Bath with 4% Chlorhexidine Gluconate for Prevention of Surgical Site Infection at the Universitas Sumatera Utara Hospital

Introduction: Elective surgery is a type of surgery that can be postponed or planned without endangering the patient's life. Every operation, the slightest, can pose a risk of infection. Surgical site infection (SSI) is still a global problem that can increase morbidity and mortality rates, prolong the time and cost of hospitalization. Chlorhexidine Gluconate (CHG) 4% is an antiseptic with broad-spectrum antimicrobial ability that can be used as an effort to prevent SSI. Aim: This study aims to analyze the effectiveness of preoperative antimicrobial baths using 4% CHG in an effort to prevent the incidence of SSI in Universitas Sumatera Utara hospitals. Methods: The design used in this study was a quasi-experimental method with a nonequivalent control group posttest only design method. The total sample in this study was 60 respondents according to the inclusion criteria. Bivariate analysis using Chi-square statistical test. Results: A total of 60 samples that met the research criteria were then divided into the preoperative bath intervention group with 4% CHG (n = 30) and the control group was not given any treatment (n = 30). In the preoperative bath intervention group with 4% CHG, there was no incidence of SSI, while in the control group, 5 (n=8.3%) respondents experienced SSI. Preoperative bath with 4% CHG was statistically more effective than not given preoperative bath with 4% CHG in preventing the incidence of SSI (p = 0.02). Conclusion: Preoperative bath with 4% CHG is effective in preventing SSI because 4% CHG is bactericidal, bacteriostatic, lasts a long time on the skin thereby reducing the number of bacterial colonies nine times and increasing the skin's ability to be antiseptic for longer.

What Is the Duration of Irrigation? An In Vitro Study of the Minimum Exposure Time to Eradicate Bacteria With Irrigation Solutions

BACKGROUND

Antiseptic irrigation solutions are commonly used by arthroplasty surgeons to reduce intraoperative bacterial colonization with the goal of reducing postoperative infections in the setting of primary total joint arthroplasty. Currently, the minimum irrigation time to eliminate common microbes implicated in periprosthetic joint infection is unknown. We sought to determine the minimum effective exposure time required to prevent growth of Staphylococcus aureus, Staphylococcus epidermidis, and Cutibacterium acnes with common antiseptic solutions.

METHODS

S aureus, S epidermidis, and C acnes cultures were treated with povidone-iodine (0.35%), chlorhexidine (0.05%), sodium hypochlorite (0.5%), polyhexamethylene biguanide, and an acetic acid-based solution for 15, 30, 60, 90, and 120 seconds in triplicate. Bacterial growth was quantified using the drop plate method. Failure to eliminate all bacteria was considered "not effective" at that time point.

RESULTS

Povidone-iodine 0.35% (Betadine), sodium hypochlorite 0.5% (HySept), and acetic acid (Bactisure) eradicated all bacterial growth after 90 seconds of treatment, and as low as 15 seconds in S aureus and C acnes (Betadine) or S epidermidis (Bactisure). Polyhexamethylene biguanide (Prontosan) required 90 seconds for elimination of S aureus and S epidermidis, and 120 seconds for C acnes. Chlorhexidine 0.05% (Irrisept) did eliminate S epidermidis at 120 seconds but did not effectively eradicate S aureus or C acnes.

CONCLUSION

All tested antiseptic solutions demonstrated successful eradication of all bacterial growth in under 2 minutes of treatment time except chlorhexidine. Povidone-iodine may require the shortest duration of treatment time to successfully eradicate common bacteria.

A Novel Device for Blood Drainage after Le Fort I Osteotomy: Maxillary Sinus Ventilation Drainage (MSVD)

The purpose of this study is to present a novel maxillary sinus ventilation drainage (MSVD) device which facilitates blood drainage and nasal breathing after Le Fort I osteotomy. One hundred patients who underwent bimaxillary orthognathic surgery from January 2016 to June 2016 at the Department of Oral and Maxillofacial Surgery, Chung-Ang University Hospital were retrospectively selected and divided into two groups. MSVD was applied in 50 patients, who were allocated to the MSVD group, while the remaining 50 patients, in whom MSVD was not applied, were allocated to the non-MSVD group. All patients underwent a cone-beam computed tomography (CBCT) scan before and 2 days after surgery. CBCT was used to analyze middle meatus patency and the percentage of hematoma volume per entire maxillary sinus volume. Statistical comparisons between the two groups were performed using the Chi-squared and Mann–Whitney U tests to investigate the clinical effectiveness of MSVD. The MSVD group showed significantly higher maintenance ratio of the middle meatus patency and a higher percentage of maxillary sinus air volume (p < 0.05) than the non-MSVD group. MSVD facilitated nasal breathing after Le Fort I osteotomy by reducing hematoma inside the maxillary sinus and promoting middle meatal patency.

