Incidência de infecção do sítio cirúrgico com o preparo pré-operatório utilizando iodopolividona 10% hidroalcoólica e clorexidina alcoólica 0,5%

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.

Efficacy of skin preparation solutions in patients with total knee replacement: A randomized controlled trial

PURPOSE

Surgical site infection following total knee replacement is considered as one of the most severe postoperative complications. The presence of bacteria at the surgical site is the most important risk factor and therefore it is essential to prevent infection through appropriate preoperative skin preparation. The purpose of this study was to examine the presence and type of native bacteria on the incision site and to assess which skin preparation is most effective to sterilize those native bacteria.

METHODS

Scrub-and-paint 2 step method was used for standard preoperative skin preparation. 150 patients who underwent total knee replacement were grouped into 3 groups- Group 1 (povidone-iodine scrub-and-paint), Group 2 (chlorhexidine gluconate paint after povidone-iodine scrub), and Group 3 (povidone-iodine paint after chlorhexidine gluconate scrub). 150 specimens of post-preparation swabs were obtained and cultured. To analyze the native bacteria at the total knee replacement incision site, 88 additional swaps were performed before skin preparation and cultured.

RESULTS

The positive rate of bacterial culture after skin preparation was 5.3% (8/150). Positive rates of the groups were 12% (6/50) in group 1, 2% (1/50) in group, 2 and 2% (1/50) in group 3 and positive rates of bacterial culture after skin preparation in group 2 and group 3 were lower than in group 1 (p = 0.037). Among the 55 patients who had positive bacterial culture prior to skin preparation, 26.7% (4/15) in group 1, 5.6% (1/18) in group 2, and 4.5% (1/22) in group 3 were positive. Group 1 showed 7.64 times higher positive bacterial culture rate after skin preparation than group 3 (p = 0.084).

CONCLUSION

During skin preparation prior to total knee replacement surgery, chlorhexidine gluconate paint after povidone-iodine scrub or povidone-iodine paint after chlorhexidine gluconate scrub had a superior effect on sterilizing native bacteria compared to povidone-iodine scrub-and-paint method.

Hand port-site infection after hand-assisted laparoscopic donor nephrectomy for living-donor kidney transplantation: a retrospective cohort study

Background

Hand-assisted laparoscopic donor nephrectomy (HALDN) is widely performed to minimize burden on living kidney donors. However, hand port-site infections after HALDN may occur. This study aimed to assess the impact of donor characteristics including preoperative comorbidities and operative factors on hand port-site infection after HALDN.

Methods

In this single-center, retrospective cohort study, 1,260 consecutive HALDNs for living-donor kidney transplantation performed between January 2008 and December 2021 were evaluated. All living donors met the living kidney donor guidelines in Japan. Hand port-site infections were identified in 88 HALDN cases (7.0%). To investigate risk factors for hand port-site infection, donor characteristics including preoperative comorbidities such as hypertension, glucose intolerance, dyslipidemia, obesity, and operative factors such as operative duration, blood loss, preoperative antibiotic prophylaxis, and prophylactic subcutaneous suction drain placement at the hand port-site were analyzed using logistic regression analysis.

Results

In the multivariate analysis, significant differences were identified regarding sex (P = 0.021; odds ratio [OR], 1.971; 95% confidence interval [CI], 1.108-3.507), preoperative antibiotic prophylaxis (P < 0.001; OR, 0.037; 95% CI [0.011-0.127]), and prophylactic subcutaneous suction drain placement at the hand port-site (P = 0.041; OR, 2.005; 95% CI [1.029-3.907]). However, a significant difference was not identified regarding glucose intolerance (P = 0.572; OR, 1.148; 95% CI [0.711-1.856]). Preoperative comorbidities may not cause hand port-site infections within the donors who meet the living kidney donor guidelines. Preoperative antibiotic prophylaxis is crucial in preventing hand port-site infection, whereas prophylactic subcutaneous suction drain placement may increase the risk of hand port-site infection.

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.

Efficacy of surgical skin preparation with chlorhexidine in alcohol according to the concentration required to prevent surgical site infection: meta-analysis

BACKGROUND

A combination of chlorhexidine gluconate and alcohol (CHG-alcohol) is recommended for surgical skin preparation to prevent surgical site infection (SSI). Although more than 1 per cent CHG-alcohol is recommended to prevent catheter-related bloodstream infections, there is no consensus regarding the concentration of the CHG compound for the prevention of SSI.

