Are three antiseptic paints needed for safe preparation of the surgical field? A prospective cohort study with 239 patients

Povidone Iodine vs Chlorhexidine Gluconate in Alcohol for Preoperative Skin Antisepsis: A Randomized Clinical Trial

Importance

Preoperative skin antisepsis is an established procedure to prevent surgical site infections (SSIs). The choice of antiseptic agent, povidone iodine or chlorhexidine gluconate, remains debated.

Objective

To determine whether povidone iodine in alcohol is noninferior to chlorhexidine gluconate in alcohol to prevent SSIs after cardiac or abdominal surgery.

Design, Setting, and Participants

Multicenter, cluster-randomized, investigator-masked, crossover, noninferiority trial; 4403 patients undergoing cardiac or abdominal surgery in 3 tertiary care hospitals in Switzerland between September 2018 and March 2020 were assessed and 3360 patients were enrolled (cardiac, n = 2187 [65%]; abdominal, n = 1173 [35%]). The last follow-up was on July 1, 2020.

Interventions

Over 18 consecutive months, study sites were randomly assigned each month to either use povidone iodine or chlorhexidine gluconate, each formulated in alcohol. Disinfectants and skin application processes were standardized and followed published protocols.

Main Outcomes and Measures

Primary outcome was SSI within 30 days after abdominal surgery and within 1 year after cardiac surgery, using definitions from the US Centers for Disease Control and Prevention's National Healthcare Safety Network. A noninferiority margin of 2.5% was used. Secondary outcomes included SSIs stratified by depth of infection and type of surgery.

Results

A total of 1598 patients (26 cluster periods) were randomly assigned to receive povidone iodine vs 1762 patients (26 cluster periods) to chlorhexidine gluconate. Mean (SD) age of patients was 65.0 years (39.0-79.0) in the povidone iodine group and 65.0 years (41.0-78.0) in the chlorhexidine gluconate group. Patients were 32.7% and 33.9% female in the povidone iodine and chlorhexidine gluconate groups, respectively. SSIs were identified in 80 patients (5.1%) in the povidone iodine group vs 97 (5.5%) in the chlorhexidine gluconate group, a difference of 0.4% (95% CI, -1.1% to 2.0%) with the lower limit of the CI not exceeding the predefined noninferiority margin of -2.5%; results were similar when corrected for clustering. The unadjusted relative risk for povidone iodine vs chlorhexidine gluconate was 0.92 (95% CI, 0.69-1.23). Nonsignificant differences were observed following stratification by type of surgical procedure. In cardiac surgery, SSIs were present in 4.2% of patients with povidone iodine vs 3.3% with chlorhexidine gluconate (relative risk, 1.26 [95% CI, 0.82-1.94]); in abdominal surgery, SSIs were present in 6.8% with povidone iodine vs 9.9% with chlorhexidine gluconate (relative risk, 0.69 [95% CI, 0.46-1.02]).

Conclusions and Relevance

Povidone iodine in alcohol as preoperative skin antisepsis was noninferior to chlorhexidine gluconate in alcohol in preventing SSIs after cardiac or abdominal surgery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03685604.

Association between the introduction of a national targeted intervention program and the incidence of surgical site infections in Swiss acute care hospitals

BACKGROUND

In Switzerland, the national surgical site infection (SSI) surveillance program showed a modest decrease in SSI rates for different procedures over the last decade. The study aimed to determine whether a multimodal, targeted intervention program in addition to existing SSI surveillance is associated with decreased SSI rates in the participating hospitals.

METHODS

Prospective multicenter pre- and postintervention study conducted in eight Swiss acute care hospitals between 2013 and 2020. All consecutive patients > 18 years undergoing cardiac, colon, or hip/knee replacement surgery were included. The follow-up period was 30 days and one year for implant-related surgery. Patients with at least one follow-up were included. The intervention was to optimize three elements of preoperative management: (i) hair removal; (ii) skin disinfection; and (iii) perioperative antimicrobial prophylaxis. We compared SSI incidence rates (main outcome measure) pre- and postintervention (three years each) adjusted for potential confounders. Poisson generalized linear mixed models fitted to quarter-yearly confirmed SSIs and adjusted for baseline differences between hospitals and procedures. Adherence was routinely monitored through on-site visits.