Therapeutic evaluation of immunomodulators in reducing surgical wound infection

Despite many advances in infection control practices, including prophylactic antibiotics, surgical site infections (SSIs) remain a significant cause of morbidity, prolonged hospitalization, and death worldwide. Our innate immune system possesses a multitude of powerful antimicrobial strategies which make it highly effective in combating bacterial, fungal, and viral infections. However, pathogens use various stealth mechanisms to avoid the innate immune system, which in turn buy them time to colonize wounds and damage tissues at surgical sites. We hypothesized that immunomodulators that can jumpstart and activate innate immune responses at surgical sites, would likely reduce infection at surgical sites. We used three immunomodulators; fMLP (formyl-Methionine-Lysine-Proline), CCL3 (MIP-1α), and LPS (Lipopolysaccharide), based on their documented ability to elicit strong inflammatory responses; in a surgical wound infection model with Pseudomonas aeruginosa to evaluate our hypothesis. Our data indicate that one-time topical treatment with these immunomodulators at low doses significantly increased proinflammatory responses in infected and uninfected surgical wounds and were as effective, (or even better), than a potent prophylactic antibiotic (Tobramycin) in reducing P. aeruginosa infection in wounds. Our data further show that immunomodulators did not have adverse effects on tissue repair and wound healing processes. Rather, they enhanced healing in both infected and uninfected wounds. Collectively, our data demonstrate that harnessing the power of the innate immune system by immunomodulators can significantly boost infection control and potentially stimulate healing. We propose that topical treatment with these immunomodulators at the time of surgery may have therapeutic potential in combating SSI, alone or in combination with prophylactic antibiotics.

Vancomycin-Resistant Enterococci: Epidemiology, Infection Prevention, and Control

Vancomycin-resistant enterococcus (VRE) is a pathogen of growing concern due to increasing development of antibiotic resistance, increasing length of hospitalizations and excess mortality. The utility of some infection control practices are debatable, as newer developments in infection prevention strategies continued to be discovered. This article summarizes the significance of VRE and VRE transmission, along with highlighting key changes in infection control practices within the past 5 years.

Synthesis, Drug Release, and Antibacterial Properties of Novel Dendritic CHX-SrCl2 and CHX-ZnCl2 Particles

This work demonstrated for the first time the synthesis of novel chlorhexidine particles containing strontium and zinc, to provide an effective, affordable, and safe intervention in the treatment of recurrent infections found in Medicine and Dentistry. The CHX-SrCl₂ and CHX-ZnCl₂ particles were synthesized by co-precipitation of chlorhexidine diacetate (CHXD) and zinc chloride or strontium chloride, where particle size was manipulated by controlling processing time and temperature. The CHX-ZnCl₂ and CHX-SrCl₂ particles were characterized using SEM, FTIR, and XRD. UV-Vis using artificial saliva (pH 4 and pH 7) was used to measure the drug release and ICP-OES ion release. The antibacterial properties were examined against P. gingivalis, A. actinomycetemcomitans, and F. nucleatum subsp. Polymorphum, and cytotoxicity was evaluated using mouse fibroblast L929 cells. The novel particles were as safe as commercial CHXD, with antibacterial activity against a range of oral pathogens. UV-Vis results run in artificial saliva (pH 4 and pH 7) indicated a higher release rate in acidic rather than neutral conditions. The CHX-ZnCl₂ particles provided the functionality of a smart Zinc and CHX release, with respect to environmental pH, allowing responsive antibacterial applications in the field of medicine and dentistry.