METHODS

A systematic review and meta-analysis was performed. Four electronic databases were searched on 5 November 2020. SSI rates were compared between CHG-alcohol and povidone-iodine (PVP-I) according to the concentration of CHG (0.5 per cent, 2.0 per cent, 2.5 per cent, and 4.0 per cent).

RESULTS

In total, 106 of 2716 screened articles were retrieved for full-text review. The risk ratios (RRs) of SSI for 0.5 per cent (6 studies) and 2.0 per cent (4 studies) CHG-alcohol were significantly lower than those for PVP-I (RR = 0.71, 95 per cent confidence interval (c.i.) 0.52 to 0.97; RR = 0.52, 95 per cent c.i 0.31 to 0.86 respectively); however, no significant difference was observed in the compounds with a CHG concentration of more than 2.0 per cent.

CONCLUSIONS

This meta-analysis is the first study that clarifies the usefulness of an alcohol-based CHG solution with a 0.5 per cent or higher CHG concentration for surgical skin preparation to prevent SSI.

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.

Reducing surgical site infections in low-income and middle-income countries (FALCON): a pragmatic, multicentre, stratified, randomised controlled trial

BACKGROUND

Surgical site infection (SSI) is the most common postoperative complication worldwide. WHO guidelines to prevent SSI recommend alcoholic chlorhexidine skin preparation and fascial closure using triclosan-coated sutures, but called for assessment of both interventions in low-resource settings. This study aimed to test both interventions in low-income and middle-income countries.

METHODS

FALCON was a 2 × 2 factorial, randomised controlled trial stratified by whether surgery was clean-contaminated, or contaminated or dirty, including patients undergoing abdominal surgery with a skin incision of 5 cm or greater. This trial was undertaken in 54 hospitals in seven countries (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa). Patients were computer randomised 1:1:1:1 to: (1) 2% alcoholic chlorhexidine and non-coated suture, (2) 2% alcoholic chlorhexidine and triclosan-coated suture, (3) 10% aqueous povidone-iodine and non-coated suture, or (4) 10% aqueous povidone-iodine and triclosan-coated suture. Patients and outcome assessors were masked to intervention allocation. The primary outcome was SSI, reported by trained outcome assessors, and presented using adjusted relative risks and 95% CIs. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03700749.

FINDINGS

Between Dec 10, 2018, and Sept 7, 2020, 5788 patients (3091 in clean-contaminated stratum, 2697 in contaminated or dirty stratum) were randomised (1446 to alcoholic chlorhexidine and non-coated suture, 1446 to alcoholic chlorhexidine and triclosan-coated suture, 1447 to aqueous povidone-iodine and non-coated suture, and 1449 to aqueous povidone-iodine and triclosan-coated suture). 14·0% (810/5788) of patients were children and 66·9% (3873/5788) had emergency surgery. The overall SSI rate was 22·0% (1163/5284; clean-contaminated stratum 15·5% [454/2923], contaminated or dirty stratum 30·0% [709/2361]). For both strata, there was no evidence of a difference in the risk of SSI with alcoholic chlorhexidine versus povidone-iodine (clean-contaminated stratum 15·3% [223/1455] vs 15·7% [231/1468], relative risk 0·97 [95% CI 0·82-1·14]; contaminated or dirty stratum 28·3% [338/1194] vs 31·8% [371/1167], relative risk 0·91 [95% CI 0·81-1·02]), or with triclosan-coated sutures versus non-coated sutures (clean-contaminated stratum 14·7% [215/1459] vs 16·3% [239/1464], relative risk 0·90 [95% CI 0·77-1·06]; contaminated or dirty stratum 29·4% [347/1181] vs 30·7% [362/1180], relative risk 0·98 [95% CI 0·87-1·10]). With both strata combined, there were no differences using alcoholic chlorhexidine or triclosan-coated sutures.

INTERPRETATION

This trial did not show benefit from 2% alcoholic chlorhexidine skin preparation compared with povidone-iodine, or with triclosan-coated sutures compared with non-coated sutures, in preventing SSI in clean-contaminated or contaminated or dirty surgical wounds. Both interventions are more expensive than alternatives, and these findings do not support recommendations for routine use.

FUNDING

National Institute for Health Research (NIHR) Global Health Research Unit Grant, BD.

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.