RESULTS

A total of 10 151 patients were included, with a similar median age pre- and postintervention (69.6 and IQR 60.9, 76.8 years, vs 69.5 and IQR 60.4, 76.8 years, respectively; P = 0.55) and similar proportions of females (44.8% vs. 46.1%, respectively; P = 0.227). Preintervention, 309 SSIs occurred in 5 489 patients (5.6%), compared to 226 infections in 4 662 cases (4.8%, P = 0.09) postintervention. The adjusted incidence rate ratio (aIRR) for overall SSI after intervention implementation was 0.81 (95% CI, 0.68 to 0.96, P = 0.02). For cardiac surgery (n = 2 927), the aIRR of SSI was 0.48 (95% CI, 0.32 to 0.72, P < 0.001). For hip/knee replacement surgery (n = 4 522), the aIRR was 0.88 (95% CI, 0.52 to 1.48, P = 0.63), and for colon surgery (n = 2 702), the aIRR was 0.92 (95% CI, 0.75 to 1.14, P = 0.49).

CONCLUSIONS

The SSI intervention bundle was associated with a statistically significant decrease in SSI cases. A significant association was observed for cardiac surgery. Adding a specific intervention program can add value compared to routine surveillance only. Further prevention modules might be necessary for colon and orthopedic surgery.

Transitory Shifts in Skin Microbiota Composition and Reductions in Bacterial Load and Psoriasin following Ethanol Perturbation

Personal care and hygiene regimens may substantially alter the composition of the skin microbiota through direct and indirect mechanisms. An understanding of the timescales of commensal skin microbiota reestablishment following perturbation is required to inform consumer safety risk assessment, and support product development. In the current investigation, the microbiota of the volar and dorsal forearm of 10 volunteers was sampled immediately before and after wiping with 70% ethanol and at up to 24 h afterwards. Quantitative PCR and amplicon sequencing were used to measure microbial load and composition, and concentrations of the antimicrobial peptide psoriasin were measured using an enzyme-linked immunosorbent assay (ELISA). Ethanol wiping significantly reduced the total bacterial abundance at 2 h post-wipe. Recovery was observed after 6 h for total bacterial populations and for Staphylococcus epidermidis depending on the site tested. Microbiome diversity recovered by 6 h after wiping. Psoriasin concentrations were highly variable between volunteers, ranging from 42 to 1,569 ng/mL, and dorsal concentrations were significantly higher than volar concentrations (P < 0.05). For most of the volunteers, the application of ethanol decreased psoriasin concentrations, particularly for the dorsal samples, but the overall effect was not significant. This work extends observations of skin microbiome stability and demonstrates resilience in a key antimicrobial peptide.

IMPORTANCE An understanding of the timescales of commensal skin microbiota reestablishment following perturbation is required to inform consumer safety risk assessment and support product development. Following ethanol exposure, total bacterial populations and microbiome diversity recovered after 6 h. For most of the volunteers, the application of ethanol decreased psoriasin concentrations, but the overall effect was not significant. This work extends observations of skin microbiome stability and demonstrates resilience in a key antimicrobial peptide.

In Vitro Bactericidal Efficacy of Nanostructured Ti6Al4V Surfaces is Bacterial Load Dependent

The demand for medical implants globally has increased significantly due to an aging population amongst other reasons. Despite the overall increase in the survivorship of Ti6Al4V implants, implant infection rates are increasing due to factors such as diabetes, obesity, and bacterial resistance to antibiotics. Two commonly found bacteria implicated in implant infections are Staphylococcus aureus and Pseudomonas aeruginosa. Based on prior work that showed nanostructured surfaces might have potential in passively killing these bacterial species, we developed a hierarchical, hydrothermally etched, nanostructured titanium surface. To evaluate the antibacterial efficacy of this surface, etched and as-received surfaces were inoculated with S. aureus or P. aeruginosa at concentrations ranging from 10² to 10⁹ colony-forming units per disc. Live/dead staining revealed there was a 60% decrease in viability for S. aureus and greater than a 98% decrease for P. aeruginosa on etched surfaces at the lowest inoculum of 10² CFU/disc, when compared to the control surface. Bactericidal efficiency decreased with increasing bacterial concentrations in a stepwise manner, with decreases in bacterial viability noted for S. aureus above 10⁵ CFU/disc and above 10⁶ CFU/disc for P. aeruginosa. Surprisingly, biofilm depth analysis revealed a decrease in bacterial viability in the 2 μm layer furthest from the nanostructured surface. The nanostructured Ti6Al4V surface developed here holds the potential to reduce the rate of implant infections.