Therapeutic assessment of N-formyl-methionyl-leucyl-phenylalanine (fMLP) in reducing periprosthetic joint infection

Despite many preventive measures, including prophylactic antibiotics, periprosthetic joint infection (PJI) remains a devastating complication following arthroplasty, leading to pain, suffering, morbidity and substantial economic burden. Humans have a powerful innate immune system that can effectively control infections, if alerted quickly. Unfortunately, pathogens use many mechanisms to dampen innate immune responses. The study hypothesis was that immunomodulators that can jumpstart and direct innate immune responses (particularly neutrophils) at the surgical site of implant placement would boost immune responses and reduce PJI, even in the absence of antibiotics. To test this hypothesis, N-formyl-methionyl-leucyl-phenylalanine (fMLP) (a potent chemoattractant for phagocytic leukocytes including neutrophils) was used in a mouse model of PJI with Staphylococcus aureus (S. aureus). Mice receiving intramedullary femoral implants were divided into three groups: i) implant alone; ii) implant + S. aureus; iii) implant + fMLP + S. aureus. fMLP treatment reduced S. aureus infection levels by ~ 2-Log orders at day 3. Moreover, fMLP therapy reduced infection-induced peri-implant periosteal reaction, focal cortical loss and areas of inflammatory infiltrate in mice distal femora at day 10. Finally, fMLP treatment reduced pain behaviour and increased weight-bearing at the implant leg in infected mice at day 10. Data indicated that fMLP therapy is a promising novel approach for reducing PJI, if administered locally at surgical sites. Future work will be toward further enhancement and optimisation of an fMLP-based therapeutic approach through combination with antibiotics and/or implant coating with fMLP.

Driveline exit-site care protocols in patients with left ventricular assist devices: a systematic review

 

OBJECTIVES

Driveline infections continue to be a significant complication following left ventricular assist device (LVAD) implantation. Driveline exit-site care is crucial for the prevention of infections; however, there are no uniform guidelines. The goal of this study was to provide an overview of the currently published driveline exit-site care protocols in patients with LVAD.

METHODS

A systematic literature review was performed. Studies before 15 December 2020 were included if the number of driveline infections was a primary outcome and the driveline exit-site care protocol was explained.

RESULTS

Eleven articles were included in the systematic review, including 1602 patients with LVADs. The median of the frequency of driveline infections in the articles was 13.8% with a range of 0–52.6%. There was a marked variability in the methods of care of driveline exit sites, without a standardized driveline dressing technique in patients with LVADs. The frequency of driveline infections was 6–7.5% in studies using a dressing kit that included chlorhexidine, a silver-based dressing and an anchoring device. Furthermore, there was variability in the anchoring devices and the frequency of dressing changes, which varied from daily to weekly. No specific anchoring device or change frequency was found to be superior.

CONCLUSIONS

Based on this systematic review, driveline exit care protocols that included chlorhexidine, a silver-based dressing, the use of an anchoring device and dressing kits might be best in reducing driveline infection rates. However, prospective studies with larger cohorts are needed to establish the optimal protocol for driveline exit-site care.

Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

BACKGROUND

Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review.

METHODS

We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway.

RESULTS

We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components.

CONCLUSIONS

We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS. Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.

Implementation of colon surgical site infection prevention bundle-The successes and challenges

BACKGROUND

Surgical site infection (SSI) prevention bundles have proven successful in decreasing infections. Surgeon and nurse engagement and endorsement are essential for success. The objective of this quality improvement project was to develop, implement and sustain a colon SSI prevention bundle and determine which bundle components are most strongly associated with prevention of SSI.

METHODS

The bundle was developed and implemented in a 525 bed Level I trauma hospital and included pre-, intra- and postoperative components. Bundle adherence and SSI rate were continually tracked and communicated to surgeons and nursing staff throughout project. Univariate and multivariate analyses were performed to determine the components associated with lowest SSI rates.

RESULTS

There were 280 elective and urgent/emergent colon surgeries between October 2015 and March 2018. Over 60% had preoperative components, 76.5% had intraoperative components and 55.6% had postoperative bundle components with a nonsignificant decreasing trend in SSI rate of -0.5 SSI/100 procedures per quarter. The multivariate analysis suggested that use of 2% chlorhexidine gluconate/70% alcohol skin prep, use of wound protector and change of gloves for fascial closure were associated with fewer SSI.

DISCUSSION

The implementation of a colon SSI prevention bundle in a Level I trauma hospital with pre-, intra- and postoperative components was described. Future directions include focusing implementation efforts on bundle components that significantly prevent SSI to improve adherence.

Chlorhexidine Bathing Strategies for Multidrug-Resistant Organisms: A Summary of Recent Evidence

Objective

The aim of the study was to summarize the latest evidence for patient bathing with a 2% to 4% chlorhexidine gluconate solution to reduce multidrug-resistant organism (MDRO) transmission and infection.

Methods

We searched 3 databases (CINAHL, MEDLINE, and Cochrane) for a combination of the key words “chlorhexidine bathing” and MeSH terms “cross-infection prevention,” “drug resistance, multiple, bacterial,” and “drug resistance, microbial.” Articles from January 1, 2008, to December 31, 2018, were included, as well as any key articles published after December 31.