Randomised Controlled Trials of Alcohol-Based Surgical Site Skin Preparation for the Prevention of Surgical Site Infections: Systematic Review and Meta-Analysis

(1) Background: Surgical site skin preparation is an important approach to prevent postoperative wound infections. International guidelines recommend that alcohol-based combinations be used, however, the optimal combination remains uncertain. This study compares the effectiveness of alcohol-based chlorhexidine and alcohol-based iodophor for surgical site skin preparation for prevention of surgical site infections (SSIs). (2) Methods: Randomised controlled trials comparing alcohol-based interventions for surgical site skin preparation were included. The proportion of SSIs was compared using risk ratios (RR) with 95% confidence intervals (95% CI). The meta-analysis was performed with a fixed effect model using Mantel-Haenszel methods. As an a priori subgroup analysis SSI risk was examined according to different surgical procedural groups. (3) Results: Thirteen studies were included (n = 6023 participants). The use of chlorhexidine-alcohol was associated with a reduction in risk of SSIs compared with iodophor-alcohol (RR 0.790; 95% CI 0.669, 0.932). On sub-group analysis, chlorhexidine-alcohol was associated with a reduction in SSIs in caesarean surgery (RR 0.614; 95% CI 0.453, 0.831) however, chlorhexidine-alcohol was associated with an increased risk of SSI in bone and joint surgery (RR 2.667; 95% CI 1.051, 6.765). When excluding studies at high risk of bias on sensitivity analysis, this difference in alcohol-based combinations for bone and joint surgery was no longer observed (RR 2.636; 95% CI 0.995, 6.983). (4) Conclusions: The use of chlorhexidine-alcohol skin preparations was associated with a reduced risk of SSI compared to iodophor-alcohol agents. However, the efficacy of alcohol-based preparation agents may differ according to the surgical procedure group. This difference must be interpreted with caution given the low number of studies and potential for bias, however, it warrants further investigation into the potential biological and clinical validity of these findings.

Preoperative Antisepsis with Chlorhexidine Versus Povidone-Iodine for the Prevention of Surgical Site Infection: a Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

Chlorhexidine (CH) and povidone-iodine (PI) are the most commonly used preoperative skin antiseptics at present. However, the prevention of the surgical site infection (SSI) and the incidence of skin adverse events do not reach a consistent statement and conclusion. This meta-analysis aimed to evaluate the efficacy of chlorhexidine and povidone-iodine in the prevention of postoperative surgical site infection and the incidence of corresponding skin adverse events.

METHOD

Substantial studies related to "skin antiseptic" and "surgical site infection" were consulted on PUBMED, Web of Science, EMBASE, and CNKI. The primary outcome was the incidence of postoperative SSI. The secondary outcome was associated with skin adverse events. All data were analyzed with Revman 5.3 software.

RESULTS

A total of 30 studies were included, including 29,006 participants. This study revealed that chlorhexidine was superior to povidone-iodine in the prevention of postoperative SSI (risk ratio [RR], 0.65; 95% confidence interval [CI], 0.55-0.77; p < 0.00001, I² = 57%). Further subgroup analysis showed that chlorhexidine was superior to povidone-iodine in the prevention of postoperative SSI in clean surgery (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.67-0.98; p = 0.03), I² = 28%) and clean-contaminated surgery (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.47-0.73; p < 0.00001, I² = 43%). However, there was no statistically significant difference in the incidence of skin adverse events between CH and PI groups.

CONCLUSION

Chlorhexidine was superior to povidone-iodine in preventing postoperative SSI, especially for the clean-contaminated surgery. However, there was no statistically significant difference in the incidence of skin adverse events between CH and PI groups.

Low-frequency ultrasound increase effectiveness of silver nanoparticles in a purulent wound model

Bacterial biofilm formation and antibiotic resistance are the main factors of surgical wound complications. Traditional treatments in some cases cannot provide complete bacterial eradication and new therapeutic approaches should be developed to overcome antibiotic resistance. Silver nanoparticles (AgNPs) can be the first choice for bacteria treatment but their clinical application is limited due to toxic effects. Combination of AgNPs with the low-frequency ultrasound (US) treatment expected to decrease toxicity and leads to the facilitation of wound healing. In current research we investigated the antibacterial activity of AgNPs per se and in combination with low-frequency US, assessed the cytotoxicity of AgNPs on human dermal fibroblasts and finally, wound healing was evaluated in purulent wound model (96 white laboratory rats) applying AgNPs and US as a treatment strategy. Our results demonstrate no toxic effect of AgNPs in minimum inhibitory concentrations and show increasing their antibacterial effectiveness after US application. The combination of low-frequency US and AgNPs provides reduction of the inflammatory reaction, microorganism elimination and leads to facilitation of new tissue formation with complete epithelization. All effects were significant over the Chlorhexidine treatment, monotherapy with AgNPs or US. Advanced effectiveness of complex therapy opens new perspectives for clinical application of AgNPs solution accompanied by US.