Results

Our findings focused on health care–associated infections (HAIs) and 3 categories of MDROs: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and carbapenem-resistant Enterobacteriaceae (CRE). Chlorhexidine bathing reduces MRSA acquisition and carriage, but not all studies found significant reductions in MRSA infections. Several studies found that chlorhexidine bathing reduced VRE acquisition and carriage, and one study showed lower VRE infections in the bathing group. Two studies found that bathing reduced CRE carriage (no studies examined CRE infections). Two very large studies (more than 140,000 total patients) found bathing significantly reduced HAIs, but these reductions may be smaller when HAIs are already well controlled by other means.

Conclusions

There is a high level of evidence supporting chlorhexidine bathing to reduce MDRO acquisition; less evidence is available on reducing infections. Chlorhexidine bathing is low cost to implement, and adverse events are rare and resolve when chlorhexidine use is stopped. There is evidence of chlorhexidine resistance, but not at concentrations in typical use. Further research is needed on chlorhexidine bathing’s impact on outcomes, such as mortality and length of stay.

Study To Reduce Infection Prior to Elective Cesarean Deliveries (STRIPES): a randomized clinical trial of chlorhexidine

BACKGROUND

Surgical site infections after cesarean delivery are a cause of maternal morbidity and are typically caused by skin microbial flora. Preadmission application of chlorhexidine gluconate using impregnated cloths may decrease surgical site infections by decreasing the abundance of microbial flora.

OBJECTIVE

To determine whether the application of chlorhexidine gluconate cloths the night before and the morning of scheduled cesarean delivery decreases the risk of surgical site infections by 6 weeks postoperatively compared with placebo.

STUDY DESIGN

In this single-center, double-blind, placebo-controlled trial, patients were randomized (1:1) to receive either Sage 2% chlorhexidine cloths or Sage Comfort Bath fragrance-free cloths (placebo) to apply to 6 skin sites on the body (neck, shoulders and chest, armpits, arm and hands, abdomen and groin, left leg and foot, right leg and foot, back and buttocks) the night before and after a shower the morning of scheduled cesarean delivery. Routine clinical and operative procedures were followed. The primary outcome was surgical site infections (superficial or deep incisional with or without organ space endometritis) by 6 weeks after cesarean delivery. The secondary outcomes were surgical site infections by 2 weeks and other wound-related complications by 2 and 6 weeks after cesarean delivery.

RESULTS

From April 2015 to August 2019, 1356 patients were enrolled: 682 were assigned to the chlorhexidine group and 674 to the placebo group. The groups were similar in demographic and medical characteristics. A total of 14 patients were lost to follow-up before cesarean delivery (10 in chlorhexidine and 4 in placebo) and 33 were lost to follow-up after cesarean delivery (10 in chlorhexidine and 23 in placebo). Among the remaining 1309 (97%), no difference was found in surgical site infections by 6 weeks between the 2 groups (2.6% in chlorhexidine vs 3.7% in placebo; P=.24). There were no differences in secondary outcomes at 2 or 6 weeks and no differences in primary outcome in a per-protocol analysis.

CONCLUSION

Preadmission use of chlorhexidine gluconate cloths compared with placebo does not reduce the risk of surgical site infection after scheduled cesarean deliveries. Following the standard of care guidelines results in a low risk of surgical site infections in this group of patients.

The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions

INTRODUCTION

The Mulcahy salvage fundamentally altered the management of penile prosthesis infections (PPI). Central to this procedure is a sequence of antiseptic irrigations that aims to remove and eradicate pathogenic microflora from the infected field, thus preparing for immediate reimplantation. The antiseptic solutions and their respective concentrations, however, have never been evaluated for efficacy.

AIM

This review critically examines 3 commonly used antiseptic irrigation solutions (povidone-iodine [PVI], hydrogen peroxide [H₂O₂], and chlorhexidine gluconate [CHG]) in terms of their antimicrobial activity, cytotoxicity, and clinical use.

METHODS

A PubMed literature review was performed on articles published between 2003 and 2018. Both preclinical as well as clinical studies from various surgical disciplines were included in this review.

MAIN OUTCOME MEASURE

The original salvage protocol selected for irrigation solutions at concentrations that are likely detrimental to native tissue.

RESULTS

All 3 agents demonstrate in vitro cytotoxic effects at subclinical concentrations, but H₂O₂ is associated with the most significant deleterious properties. It does not seem to broaden antimicrobial coverage beyond what is covered by PVI. Dilute PVI (0.35-3.5% with exposure time of at least 3 minutes) possesses the most robust clinical evidence as an intraoperative adjunct, reducing the incidence of postoperative infectious complications. chlorhexidine gluconate is a promising new agent but lacks clinical data.

CLINICAL IMPLICATION

Improvements in the salvage protocol are warranted based on current evidence. Careful selection of lavage solution and usage of the lowest necessary concentration will help achieve desired antimicrobial activity while avoiding native tissue cytotoxicity. Strength and limitation: The study is limited by its retrospective nature, and the heterogeneity of literature reviewed precluded a formal meta-analysis. Furthermore, future studies will need to address the roles of normal saline and antibiotic irrigations as intraoperative adjuncts for infection prevention.

CONCLUSION

Diluted PVI (0.35-3.5% for 3 minutes) may be beneficial in the prevention of PPI. Evidence supports its use both in the setting of primary implantation as well as salvage of infected hardware. An improved, evidence-based protocol may increase positive outcomes of urologic prosthetic surgery. Pan S, Rodriguez D, Thirumavalavan N, et al. The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions. J Sex Med 2019;16:781-790.

Just add water? Chlorhexidine's antimicrobial properties are minimally affected by dilution in saline compared to water

BACKGROUND

Dilute chlorhexidine gluconate (CHG) in sterile water is an antiseptic solution approved for intraoperative wound irrigation by the United States Food and Drug Administration. In practice, however, CHG is commonly diluted with normal saline, which can result in its precipitation potentially reducing the antimicrobial effect. The purpose of this study was to determine if the antimicrobial properties of CHG are reduced after dilution with normal saline compared to sterile water.

MATERIALS AND METHODS

Sterile paper disks were placed into undiluted 4% CHG (positive control), 0.05% CHG in sterile water, 0.05% CHG in normal saline, or normal saline alone (negative control) and then placed in triplicate onto the agar plates inoculated with Staphylococcus aureus. After incubating at 37 °C for 24 h, the diameter of the zone of inhibition around each disk was measured.

RESULTS

The mean zone of inhibition for 4% CHG, 0.05% CHG in sterile water, 0.05% CHG in normal saline, and normal saline alone was 24 ± 0.6 mm, 16 ± 0.9 mm, 14 ± 0.5 mm, and 0 ± 0 mm, respectively (p < 0.01). The zone of inhibition for dilute CHG in normal saline was on average 2.5 mm less (95% CI 1.7-3.2 mm) than that of CHG in sterile water.

CONCLUSIONS

Dilute CHG in normal saline, versus sterile water, retained its antimicrobial activity with a small reduction in the zone of inhibition. Surgeons and scientists should be aware of the interaction between normal saline and CHG. Future scientific studies need to control for what solution is used for dilution.

Enhanced Clearing of Wound-Related Pathogenic Bacterial Biofilms Using Protease-Functionalized Antibiotic Nanocarriers

Biofilms are prevalent in chronic wounds and once formed are very hard to remove, which is associated with poor outcomes and high mortality rates. Biofilms are comprised of surface-attached bacteria embedded in an extracellular polymeric substance (EPS) matrix, which confers increased antibiotic resistance and host immune evasion. Therefore, disruption of this matrix is essential to tackle the biofilm-embedded bacteria. Here, we propose a novel nanotechnology to do this, based on protease-functionalized nanogel carriers of antibiotics. Such active antibiotic nanocarriers, surface coated with the protease Alcalase 2.4 L FG, "digest" their way through the biofilm EPS matrix, reach the buried bacteria, and deliver a high dose of antibiotic directly on their cell walls, which overwhelms their defenses. We demonstrated their effectiveness against six wound biofilm-forming bacteria, Staphylococcus aureus, Pseudomonas aeruginosa, Staphylococcus epidermidis, Klebsiella pneumoniae, Escherichia coli, and Enterococcus faecalis. We confirmed a 6-fold decrease in the biofilm mass and a substantial reduction in bacterial cell density using fluorescence, atomic force, and scanning electron microscopy. Additionally, we showed that co-treatments of ciprofloxacin and Alcalase-coated Carbopol nanogels led to a 3-log reduction in viable biofilm-forming cells when compared to ciprofloxacin treatments alone. Encapsulating an equivalent concentration of ciprofloxacin into the Alcalase-coated nanogel particles boosted their antibacterial effect much further, reducing the bacterial cell viability to below detectable amounts after 6 h of treatment. The Alcalase-coated nanogel particles were noncytotoxic to human adult keratinocyte cells (HaCaT), inducing a very low apoptotic response in these cells. Overall, we demonstrated that the Alcalase-coated nanogels loaded with a cationic antibiotic elicit very strong biofilm-clearing effects against wound-associated biofilm-forming pathogenic bacteria. This nanotechnology approach has the potential to become a very powerful treatment of chronically infected wounds with biofilm-forming bacteria.