Lignin-mediated green synthesis of AgNPs in carrageenan matrix for wound dressing applications

Carrageenan-based functional wound dressing materials were prepared through a one-pot green synthesis of silver nanoparticles (AgNPs) using lignin as a reducing and capping agent in the carrageenan matrix cross-linked with divalent cations such as CaCl₂, CuCl₂, and MgCl₂. The wound healing efficacy of the hydrogel film was evaluated using Sprague-Dawley rats. Crosslinking with divalent cations improved the physical properties of carrageenan-based hydrogels containing AgNPs such as strength, flexibility, swelling ratio, and release rate of Ag ions depending on the type of crosslinking agent used. The carrageenan-based hydrogels were biocompatible against the mouse fibroblast cell line (L929 cell line). Carra/Lig/AgNPs/MgCl₂ hydrogel significantly healed the wounds in Sprague-Dawley rats within two weeks, reducing the wound area to <3%, which was further confirmed by histological analysis with the epidermis and mature glands. Carrageenan-based multifunctional hydrogels have a high potential for wound dressing applications.

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.

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.

Pre-Operative Skin Antisepsis with Chlorhexidine Gluconate and Povidone-Iodine to Prevent Port-Site Infection in Laparoscopic Cholecystectomy: A Prospective Study

BACKGROUND

Skin preparation with antiseptic agents is commonly recommended for incisional site cleansing before surgery. We present the result of a prospective case series submitted to a scheduled pre-operative antiseptic procedure combining chlorhexidine gluconate and povidone-iodine before elective laparoscopic cholecystectomy.

PATIENTS AND METHODS

Consecutive patients underwent pre-operative standardized cleansing of the operation site combining chlorhexidine gluconate and povidone-iodine. Patients were reviewed one week and four weeks post-operatively.

RESULTS

Post-operative infection was observed in seven patients (4.3%). All observed infections were port-site infections, always located at the level of the umbilical incision. In all cases infections involved skin and subcutaneous tissue. Staphylococcus aureus was isolated in five patients (71.4%) and miscellaneous aerobic gram-positive bacteria in two subjects (28.6%). Post-operative hospital stay was the only factor significantly associated with the development of port-site infections.

CONCLUSIONS

Port-site infections are a common complication after elective laparoscopic cholecystectomy. The proposed pre-operative disinfection procedure is effective in reducing port-site infections. Reducing hospital stay may contribute to limiting the occurrence of this complication.

What Is the Real Rate of Surgical Site Infection?

PURPOSE

Surgical site infections (SSIs) are associated with patient morbidity and increased health care costs. Although several national organizations including the University HealthSystem Consortium (UHC), the National Surgical Quality Improvement Program (NSQIP), and the National Healthcare Safety Network (NHSN) monitor SSI, there is no standard reporting methodology.

METHODS

We queried the UHC, NSQIP, and NHSN databases from July 2012 to June 2014 for SSI after gynecologic surgery at our institution. Each organization uses different definitions and inclusion and exclusion criteria for SSI. The rate of SSI was also obtained from chart review from April 1 to June 30, 2014. SSI was classified as superficial, deep, or organ space infection. The rates reported by the agencies were compared with the rates obtained by chart review using Fisher's exact test.

RESULTS

Overall SSI rates for the databases were as follows: UHC, 1.5%; NSQIP, 8.8%; and NHSN, 2.8% (P < .001). The individual databases had wide variation in the rate of deep infection (UHC, 0.7%; NSQIP, 4.7%; NHSN, 1.3%; P < .001) and organ space infection (UHC, 0.4%; NSQIP, 4.4%; NHSN, 1.4%; P < .001). In agreement with the variation in reporting methodology, only 19 cases (24.4%) were included in more than one database and only one case was included in all three databases (1.3%).

CONCLUSION

There is discordance among national reporting agencies tracking SSI. Adopting standardized metrics across agencies could improve consistency and accuracy in assessing SSI rates.

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-site infection in gynecologic surgery: pathophysiology and prevention

Surgical-site infections (SSIs) represent a well-known cause of patient morbidity as well as added health care costs. In gynecologic surgery, particularly hysterectomy, SSIs are often the result of a number of risk factors that may or may not be modifiable. As both the Centers for Medicaid and Medicare Services and the Joint Commission on the Accreditation of Healthcare Organizations have identified SSIs as a patient safety priority, gynecologic surgeons continue to seek out the most effective interventions for SSI prevention. This review studies the epidemiology and pathophysiology of SSIs in gynecologic surgery and evaluates the current literature regarding possible interventions for SSI prevention, both as individual measures and as bundles. Data from the obstetrical and general surgery literature will be reviewed when gynecological data are either unclear or unavailable. Practitioners and hospitals may use this information as they develop strategies for SSI prevention in their own practice.

Alternatives to antibiotics for prevention of surgical infection

BACKGROUND

Surgical-site infection (SSI) is still the second most common healthcare-associated infection, after respiratory tract infection. SSIs are associated with higher morbidity and mortality rates, and result in enormous healthcare costs. In the past decade, several guidelines have been developed that aim to reduce the incidence of SSI. Unfortunately, there is no consensus amongst the guidelines, and some are already outdated. This review discusses the recent literature regarding alternatives to antibiotics for prevention of SSI.

METHODS

A literature search of PubMed/MEDLINE was performed to retrieve data on the prevention of SSI. The focus was on literature published in the past decade.

RESULTS

Prevention of SSI can be divided into preoperative, perioperative and postoperative measures. Preoperative measures consist of showering, surgical scrubbing and cleansing of the operation area with antiseptics. Perioperative factors can be subdivided as: environmental factors, such as surgical attire; patient-related factors, such as plasma glucose control; and surgical factors, such as the duration and invasiveness of surgery. Postoperative measures consist mainly of wound care.

CONCLUSION

There is a general lack of evidence on the preventive effectiveness of perioperative measures to reduce the incidence of SSI. Most measures are based on common practice and perceived effectiveness. The lack of clinical evidence, together with the stability of the high incidence of SSI (10 per cent for colorectal procedures) in recent decades, highlights the need for future research.

The DISINFECT Initiative: Decreasing the Incidence of Surgical INFECTions in Gynecologic Oncology

BACKGROUND

Surgical site infections (SSIs) lead to increased patient morbidity and healthcare costs. Our objective was to decrease the SSI rate following gynecologic surgery.

METHODS

Adult patients undergoing abdominal surgery for gynecologic malignancy or benign disease received the following: patient education; preoperative antibacterial soap; appropriate antibiotic prophylaxis; change of gloves and use of clean instruments at surgical closure; surgical dressing for 48 h; and a post-discharge phone call. The baseline SSI rate was determined retrospectively (1 April 2014-30 June 2014), while the post-intervention SSI rate was determined prospectively (16 February 2015-15 October 2015). The main outcome was the overall SSI rate with secondary outcomes, including the rate of superficial, deep, incisional and organ space infection, as well as the cost effectiveness of the bundle.

RESULTS

A total of 232 baseline and 555 post-intervention patients were included in the study. No differences were observed between the baseline and post-intervention groups with regard to median body mass index (BMI), surgical approach, receipt of preoperative chemotherapy and/or radiation therapy, and cases including bowel surgery. Overall, the SSI rate decreased significantly from baseline [12.5 %] to post-intervention [7.4 %] (odds ratio [OR] 0.56, 90 % confidence interval [CI] 0.37-0.85; p = 0.01). A 40 % decrease was noted in the rate of superficial and deep infections (9.5 vs. 5.9 %; OR 0.60, 90 % CI 0.38-0.97; p = 0.04) and SSIs after open surgery (21.4 vs. 13.2 %; OR 0.56, 90 % CI 0.34-0.92; p = 0.03). The estimated cost of the intervention was $19.26/case and the net total amount saved during the post-intervention period was $65,625 month.

CONCLUSIONS

This bundled intervention led to a significant decrease in the overall SSI rate and was cost effective. The largest decreases in SSIs were in incisional infections and following open surgery.

Effect of chlorhexidine pretreatment on bacterial contamination at rhinoplasty field

BACKGROUND

This study investigated on bacterial contamination of the rhinoplasty field. The effect of preoperative chlorhexidine treatment on decreasing bacterial contamination in the rhinoplasty field is examined.