Wound Irrigation with Chlorhexidine Gluconate Reduces Surgical Site Infection in Pilonidal Disease: Single-Blind Prospective Study

Background: The aim of this study was to determine whether incision irrigation with chlorhexidine gluconate (CHG) reduces surgical site infections (SSIs) in pilonidal disease surgery. Methods: Between 2013 and 2018, patients who underwent wide excision with primary closure for pilonidal disease were enrolled in this prospective observational multi-institutional cohort. The incision was irrigated with either saline or 0.05% CHG before skin closure. The infection risk of each patient was determined by the National Nosocomial Infection Surveillance System. Post-operative site care and follow-up were carried out according to the U.S. Centers for Disease Control and Prevention guideline by two surgeons blinded to the irrigation solution used. Surgical site infection rates in the saline and 0.05% CHG groups were compared. The secondary outcomes were seroma formation, incision dehiscence, and time to healing. Results: There were 129 patients in the control group and 138 patients in the CHG group. The mean age was 25.1 ± 5.4, and 225 patients (84.3%) were male. Surgical site infection was seen in 35 patients (13.1%): 26 (20.2%) in the control group and 9 (6.5%) in the CHG group (p = 0.001). There were no differences in seroma formation (n = 12; 9.3% in the control vs n = 12; 8.7% in the CHG group; p = 0.515) or incision dehiscence (n = 9; 7% in the control vs n = 9; 6.5% in the CHG group; p = 0.537). The primary healing rate was higher in the CHG group (n = 130; 94.2%) than in the control group (n = 104; 80.6%). Time to healing was 20.5 ± 7.8 days in the control group and 16 ± 4.3 days in the CHG group (p < 0.001). Conclusion: Intra-operative incision irrigation with CHG decreased the SSI rate and time to healing in pilonidal disease surgery. Further randomized trials should focus on specific irrigation methods and procedures to build a consensus on the effect of incision irrigation on SSIs.

Back to Basics: Could the Preoperative Skin Antiseptic Agent Help Prevent Biofilm-Related Capsular Contracture?

BACKGROUND

Capsular contracture (CC) has remained an unresolved issue throughout history. Strong evidence focuses on bacterial biofilm as its main source. A literature review revealed that more than 90% of bacteria found in capsules and implants removed from patients with Baker grade III-IV CC belong to the resident skin microbiome (Staphylococcus epidermidis, predominant microorganism). The use of an adequate preoperative skin antiseptic may be a critical step to minimize implant contamination and help prevent biofilm-related CC.

OBJECTIVES

The authors sought to compare the effect of 2 different antiseptic skin preparations: povidone-iodine (PVP-I) vs chlorhexidine gluconate (CHG) on CC proportions after primary breast augmentation through a periareolar approach.

METHODS

In June of 2014, The Society for Healthcare Epidemiology of America proposed to use CHG for preoperative skin preparation in the absence of alcohol-containing antiseptic agents as strategy to prevent surgical site infection. The clinical safety committee of a surgical center in Colombia decided to change PVP-I to CHG for surgical site preparation thereafter. The medical records of 63 patients who underwent to primary breast augmentation through a periareolar approach during 2014 were reviewed. In the first 6 months PVP-I was used in 32 patients, and later CHG was employed in 31 patients.

RESULTS

Pearson's chi-squared test to compare CC proportions between subgroups showed a statistically significant difference. The CC proportion was higher for patients who had antisepsis with PVP-I. CC was absent when CHG was employed.

CONCLUSIONS

CHG as preoperative skin antiseptic for primary breast augmentation surgery was more effective than PVP-I to help prevent biofilm-related CC.