METHODS

Thirty patients who underwent rhinoplasty were block randomized into a chlorhexidine, regular-soap, or control group comprising ten participants each. The chlorhexidine group was subjected to chlorhexidine showering, shampooing, and facial-cleansing 12 h prior to the operation. The regular-soap group was subjected to cleansing with regular soap, and the control group did not have any skin pretreatment. Bacterial cultures were done 12 h preoperatively from nasal cavity and perinasal skin, immediately preoperatively from perinasal skin and at 1 and 2 h intraoperatively from operation field. Culture results were compared between the three groups, according to operation time, or whether infection-prone procedure was performed.

RESULTS

The bacterial species and colony-forming unit numbers at preoperative nasal cavity and perinasal skin were similar. In all three groups, Coagulase-negative staphylococcus was the most common bacteria found in the rhinoplasty field. The numbers of Staphylococcus aureus and Corynebacterium decreased rapidly after preoperative chlorhexidine treatment. The infection-prone procedure was associated with increased bacterial numbers over time during the operation. In all three groups, there was no postoperative infection in a follow-up period of 6 months.

CONCLUSION

Rhinoplasty is confirmed as a clean contaminated operation with skin flora consistently found in the operation field. Chlorhexidine pretreatment in rhinoplasty patients has a tendency to decrease the numbers of Staphylococcus aureus and Corynebacterium on the perinasal skin.

LEVEL OF EVIDENCE

Randomized controlled trial, Level I.

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

Background

Skin antiseptic agents are used to prevent surgical-site infection (SSI); few trials have reported the superiority of any specific agent in clean-contaminated abdominal surgery. This RCT was designed to compare the effectiveness of chlorhexidine gluconate and povidone–iodine.

Methods

Consecutive patients who underwent clean-contaminated upper gastrointestinal or hepatobiliary–pancreatic open surgery between 2011 and 2014 were assigned randomly to either chlorhexidine gluconate or povidone–iodine. The primary endpoint was the occurrence of SSI within 30 days of surgery. Secondary endpoints included causative organisms and risk factors for SSI.

Results

A total of 534 patients were randomized; 31 (5·8 per cent) developed an SSI. There was no difference in the overall SSI rate in the chlorhexidine gluconate and povidone–iodine groups: 15 of 267 (5·6 per cent) and 16 of 267 (6·0 per cent) respectively (P = 0·853). The most common causative organism was Enterococcus faecalis. In subgroup analysis, biliary–pancreatic surgery had a higher SSI rate (26 of 127, 20·5 per cent) than upper gastrointestinal (2 of 204, 1·0 per cent) and hepatic (3 of 203, 1·5 per cent) resection. Both age (60 years and over) and type of incision were associated with the risk of SSI.

Conclusion

No difference was detected between chlorhexidine gluconate and povidone–iodine antiseptics for prevention of SSI. Registration number: NCT01495117 (http://www.clinicaltrials.gov).

New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective

Surgical site infections (SSIs) are among the most preventable health-care-associated infections and are a substantial burden to health-care systems and service payers worldwide in terms of patient morbidity, mortality, and additional costs. SSI prevention is complex and requires the integration of a range of measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations of national guidelines have been identified. Given the burden of SSIs worldwide, the numerous gaps in evidence-based guidance, and the need for standardisation and a global approach, WHO decided to prioritise the development of evidence-based recommendations for the prevention of SSIs. The guidelines take into account the balance between benefits and harms, the evidence quality, cost and resource use implications, and patient values and preferences. On the basis of systematic literature reviews and expert consensus, we present 13 recommendations on preoperative preventive measures.

Cardiac Implantable Electronic Device Infection: From an Infection Prevention Perspective

A cardiac implantable electronic device (CIED) is indicated for patients with severely reduced ejection fraction or with life-threatening cardiac arrhythmias. Infection related to a CIED is one of the most feared complications of this life-saving device. The rate of CIED infection has been estimated to be between 2 and 25; though evidence shows that this rate continues to rise with increasing expenditure to the patient as well as healthcare systems. Multiple risk factors have been attributed to the increased rates of CIED infection and host comorbidities as well as procedure related risks. Infection prevention efforts are being developed as defined bundles in numerous hospitals around the country given the increased morbidity and mortality from CIED related infections. This paper aims at reviewing the various infection prevention measures employed at hospitals and also highlights the areas that have relatively less established evidence for efficacy.