LEVEL OF EVIDENCE: 3

A Novel, Widespread qacA Allele Results in Reduced Chlorhexidine Susceptibility in Staphylococcus epidermidis

Chlorhexidine gluconate (CHG) is a topical antiseptic widely used in health care settings. In Staphylococcus spp., the pump QacA effluxes CHG, while the closely related QacB cannot due to a single amino acid substitution. We characterized 1,050 cutaneous Staphylococcus isolates obtained from 173 pediatric oncology patients enrolled in a multicenter CHG bathing trial. CHG susceptibility testing revealed that 63 (6%) of these isolates had elevated CHG MICs (≥4 μg/ml). Screening of all 1,050 isolates for the qacA/B gene (the same qac gene with A or B allele) by restriction fragment length polymorphism (RFLP) yielded 56 isolates with a novel qacA/B RFLP pattern, qacA/B₂₇₃ The CHG MIC was significantly higher for qacA/B₂₇₃ -positive isolates (MIC₅₀, 4 μg/ml; MIC range, 0.5 to 4 μg/ml) than for other qac groups: qacA-positive isolates (n = 559; MIC₅₀, 1 μg/ml; MIC range, 0.5 to 4 μg/ml), qacB-positive isolates (n = 17; MIC₅₀, 1 μg/ml; MIC range, 0.25 to 2 μg/ml), and qacA/B-negative isolates (n = 418, MIC₅₀, 1 μg/ml; MIC range, 0.125 to 2 μg/ml) (P = 0.001). A high proportion of the qacA/B₂₇₃ -positive isolates also displayed methicillin resistance (96.4%) compared to the other qac groups (24.9 to 61.7%) (P = 0.001). Whole-genome sequencing revealed that qacA/B₂₇₃ -positive isolates encoded a variant of QacA with 2 amino acid substitutions. This new allele, named qacA4, was carried on the novel plasmid pAQZ1. The qacA4-carrying isolates belonged to the highly resistant Staphylococcus epidermidis sequence type 2 clone. By searching available sequence data sets, we identified 39 additional qacA4-carrying S. epidermidis strains from 5 countries. Curing an isolate of qacA4 resulted in a 4-fold decrease in the CHG MIC, confirming the role of qacA4 in the elevated CHG MIC. Our results highlight the importance of further studying qacA4 and its functional role in clinical staphylococci.

Surgical site infections: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of post-operative surgical site infections (SSIs) in solid organ transplantation. SSIs are a significant cause of morbidity and mortality in SOT recipients. Depending on the organ transplanted, SSIs occur in 3%-53% of patients, with the highest rates observed in small bowel/multivisceral, liver, and pancreas transplant recipients. These infections are classified by increasing invasiveness as superficial incisional, deep incisional, or organ/space SSIs. The spectrum of organisms implicated in SSIs in SOT recipients is more diverse than the general population due to other important factors such as the underlying end-stage organ failure, immunosuppression, prolonged hospitalizations, organ transportation/preservation, and previous exposures to antibiotics in donors and recipients that could predispose to infections with multidrug-resistant organisms. In this guideline, we describe the epidemiology, clinical presentation, differential diagnosis, potential pathogens, and management. We also provide recommendations for the selection, dosing, and duration of peri-operative antibiotic prophylaxis to minimize post-operative SSIs.

Standardising intraoperative irrigation with 0.05% chlorhexidine gluconate in caesarean delivery to reduce surgical site infections: A single institution experience

Background

Surgical site infection is a significant cause of morbidity and mortality following caesarean delivery.

Objective

To determine whether standardising intraoperative irrigation with 0.05% chlorhexidine gluconate during caesarean delivery could decrease infection rates.

Methods

This was a process improvement project involving 742 women, 343 of whom received low-pressured 0.05% chlorhexidine gluconate irrigation during caesarean delivery over a one-year period. Infection rates were compared with a standard-of-care control group (399 women) undergoing caesarean delivery the preceding year.

Results

The treatment group infection rate met the study goal by achieving a lower infection rate than the control group, though this was not statistically significant. A significant interaction effect between irrigation with 0.05% chlorhexidine gluconate and antibiotic administration time existed, such that infection occurrence in the treatment group was not dependent on antibiotic timing, as opposed to the control group infection occurrence, which was dependent on antibiotic timing.

Conclusion

Intraoperative irrigation with 0.05% chlorhexidine gluconate during caesarean delivery did not statistically significantly reduce the rate of infections. It did render the impact of antibiotic administration timing irrelevant in prevention of surgical site infection. This suggests a role for 0.05% chlorhexidine gluconate irrigation in mitigating infection risk whether antibiotic prophylaxis timing is suboptimal or ideal.

Implementation of an evidence-based practice to decrease surgical site infection after coronary artery bypass grafting

Objective

Surgical site infection (SSI) is a serious complication after coronary artery bypass grafting (CABG). This study was performed to evaluate evidence-based practice and structured problem-solving to reduce SSI after CABG.

Methods

An infection control strategy including supervised chlorhexidine gluconate (CHG) showers was implemented from January 2017 to March 2018 for 119 patients undergoing CABG. The controls comprised 244 patients who underwent CABG from 2014 to 2016. Risk factors for SSI were identified, and a problem-focused strategy was used to control SSI. Propensity score matching was used to study the effect of CHG showers on SSI.

Results

SSI occurred in 25 patients (10.25%) in the control group, and the significant risk factors were the postoperative blood glucose level, transfer from an outside hospital, emergency operation, redo sternotomy, a higher American Society of Anesthesiologists score, and the duration of surgery. After implementation of the program, the SSI rate significantly decreased to 3.36%. Patients who had undergone preoperative CHG showers had a significantly lower SSI rate (1.69%) than the matched controls (13.56%).

Conclusion

SSI after CABG can be reduced using evidence-based practice and structured problem-solving to identify risk factors. A preoperative CHG shower is associated with a lower SSI rate after CABG.

Infecção de sítio cirúrgico após cirurgia bariátrica: resultados de uma abordagem com pacote de cuidados

RESUMO Objetivo: apresentar uma análise descritiva dos resultados de um pacote de cuidados aplicado em pacientes obesos submetidos à cirurgia bariátrica, no que diz respeito ao controle de infecção. Métodos: um pacote de cuidados foi estruturado, visando a conter as taxas de infecção de sítio cirúrgico (ISC) em pacientes submetidos à cirurgia bariátrica. O pacote incluiu interrupção de tabagismo, banho com clorexidina 4% duas horas antes da cirurgia, cefazolina 2g em bolus na indução anestésica associada à administração da mesma droga com dose de 1g em infusão contínua, tricotomia apropriada, controle glicêmico, oxigênio suplementar, normotermia, controle da dor com morfina intrarraquidiana e remoção do curativo estéril 48 horas após a cirurgia. Todos os pacientes foram seguidos por 30 dias. Resultados: entre os 1.596 pacientes incluídos, 334 (20,9%) foram submetidos à cirurgia aberta e 1.262 (79,1%) à cirurgia videolaparoscópica. As taxas de ISC foram de 0,5% no grupo submetido à cirurgia laparoscópica e de 3% nos submetidos à cirurgia aberta. A incidência geral de ISC foi de 1%. Infecções intra-abdominal, do trato respiratório e do trato urinário ocorreram em 0,9%, 1,1% e 1,5% da amostra, respectivamente. Faixas mais elevadas de índice de massa corporal foram associadas a maiores incidências de ISC (p=0,001). Entre os pacientes com diabetes, 2,2% desenvolveram ISC, enquanto a taxa de infecção entre os não diabéticos foi de apenas 0,6%. Conclusão: o pacote de cuidados instituído, estruturado por estratégias centrais baseadas em evidências, associadas à medidas secundárias, foi capaz de manter baixas taxas de ISC após cirurgia bariátrica.

Antiseptic Irrigation as an Effective Interventional Strategy for Reducing the Risk of Surgical Site Infections

A surgical site infection (SSI) can occur at several anatomic sites related to a surgical procedure: Superficial or deep incisional or organ/space. The SSIs are the leading cause of health-care-associated infection (HAI) in industrialized Western nations. Patients in whom an SSI develops require longer hospitalization, incur significantly greater treatment costs and reduction in quality of life, and after selective surgical procedures experience higher mortality rates. Effective infection prevention and control requires the concept of the SSI care bundle, which is composed of a defined number of evidence-based interventional strategies, because of the many risk factors that can contribute to the development of an SSI. Intra-operative irrigation has been a mainstay of surgical practice for well over 100 years, but lacks standardization and compelling evidence-based data to validate its efficacy. In an era of antibiotic stewardship, with a widespread prevalence of bacterial resistance to multiple antibiotic agents, there has emerged an interest in using intra-operative antiseptic irrigation to reduce microbial contamination in the surgical site before closure and possibly reduce the need for antibiotic agents. This approach has gained added appeal in an era of biomedical device implantation, especially with the recognition that most, if not all, device-related infections are associated with biofilm formation. This review focuses on the limited, evidence-based rationale for the use of antiseptic agents as an effective risk reduction strategy for prevention of SSIs.